DeFatta Health aspires to be your first stop for both concierge service and compassionate care. We offer the widest range of treatment options administered by the most advanced degreed physician team.
Whether you area new patient just getting started with us or preparing for a procedure, we've stored all your necessary forms below. Feel free to print, fill out, and bring your document in for as smoother check in experience!
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Patient Referral Form to DeFatta Health
Adult Medical History Form
Minor Consent Form
Driving Directions to DeFatta Health
Financial Policy
HIPAA Privacy Notice
Infant Medical History Form
New Patient Packet
Pediatric Medical History Form
Release of Information to DeFatta Health
Animal Dander Control Measures
Dust & Mite Management
Mold Allergy Control Measures
Pollen Environmental Control Measures
Pre-Allergy Test Information
Post-Allergy Test Information
Bactroban Irrigation Instructions
Post-Op Ear Surgery
Post-Op Ear Tubes
Post-Op Nose Sinus Surgery
Post-Op Sleep Apnea
Post-Op Tonsil & Adenoids
Post-Op Vocal Fold Surgery
Post-Op Neck Surgery
Post-Op Nose Bleeds
Managing Dizziness
OTC Ear Remedies
Post-Op Skin Lesions Exicision
Adult ABR Instructions
Pediatric ABR Instructions
Adult Hearing Health History
Pediatric Hearing Health History
VNG Packet
What is An ECochG Test
Bellafil Informed Consent
Botox or Dysport Consent Form
Chin Augmentation Pre/Post Op Instructions
Costmetic In Office Procedure Consent
Cosmetic Intake Form
Cosmetic Surgery Price Quote
Defenage Products & Kit Descriptions
Dermal Filler Consent
Instructions for Minor Surgery
MiraDry Consent
MiraDry Pre/Post Procedure Instructions
Post-Op Brow & Midface Lift
Post-Op Face Neck Lift
Post-Op Fat Transfer
Post-Op Rhinoplasty
SkinPen Post Procedure Premium
SkinPen Post Procedure Ultimate
SkinPen Consent
Transconjunctival Blepharoplasty Instructions
Transcutaneous Blepharoplasty Instructions
Have questions about your bill or payment options for our various services? Our Billing Specialists are available to assist you with the financial aspects of your care at DeFatta Health. Please ask about our financing options.
We at DeFatta Health are committed to building a successful physician-patient relationship with you and your family. Your clear understanding of our Patient Financial Policy is important to our professional relationship.
Co-Payment is due at the time of service. Your insurance company requires that we collect all co-pays at the time of check-in. The amount of your co-pay may be listed on the front of your insurance card. If not listed, please contact your insurance provider.
Payment of outstanding balances is required every 30 days. Balances over $1000 require a minimum payment of 10% of the original balance.
A deposit of $200 for new patients and $100 for established patients is due at the time of check-in if you are without insurance coverage, covered by insurance plans in which the clinic does not participate or do not have an insurance card on file with us.
Two options are available for payment of the balance:
Prior to any additional services being rendered, self-pay patients are required to pay in full or set up a payment plan with our billing specialists.
For your convenience we accept:
DeFatta Health realizes that medical costs can be an unexpected expense. It is never our intention to cause financial hardship on our patients, only to provide them with the best care possible with the least amount of stress. We are willing to work with you on a payment arrangement for the balance of your account if necessary. It is important that you let us know as soon as possible if you will have difficulty paying your bill.
DeFatta Health participates with the following health plans*:
Anthem Blue Cross and Blue Shield
Choice Care Network
Cigna
Coventry HealthCare
Dean Health Plan
Group Health Coop of Eau Claire
HealthEOS
HealthPartners
Humana
Interplan Health Group
Managed Health Services (Medicaid)
Medica
Medicaid
Medicare
Multiplan
Northcentral Healthcare Alliance (NEHA)
Preferred OnQuartz
Security Health Plan
SelectCare-LaborCare
The Alliance
United Healthcare
WEA Trust
WPS
*To receive maximum benefits it is important for you to contact your insurance company to identify providers who are in network for your plan. The phone number for your insurance company is usually on the back of your insurance card. If you have benefit or coverage questions, contact your insurance company directly. If you need assistance in contacting your insurance company, please let us know, and we will assist you in facilitating this discussion.
Charges may be applied to your deductible, copay or coinsurance; charges may not be covered under your benefit plan; coverage was not active at the time of services; or your insurance company may need additional information from you. Please review your EOB (Explanation of Benefits) for information regarding the amount you owe, and call your insurance company or our Billing Specialists if you have any questions or concerns.
Medicare usually pays 80 percent of the allowed amount for covered services after the annual deductible is met.
When you schedule your appointment or check in, please notify us, and we will bill your employer or workers’ compensation for your services. You should notify your employer of the injury, or they may deny your workers’ compensation claim.
There are some instances where we can bill your accident/liability insurance. Please present your information when you check-in and our billing team will investigate if we can bill the third party.
Still have questions? We are here to help you through any billing questions may have. Please do not hesitate to contact us at (715) 828-2368
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