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New Patients
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Waukesha Family Practice Clinic celebrates over 25 years of service to the community. Only through the trust and support of our patients, have we become an established and well-respected health care clinic.
The staff at Waukesha Family Practice Clinic welcomes you as a new patient. We value the trust you have placed in us to provide you and your family with the best possible health care and service excellence. Please take some time to browse our web site. It contains basic clinic policies and answers to most-often asked questions.
New Patient Forms (You will need Adobe Reader to view and print the following forms)
If you are a new patient coming to Waukesha Family Practice Clinic for the first time, you may prefer to print and complete our Patient Registration Form and History Form prior to your appointment. You can complete these forms at your convenience and bring them with you to your appointment. If you prefer to receive and complete these at our office, please arrive at least 15 minutes prior to your appointment time to allow sufficient time for completion in our office. Please bring your insurance card with you to your appointment since we will need to make a copy at the time of your visit.
Click the document name to open the document. For Child Registration Forms or Adult Patient Registration Forms - Spanish version, please click here.
 Portable Document Form (PDF) forms need to be printed, filled out and when required returned at time of visit.
To Get Adobe Reader:
 Click on this icon and follow the easy instructions included with the Adobe
Reader software to install Adobe Reader on your computer. Then click any PDF
file to view, navigate, or print.
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Billing
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We will be happy to file your insurance claims. Ultimately, however, all charges
are your responsibility. If your insurance company has not paid your bill
in 60 days, we will expect you to pay all outstanding charges and work with
the insurance company to recoup your expense. (This policy applies to those
covered by standard insurance, not Medicare or Title 19.) We will send monthly
statements to you until your account reaches a zero balance. Your initial
statement will include a detailed description of services rendered: type
of service performed, date, and charges. Subsequent statements will include
any balance still remaining along with an itemized list of current charges.
Please call our Billing Department with questions or problems - or to make special payment arrangements.
Billing Department hours:
| Monday - Thursday |
7:30 a.m. - 4:00 p.m. |
| Friday |
7:30 a.m. - 1:00 p.m. |
| Call 262-542-5199 (ext. 3) |
Accepted Payments
We welcome MasterCard, Visa, Discover, Cash, Debit Card and Personal Checks. However, to offset bookkeeping expenses, the Clinic must assess a fee for each "insufficient funds" check returned to us.
Past Due Balances
An account is considered "delinquent" after 60 days. If you receive a final notice from us, you must pay your balance in-full. If the balance is not paid in full, all future services must be paid in cash at the time of service until your account balance is paid. If we do not receive payment after sending a final notice, we will be forced to send your account to a collection agency and/or list your failure to pay with the Credit Bureau.
Billing Policies
We comply with all guidelines set forth by Medicare, Title 19, and participating HMO, PPO, and POS plans.
Yet understanding health insurance coverage can sometimes be complicated and confusing. Knowing how and what your health insurance covers will clarify your responsibility for any non-covered balance remaining for Clinic services.
Many insurance companies will pay only what they consider to be usual and customary charges. In such cases, you are responsible for any remaining balance. We try hard to keep our fees fair and reasonable; however, the definition of usual and customary varies from one insurance company to the next.
If time permits, we will send you a patient registration form to complete before your first visit. If there isn't time to mail the form before your appointment, you can complete it at our office before your visit. The form gathers facts about employment and insurance. It also grants us permission to file claims with your insurance company on your behalf.
To view and print this form and any other new patient forms, please click on the specific PDF document below. Completed forms should be submitted to the receptionist at time of your appointment.
Adult Patient Registration Form - English
Adult Patient Registration Form - Espanol
Adult History Form - English
Adult History Form - Espanol
Child Registration Form - English
Child History Form - English
Child History Form - Espanol
At the end of each appointment, you will be given a routing slip to take to the reception desk. This slip contains information about future appointments, referrals, or tests needed. It also lists charges for the visit.
If you have not satisfied your deductible for the calendar year, you must pay your deductible and any co-insurance at that time. If you have satisfied your deductible, you simply pay any co-insurance.
