2017 Medical Home Fee Return Form

William P. Sawyer MD

Year 2017

Our patient centered medical home environment has many amenities that differentiate us from other practices:

  • You can count on seeing Dr. Sawyer each time you come for an office visit
  • We answer the phone, not an automated system
  • Same day office appointments are the norm, not the exception
  • Personal coordination with other physicians and diagnostic test sites to ensure timely care
  • Comfortable and quiet office setting and staff who care for and about you
  • Home visits by Dr. Sawyer for those who become home bound
  • Ease of communication via Dr. Sawyer’s personal cell phone number
  • Provide copies of all your diagnostic tests for your personal records in a timely manner
  • Help interpret health insurance coverage and payments
  • Offers cash-payment discounts at time of service for medical services to help cushion the cost of high deductibles and out of network services.

 

Please CHECK your option, SIGN and RETURN this form with your payment.

Individual:                     $140.00

Family:                             $280.00

To qualify as part of family, children must be under 25 and living at the same address or in college:

______________________________       _____________________________

______________________________       _____________________________

I understand and agree to pay the Annual Medical Home Fee charged by Dr. William Sawyer.

Name: _________________________              Date:  ____________

 

Changed your e-mail? Want to start receiving information from our office?  Jot it down below.

E-mail address: _________________________________________

**Remember**, if you do not pay the Medical Home fee by December 31st you need to send a signed, dated release of medical records request that includes the name and address of your new physician plus any balance owed on your account prior to us forwarding your health summary.

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