2011 INSURANCE PLAN TYPE[NAME]:PPO OR POS OR HMO OR EPO PHYSICIAN IN-NETWORK: YES OR NO DOES PATIENT HAVE OUT OF NETWORK

FACILITY BENEFITS: YES OR NO EFFECTIVE DATE: CONTRACT/CALENDAR YEAR:CALENDAR OR CONTRACT PRE-EXISTING CLAUSE:YES OR NO REFERRAL NEEDED FOR SPECIALIST OFFICE VISIT:YES OR NO VERIFIED BY: DATE VERIFIED: --SPECIALIST OFFICE VISIT-COPAY$ OR DED$ [MET$ ] COINS % OOPMAX$ [MET$ ] --OFFICE VISIT DEPOSIT-OFFICE CONSULTATION [E/M CODE 99243]=$ [COINS/DED] NP VISIT [E/M CODE 99203]=$ [COINS/DED] NP VISIT [E/M CODE 99204]=$ [COINS/DED] FOLLOW UP VISIT [E/M CODE 99213]=$ [COINS/DED] FOLLOW UP VISIT [E/M CODE 99214]=$ [COINS/DED] --OUTPATIENT SURGERY BENEFITS (FOR PHYSICIAN)-GENERAL SURGERY BENEFITS: DED$ [MET$ ] COINS % OOPMAX$ [MET$ ] ROUTINE COLONOSCOPY[CPT CODE 45378]:DED $ AGE LIMIT --PRE-AUTHORIZATION FOR OUTPATIENT SURGERY-COLONOSCOPY [CPT CODE 45378]UPPER ENDOSCOPY [CPT CODE 43235]TELEPHONE NUMBER--PROCEDURE DEPOSIT-MEDICAL NECESSARY COLON=$ [COINS/DED] EGD=$ [COINS/DED] DOUBLE=$ [COINS/DED] ROUTINE COLON=$ [COINS/DED]

****TRADITIONAL MEDICARE**** PLAN YEAR: EFFECTIVE DATE: DEDUCTIBLE: REMAINING: SUPPLEMENTAL CROSS OVER COVERAGE: NEED TO COLLECT 20% COINSURANCE: MANAGED CARE PLAN: NO --PLAN CODE: VERIFIED BY: DATE VERIFIED: **SECONDARY INSURANCE PLAN** OR **MANAGED CARE PLAN** 2009 PLAN TYPE: EFFECTIVE DATE: PRE-EXISTING CLAUSE: CALENDAR OR CONTRACT YEAR: REFERRAL NEEDED FOR SPECIALIST OFFICE VISIT: VERIFIED BY: DATE VERIFIED: ----SPECIALIST OFFICE VISIT---COPAY$ DED$ [MET$ ] COINS % OOPMAX$ [MET$ ] ----OUTPT SURGERY BENEFITS (FOR PHYSICIAN)---GENERAL SURGERY: DED$ [MET$ ] COINS % OOPMAX$ [MET$ ] ROUTINE COLONOSCOPY[CPT CODE 45378]:DED $ ----PRE-AUTHORIZATION FOR OUTPATIENT SURGERY----COLONOSCOPY[CPT CODE 45378]UPPER ENDOSCOPY[CPT CODE 43235]TELEPHONE NUMBER-