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Policies, Insurance, Forms PDF Print E-mail

Capitol Medical Group works with all ages

Office Policies | Insurance | Downloadable Forms 

Office Policies 

CMG strives to provide the best possible care in the most efficient manner while keeping healthcare costs down for all of our patients. As such, certain guidelines are necessary as well as fees for additional services provided to you and your family.

CategoryProcessAdditional Fees
Scheduled AppointmentsAll appointments should be made in advance of your arrival to the office – including sick visits. Late arrivals will be seen as time becomes available – however, if the patient load does not permit, it may be necessary to reschedule.Aside from standard charge for services rendered, no fees
Walk-insIf no appointment was made in advance of your arrival or if you desire a child to be seen at the time of a scheduled visit for another child.$40
Appointment cancellations 24 hour notice required for Sick Visit
24 hour notice required for Well Visit 		Fail to show $25
Fail to show $50
After Hours Access to On-call DoctorContact main CMG office number and follow instructions to have your call transferred to the call service; provide the service agent your contact information and reason for call.$25
PrescriptionsMost new or refills provided at office visitNo charge
 New or Refill called into pharmacy or mailed to patients$5
 Monthly Schedule II may be picked up at office or mailed to patient. They cannot be post-dated.$5
FormsMake request in writing with stamped, self-addressed envelope or arrange to pick up forms at the office. 3-5 working days are required to complete forms. Forms cannot be faxed.Varies
 School Forms (Note: Allow 4-6 weeks to schedule physical exams for school)Varies
Co-pays, deductibles and account balancesDue at the time of the visitVaries
Medical Record Transfers This process is handled by Universata. Please submit your requests in writing on one of their forms and allow 7 business days for the transfer. All charges and payments are handled directly by Universata.  

Payment is required at the time of service. For your convenience, we accept cash, check, Visa, and MasterCard.

Insurance

Your insurance coverage is a contract between you and your insurance company and it is your responsibility to know the limits and benefits. CMG will assist your insurance company in processing your claim when necessary: however, you are ultimately responsible for the payment of your account.

We will file insurance claims only for the plans in which we participate at any given time. These plans currently include:

NCPPO (Georgetown)BCBSNCA
NCPPOMAMSI (not medicaid products)
ChampusBlue Choice
AETNA (Not HMO or POS)United Health Care (not medicaid products)
Guardian (Indemnity) 

Due to variations in policies, it is your responsibility to check with us and your insurance plan to be sure they consider us as participating providers.

As a patient of CMG, we will bill your insurance company and be reimbursed directly. You are responsible for the co-payment and deductibles at the time of service. There will be a $5 processing fee for any additional forms that must be completed by the billing office. We do not file secondary insurances.

If your insurance denies payment for services rendered for any reason, we will bill you directly and payment is expected within 30 days. Your insurance company may reimburse only part of your claim if:

  1. You have not met your deductible.
  2. Our fees are above their usual customary rate.
  3. Your policy does not cover the service rendered.
  4. Patient is not covered at the time of service.

There is a $25 charge for all returned checks.

You should communicate directly with your insurance company to settle any disputes over claims and reimbursements. We appreciate your cooperation. Inquiries or concerns regarding your bills should be directed to CMG’s billing department at 240-482-1544 or 240-482-1545.

Downloadable Forms

For your convenience attached are forms you can prepare in advance and bring with you to your visit. If you have any questions or problems downloading forms, please do not hesitate to call us at 301-907-3960.

Children's Registration Form (with and without insurance)
Patient Acknowledgement/Consent Form - HIPAA Registration - Waiver Form (for all new patients)
Insurance Card Waiver (for patients without insurance cards)
Transfer of Medical Records-Universata Release (Request Form)
Change of Address Form

Adobe PDF Files
The forms are formatted in Adobe Acrobat.   The acrobat reader program is required to view and print them.  The reader program is a FREE download - Click here.