2018 Medical Home Fee Return Form

Sharonville Family Medicine

William P. Sawyer MD

Year 2018

Some benefits of our patient centered medical home environment:

  • You can count on seeing Dr. Sawyer each time you come for an office visit
  • 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
  • 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.
  • Recommends and coordinates visits to specialists for specific medical issue.
  • Pharmaceutical grade supplements offered conveniently for sale in our office.

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

Individual:                                  $160.00

Family (2 or more):                   $320.00

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? We want to conveniently share information from our office.

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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