Carls Center Health Forms and Billing Information

Forms

Prior to visiting the Carls Center for Clinical Care and Education, you will need to complete the following forms:

1. Carls Center consent for treatment and assignment of benefits
   
2. Patient registration and HIPAA
   

Before visiting one of our supervised student clinics, you will need to complete one or more of the following forms:

1. Audiology adult history form
2. Audiology pediatric history form
   
3. Audiology medication list
4. Audiology vestibular history form
5. Augmentative and Alternative Communication Center pre-assessment form
6. Dyslexia case history questions

Billing and payment information

Our charges may be billed to the patient's primary health insurance. For co-pays or payment of deductibles, we accept cash, check, money order, MasterCard®, Visa®, Discover Card® or bank debit cards, and most Flexible Spending Account and Health Saving Account cards. For the student-run clinics, there is no billing to insurance companies and no charge to clients.

Insurance billing

We will bill primary and secondary health insurance plans if you provide current insurance coverage information for all plans and sign an authorization at the time of the visit to allow us to do so. We participate with several insurance programs, but please review your benefits contract or call your health plan rep to learn about your benefit options. Please note, insurances companies:

• Often change their provider network, so please verify with your plan if there have been any provider or coverage changes.
• May require prior authorization and paperwork verifying the need for services. If prior authorization is required, we will obtain this from your primary care provider before your appointment.

Managed care plans

Our billing staff will arrange for any needed prior authorizations required by Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) plans, in order to try to arrange for payment coverage clearance prior to our seeing you. Prior authorizations may also be needed for non-emergency out-of-network care prior to being seen at the Carls Center. If authorization is denied by the insurance carrier, can still be seen at the Carls Center on a fee-for-service basis.

The CMU Student Health Insurance Plan is available for CMU students, their spouses, and dependents to purchase.

You remain responsible for the payment of any co-pays or deductibles required by the health insurance plan. Certain insurance and community service programs cover specific diagnostic tests or treatment interventions. For instance, many insurance plans cover hearing testing, but may not cover the purchase of prescribed hearing aids. Please check with your health plan or program, and consult with our staff to learn what is covered and options for getting the help of needed services.