Patient Forms and Financial Policy

Thank you for choosing the Mountain Area Health Education Center (MAHEC) as your healthcare provider. We value the relationships we have built with our patients and are committed to maintaining a successful provider-patient relationship with you and your family. Thank you for understanding that payment for services is part of that relationship. Our financial policy assures that we can continue to provide quality care to all our patients, while being sensitive to economic challenges many of us face.

Patient Forms

Please fill out all applicable forms and bring with you to your first appointment. 

New Patient Information Form

Medical Records Release Form (use page 1 to have your records SENT to another facility; use page 2 to request that MAHEC receive your records. Note that a fee will be charged if you are requesting the records for yourself.  There is no charge for sending records to another facility).

HIPAA Notices of Privacy Practices

Patient Bill of Rights

Wellness Visit Form

If you're looking for patient portal information or patient portal forms, please click here

If you'd like a copy of our MEND telemedicine forms that you will sign electronically before your telemedicine appointment, please click here.

Patient Financial Policy

  • Patients are entitled and encouraged to seek financial guidance from MAHEC’s Patient Financial Advocates who can offer possible solutions for those who cannot pay in full at time of service and who may qualify for MAHEC’s Financial Care Program.  MAHEC’s Patient Financial Advocates work with the patient and /or guarantor to find reasonable payment alternatives. It is the policy of MAHEC to provide essential services regardless of the patient’s ability to pay. Discounts are offered based on family size and annual income. The discount will apply to all services provided and billable by MAHEC. Services performed by outside organizations and equipment that is purchased from outside companies, including outside laboratory testing, drugs, and x-ray interpretation by a consulting radiologist, and other such services, will not be covered under MAHEC’s financial care policy. 

    Click here to download and print our financial care application form in English. Click here to download and print our financial care application form in Spanish. The financial care application form must be completed every 12 months and when your financial situation changes.

  • All co-payments are expected at the time of check-in. Failure to pay co-payment at the time of service may result in a delay in scheduling future appointments.
  • MAHEC’s Patient Financial Advocates are able to set up payment arrangements for old balances to avoid delays in scheduling future appointments.
  • The amount you are asked to pay at your visit is an estimate of the charges for your care. All charges may not be captured at the time of check-out so you may receive an additional bill. Any time you have a billing question, please don’t hesitate to call the MAHEC Billing Department at (828) 257-4725 for clarification.
  • Payment in full is expected on receipt of your billing statement. The statement will reflect the amount you owe after your insurance, if any, has processed your claim. If no resolution can be made within thirty (30) calendar days, the account will be sent to the collection agency and discharge from the practice may be initiated.

We trust you will understand the need to establish these payment standards for all our patients. If you need further information, please contact a Patient Financial Advocate at (828) 771-3507.

National Health Services Corps
As a National Health Services Corps site, no one will be denied access to services at our office due to inability to pay.  In addition, we offer discounts based on family size and income to those who qualify.

Insurance Claims
Health Insurance is a contract between you and your insurance carrier. We will bill your primary, secondary, and tertiary insurance carrier as a courtesy to you.  It is your responsibility to provide MAHEC with current, accurate and complete insurance information.   Failure to provide complete insurance information may result in patient responsibility for the entire bill. Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility and benefits. If your insurance company is not contracted with us, you agree to pay any portion of the charges not covered by insurance, including but not limited to those charges above the usual and customary allowance. If we are out of network for your insurance company and your insurance pays you directly, you are responsible for payment and agree to forward the payment to us immediately.

Participating Insurance Companies 
Blue Cross/Blue Shield
Champ VA
United Healthcare
Medicare (including replacement policies)

Workers' Compensation and Automobile Accidents
Our Health Centers provide treatment for established patients for both work-related injuries and automobile accidents. You are responsible for providing MAHEC with the appropriate information from your employer in order for us to bill the workers comp carrier for your work-related injury.  We are unable to bill auto insurance carrier for automobile accident injuries.  We can bill your health insurance carrier or consider the visits related to automobile accident injuries as patient responsibility to be paid by you.  It is your responsibility to submit appropriate information to the responsible auto insurance carrier for reimbursement.

Missed Appointments
If you need to cancel an appointment, we ask for at least a 24-hour notice. This allows us to offer the appointment to another patient. If you fail to keep your appointments without letting us know in advance, you may be discharged from the practice so that we can provide care to other patients.

Returned Checks
The charge for a returned check is $25.00 payable by cash or money order. This will be applied to your account in addition to the insufficient funds amount. You may be placed on a cash only basis following any returned check.

Medical Record Copies
A nominal fee, as recommended by North Carolina State Statute, may be charged for copies of medical records. Please call (828)771-5406 at OB/GYN or (828)771-3410 at Family Medicine if you need this service.

The parent(s) or guardian(s) are responsible for full payment.

This financial policy helps the office provide quality care to our patients. If you have any questions or need clarification of any of the above policies, please contact our Patient Billing Department at (828) 257-4725.