For appointments: 1 203 661 7546|40 West Elm Street, Greenwich CT 06830
For appointments call 1 203 661 7546

PATIENT INFORMATION FORM

Henry C. Gasiorowski, M.D.
Michele E. Gasiorowski, M.D..
40 West Elm Street
Greenwich, CT 06830
Telephone: 203-661-7546
Facsimile: 203-661-0085

MEDICARE POLICY:

Since February 1998, our office has privately contracted with our Medicare participants. This means that you may still be seen in our office, however, you will be responsible to pay your bill at regular office prices minus a 20% courtesy on all non-cosmetic procedure if Medicare is your primary insurance and you are over the age of 65. These charges cannot be submitted to Medicare by our office and Medicare will not pay for services provided in our office. Your secondary carrier may or may not consider these charges and may alter their reimbursement accordingly.

BILLING POLICY:

The policy of this office requires payment at the time of services are rendered. Certain surgical procedures may require advance payment or deposit. We do not participate in withany insurance plans. You will be furnished with a receipt for your insurance company to reimburse you directly providing you attach the copy of your bill to your claim form. Please call your insurance company for claim submission instructions. Under certain circumstances, additional information may be necessary to process your claim. Your signature below authorizes this office to release any medical information requested. You are responsible for payment in full regardless of any insurance company’s determination of usual and customary rates.

CANCELLATION POLICY:

I understand that I will be charged an office visit starting with the third late cancellation or missed appointment unless I notify the office 24 hours prior to my scheduled appointment.

The following questions are for female patients only:
Check one (when exposed to the sun without protection for approximately 1 hour):

Has anyone inyour family ever had the following:

List all medications you are taking, including vitamins, laxatives, pain relievers and herbal remedies:

Patient Social History:

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