Vasectomy

PLEASE READ THE FOLLOWING INFORMATION PRIOR TO SUBMITTING THE FORM

Please complete the below form in its entirety, and confirm all information is accurate and up to date. We are unable to process incomplete requests. Once we have reviewed your information, you will be contacted via phone with the estimated cost for the consultation, procedure, and surgeon’s fees.

We are currently in network with Aetna, Humana & Tricare, if you have any of these plans, we will give you an estimate on IN NETWORK benefits.

If the insurance being filed for the procedure is OUT OF NETWORK with the Surgery Center, we will give you an estimated cost with the OUT OF NETWORK benefits available.

If you do not want information on OUT OF NETWORK BENEFITS, please do not complete the form.
If no insurance is being filed, please complete the form for a self-pay estimate.

RESPONSE TIME: 7-14 days

PLEASE NOTE: This is an elective procedure with no guarantee of payment until the claim has been submitted to your insurance company. All payments are expected in full on the date of the scheduled consultation and procedure

Once the form is completed it will be sent to the appropriate department for review. If you have any questions regarding the completion of the estimate, please email WMSUroVas@woodlandsmed.com.

If you have any questions regarding insurance benefits for in-network or out-of-network, we encourage you to contact your insurance for further explanation of your policy.

NORTH DAVIS