Paragard, Mirena, Kyleena & Nexplanon Coverage …

1 TAX ID 54-1850988 paragard , Mirena, Kyleena & Nexplanon Coverage worksheet **Please bring this completed form with you to your appointment for insertion** Please contact your insurance company and verify that the device you would like to have is a covered medical benefit with your insurance. Procedure codes for the device and insertion are as follows: Name Procedure Code Charge Insert of IUD 58300 $175 paragard IUD J7300 $1200 Mirena IUD J7298 $1200 Insert of Nexplanon 11981 $200 Nexplanon Implant J7307.

2 $1200 Kyleena J7296 $1200 Not all patients require ultrasound guidance for IUD s. However, it is best to check your benefits for the device, insertion and the following sonogram codes: transabdominal, transvaginal and ultrasound guidance. Transabdominal 76856 $220 Transvaginal Ultrasound 76830 $220 Ultrasound Guidance 76942 $225 Date: _____ Person you spoke with: _____ Insertion covered at what percentage of contracted rate? _____ IUD/ Nexplanon covered as a Medical Benefit @what percentage?

3 _____ Do I have a copay with the visit? _____ I understand, I am responsible for any payment denied or not covered by my insurance company if, I elect to proceed with the ordering and insertion of the device. Name: _____ Date of Birth: _____ Signature _____ Date: _____ Revised 2/5/18