- Scheduling Appointments
- What to Bring to Your Appointment
- Insurance and Payment Information
- Hospital Affiliations
- Welcome Sheet and Notice of Privacy Practices
We realize that our patients' time is valuable, and we make every effort to see patients at their scheduled time. However, occasionally, our office falls behind schedule. We ask for your understanding; we, also, ask that patients provide as much advanced notice as possible when running late for an appointment or when needing to cancel. With this advanced notice, the time can be scheduled for another patient.
What to Bring to Your Appointment
If you are a first-time patient, please plan on arriving early in order to complete a patient registration form and please bring the following items to the appointment:
- Welcome sheet and notice of privacy practices
- Insurance card(s)
- Referral forms (if required)
- List of all prescription and over-the-counter medications that you are currently taking
- Any required co-payment
- Pertinent medical and surgical history information
- X-ray films
Insurance and Payment Information
We are a provider for Medicare and most major insurance plans. Since we provide insurance billing, we encourage all patients to confirm their coverage prior to making an appointment. Co-payments are due at the time of the appointment, along with any applicable deductible payment. If the insurance company does not pay the full balance, or denies the claim, then any unpaid balance is due within 30 days following the appointment.
Please call us with any questions regarding which insurance plans we accept or other billing concerns. Insurance coverage and benefit questions should be directed to your insurance company.
Dr. Thomas F. Bembynista maintains affiliations with the following hospitals:
- St. Luke's North
- Johnson County Surgical Center
Welcome Sheet and Notice of Privacy Practices
Please arrive 15 minutes early for your first appointment to allow time to complete our welcome sheet and notice of privacy practices, or you may print and complete the forms at home prior to your visit.
If you have trouble accessing the PDF form above, go to PDF Help >>