Form Completion Policy

posted May 7, 2014, 8:13 AM by Daniel Zerbe   [ updated May 28, 2014, 8:42 AM ]
 In response to increasing demands for the completion of medical forms, which require increased administrative time and financial resources, Letchworth Family Medicine has adopted a policy to charge for these services.


In order for us to better serve you, we request that you are aware of the following:

· Submit the form or request well in advance of when they are needed. We will attempt to complete the form(s) as quickly as possible, however, in order to properly address them we need adequate time to review the patient’s records. Turnaround time is usually 7 business days.

· Patients must complete all of their information on the form prior to submitting for completion.

· Payment is required prior to completion of all form(s). If the form is brought in and completed at the time of an office visit, there will be no charge.

· Your insurance company will not be billed as insurance companies do not reimburse for the time and judgment that are required to complete these forms.



The following fees will be assessed:

· $5.00 Simple Form (1 page with no clinical judgment)

· $10.00 Medium Form (camp, school, college, sports, etc.)

· $20.00 Multi-part Form (requires clinical decision and/or patient input, 2 or more pages; disability forms, FMLA, etc.)

· No charge if the form is brought in and completed at the time of an office visit.
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