Patient Information

Financial Policy Agreement

You are responsible for knowing the extent of your insurance coverage, cost of co-pays, and co-insurance BEFORE your visit.

Insurance coverage:

Payment for services that have been submitted to your insurance company and determined to be your responsibility is due upon notification by statement.

Please note, you are responsible for knowing the extent of your insurance coverage prior to your visit. To confirm your plan is in-network, please contact your insurance carrier and reference the following NPI numbers:

• Dr. Sam Russo: 1891828398
• Katlin Mostue-Nesbit, APRN: 1427665017

Currently, we are in-network with the following insurance plans:

• Blue Cross to include BCBS of Vermont, Federal BCBS, CBA Blue, and Vermont Blue Advantage (UVM Retirees only)
• Cigna
• MVP
• Vermont Medicaid
• Aetna: We are in-network for some plans; check with your plan.

Payment for all other services including out-of-network services, co-pays, and nonbillable laboratory tests, are due at time of service by cash, check, credit card (Visa, MC, Amex).

Services provided outside of an office visit:

Payment for services for which you are not present will be billed at the time of service.

These services include:

• Initiation of services that require evaluation and management through the patient portal or by telephone
• Refill requests when an office visit is due
• Resubmitting expired orders for laboratory testing or diagnostic imaging
• Completing specialist referrals that were requested outside of an office visit
• Completion of letters and forms outside of an office visit.

The CPT codes for these services will be used to submit a claim to your insurance company if applicable: 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98012, 98013, 98014, 98015, 98016.

Preventive visits and Office visits:

Preventive visits include age- age-appropriate screening for disease prevention and immunization counseling. A preventive care visit is different from an office visit:

A preventive visit is the time to review your overall health, identify risks for chronic disease, and prevent them. Your plan should cover 100% of a preventive visit when you see a doctor in your plan’s network. For example, a visit for screening for chronic diseases such as hyperlipidemia, diabetes, colon cancer, breast cancer, or cervical cancer would be a preventive visit.

An office visit is a time to evaluate and treat a specific health condition. For example, at your preventive care visit, you ask your doctor about a specific health concern or condition that requires further evaluation or a new treatment, such as joint pain, elevated blood pressure readings, a changing skin lesion, or changes in your mood. These problems would be addressed through an evaluation and management or office visit.

Missed Appointments

Patients are expected to provide 24 24-hour notice of a cancellation. There is no penalty for the first missed appointment or late cancellation. Patients who have their second missed appointment or late cancellation within 12 months will be charged for the appointment, with the exception of Medicaid patients. Patients will also receive a letter notifying them that they will only be able to make same-day appointments for six months. If, after six months, the patient is able to keep appointments according to our scheduling policy, they can resume normal scheduling. Otherwise, patients who continue to have missed appointments or late cancellations will be dismissed from the practice.