Forms
Physical Forms
Privacy Forms
Please read Prairie Clinic's Notice of Privacy Practices first. To use the forms print, complete, sign, date and send the form(s) to:
Prairie Clinic S.C., 112 Helen Street, Sauk City, WI 53583.
| Form | Purpose | Example |
|---|---|---|
| Communication Authorization | Authorization for Prairie Clinic to discuss my condition with designated individual(s). | If you want your provider to be able to discuss your health with your spouse, adult child, caregiver or other person(s). |
| Confidential Communication | To request alternate (confidential) communication with the clinic. | If you want the clinic to call you on your cell phone instead of your home phone for sensitive lab results. |
| Information Release | To request copies of your medical record. | If you are moving and want to transfer your medical records to another clinic. |
| Information Release Revocation | Revocation of the Authorization for Prairie Clinic to send your medical record. | If you were sharing health information for a court case or don't want additional medical records sent. |
| Information Amendment | To amend your medical record. | If you want to request a change to your medical record. |
Other Forms
Authorization for Prairie Clinic to discuss my condition with designated individual(s).
| Form | Purpose | Example |
|---|---|---|
| Advanced Directives | Advanced directives in case you are incapacitated. | If you do not want to be resuscitated. |
| Job Application | Employment application. | If you would like to work at Prairie Clinic. |
| Medicare Annual Health Risk Assessment (HRA) |
Insurance Coverage
Prairie Clinic is able to file the majority of insurance claims directly with your insurance company if we have received all the necessary information. When you have a change in insurance coverage, our office needs to know before services are provided, in order to file your claim more efficiently. When you check in for an appointment, please let the receptionist know of any changes. Please bring your insurance card with you. It is your responsibility to be aware of the coverage of your insurance plan. If you are a member of an HMO plan, Prairie Clinic must be selected as your primary care provider for you to be seen here.
Workmen's Compensation
It is the responsibility of the employee with a work-related injury or illness to inform the Clinic when the appointment is made or at the time of service. The Clinic will complete the form and forward it directly to the patient's employer or insurance company. For questions, ask for the Workmen's Compensation Specialist.
Medicare
All services provided by the Clinic Physicians are filed automatically with Medicare. Please let your doctor or nurse know if this is your first physical with Medicare, so we can process your claim properly. We accept assignment. For questions, ask for the Insurance Department.
Insurance Coverage Includes:
Alliance
Anthem Blue Cross/Blue Shield - Excludes Blue Priority
Cigna
Dean Gold
Dean Health Care - Excludes Dean FOCUS
DHP Administrators
Great West
Group Health Cooperative SCW
Health EOS
HPS - Health Payment Systems
Humana
Interplan Health Group
Medicare
Quartz
United Health Care
WellFirst Health
WPS
BILLING
Billing Phone: 608-644-2419
On Line Bill Pay: https://pay.instamed.com/PRAIRIE
Charges
Our fees are comparable to surrounding communities. Our charges for service including office visits and procedures are based upon the severity and complexity of your injury or illness; as well as the time needed treating you. If you have any questions, please feel free to discuss them with us. We would appreciate your efforts to pay for your medical services as you receive them.
All co-pays are due at the time of service We maintain one account per family with a running total balance due. This account has notations by our office, i.e. dates of service, patient seen, type of service, payments and adjustments made by you or your insurance.
Statements
Statements are mailed every 4 weeks. The statement you receive is an exact copy of your account. You will not receive a statement if we are waiting for payment from your insurance company. After insurance pays on that date of service, you will receive a statement. We try to send everything to your insurance company as soon as possible, although your insurance company can take up to 6 weeks to pay on your claim.
Other Questions
Other questions regarding your account should be directed to our Billing Office. Please notify us upon registration of any insurance or address changes.
My Patient Portal / Web Portal
Prairie Clinic uses a patient portal (also known as the Medfusion Patient Portal) as our patient portal service. A patient portal allows our patients on-line access to their physician's office for secure messages, medication refill requests, records requests and even look up health information. Requests are typically answered with 2 business days.
If you feel a life threatening situation exists, immediately call 911.
A Patient Portal offers a secure way to send messages, using encryption, firewalls and secured systems. Once you sign up for your Patient Portal you'll use a username and password and a confirmation question to access your on-line account. When we send you information, you'll receive a notification e-mail, but you need to log onto the secure website to read your confidential information.
(All patients who are already enrolled will need to re-enroll)
How to Sign-Up
If you are a Prairie Clinic patient interested in signing up for Patient Portal, please ask at the front desk when checking in at your next appointment.
For a handy guide to using your Patient Portal, click here.
Medication Refills
We are happy to order medication refills prescribed by your provider when appropriate.
To refill your prescription, please call your pharmacy and ask them to fax us the request for a prescription refill.
We receive many requests for refills each day, and the process takes time, (especially when your provider is not in the office). Please allow 48 hours for your request to be processed.
- Refill requests are processed Monday through Friday between 8:00 am and 4:00 pm. Medication refill requests made on Saturday will be processed on Monday
- An office visit may be required (to monitor your overall health and condition) prior to refilling your medication.
- An office visit may be required prior to filling or refilling an antibiotic prescription.
- We are not able to refill medications we have not prescribed.
There are some programs available to assist patients in paying for medications you need:
SeniorCare
A description of the SeniorCare Program is available at: http://www.dhfs.state.wi.us/seniorcare.
An application is available at: http://dhfs.wisconsin.gov/SeniorCare/app-instruc-info.htm
Medicare
Information about Medicare's Prescription Drug and other assistance programs is available at: http://www.medicare.gov/A