If you belong to a participating HMO, PPO, or POS, any co-pay will be collected when you check-in for your visit. If you do not have insurance coverage, you must pay for your charges in-full at the time of treatment - unless you have already made other arrangements with our billing department.
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Accepted Insurance
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Below is a listing of health insurance plans accepted at Waukesha Family Practice Clinic. Please be aware that full or partial coverage may be denied under certain circumstances. Contact your insurance company for coverage and benefit verification.
Health Plans
These plans are subject to change at any time. If your plan is not listed below or to verify coverage, please contact our office at 262-542-5557.
Accountable Health Plan (AHP)
Aetna Managed Choice, Choice POS II & PPO
Alliance
Anthem Blue Cross - Blue Access and Blue Preferred Plans
Associates For Health Care (AHC)
Beech Street
BCE Emergis
Blue Cross Advantage PPO
Blue Cross Design POS
Bowers PPO
Capp Care
Champus Tricare - Standard Indemnity Plan only
Choice Care/Humana
CIGNA Managed Care, PPO and Health Partners plans
Community Care Network (CCN)
Compcare
First Health Network PPO
Great West PPO & POS
Health Care Direct (HCD)
Health Care Network (HCN) POS & PPO
Health EOS
Humana Advantage & Premier Network
Humana Gold Choice - Medicare product
Humana One PPO
Humana POS & HMO
Humana Smart Net PPO
Interplan Health Group
Medicare: Accept Assignment
Medicare Advantage PPO (Humana product)
Medicare Secure Horizons (United Healthcare Product)
Medicare Open (Aetna Product)
NPPN
One Health Plan
PHCS Choice Care Network & PPO
Paradigm Network
Patient Choice
Plains Health Network
ProAmerica
ProHealth Care PPO/WIDS
Trilogy Health
United Healthcare (UHC) POS & PPO
WEA POS - SE WI broad network & metro area narrowed network
WPPN
WPS HCN
WPS Statewide POS
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Notice of Privacy Practices
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This notice describes how medical information about you may be used and disclosed; and how you can get access to this information. Please review it carefully.
Notice
of Privacy Practices (PDF document)
It is your right as a patient to be informed of the privacy practices of your health care provider as well as to be informed of your privacy rights with respect to your personal health information. This Notice of Privacy Practices is intended to provide you with this information.
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Advanced Directives
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Click on the link below to obtain Declaration to Physicians (Living Will) and Power of Attorney-Healthcare forms.
http://www.dhfs.state.wi.us/forms/AdvDirectives/ADFormsPOA.htm
It can be hard for doctors and loved ones to know what kind of treatment you would want when you are too sick to tell them. Advance directives are legal documents designed to allow competent patients the opportunity to guide future health care decisions in the event that they are unable to participate directly in medical decision making.
The two basic types of advance directives are Living Wills and Power of Attorney-Health Care.
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Living Wills
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A Living Will, or "Declaration to Physicians," is a signed and notarized legal document in which you declare that in the event you have a terminal illness or injury, you want to die naturally and not be kept alive by extraordinary or artificial means.
Once your Living Will is executed, the original should be made part of your medical record. Give copies to family members and friends who are likely to be involved in your health care decision-making.
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Power of Attorney - Health Care
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A durable power of attorney (DPA) for health care is another kind of advance directive. A DPA is a legal document that states the person you have chosen to make health care decisions for you if you are unable to make those decisions for yourself. It becomes active any time you are unconscious or unable to make medical decisions. A DPA is generally more useful than a living will. However, a DPA may not be a good choice if you don't have another person you trust to make these decisions for you.
The person you choose to act on your behalf is called a health care "agent". Anyone of sound mind who is at least 18 years old may be designated as your health care agent except for your health care provider, or an employee of your health care provider, unless that person is your relative.
Upon completion of your Health Care Power of Attorney, give the original document to your physician. Give copies to your health care agent, your family members, and your attorney.
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