West Orange Endocrinology, PA complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. West Orange Endocrinology, PA does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

West Orange Endocrinology, PA Provides free aids and services to people with disabilities to communicate effectively
with us, such as:
- Qualified sign language interpreters
- Written information in other formats (large print, audio, accessible electronic formats, other formats)
- Provides free language services to people whose primary language is not English, such as:
- Qualified interpreters
- Information written in other languages

If you need these services, contact [Name of Civil Rights Coordinator]

If you believe that West Orange Endocrinology, PA has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

West Orange Endocrinology, PA Administrator, Kathy Mandry, 510 Citrus Medical Court Ocoe, FL 34761, (407) 480-4836, Fax # (407) 480-4834, email kathy.mandry@woendo.com. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Kathy Mandry is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW,
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

I understand that me medical insurance is a contract between my insurance company and MYSELF. I am responsible for payment of services at time they are rendered by Victor L. Roberts M.D./Jose M. Mandry M.D. I authorize the release of any me dical information necessary to process the claim for payment of insurance benefits. I permit a copy of this authorization to be used in place of the original and request payment of medical insurance benefits either to myself or to the party who accepts assignment. I authorize my insurance company to pay medical benefits to Victor L. Roberts M.D./Jose M. Mandry M.D. For services rendered. Further, I authorize treatment of my condition.

1) The physicians and staff will do our best to address your concerns and needs and expect your cooperation to comply with all policies and procedures of this office.

2) WOE provides private patient portal to access to your health information and encourage use of your patient portal to check information about your progress and to retrieve labs, schedules and medical history. You may submit medical questions to the staff through the portal.

3) Your appointment with us is a mutual agreement. In the event that you miss an appointment without giving us at least 24 hours’ notice, you will be charged a No Show Fee of $50.00.

4) Repeated RESCHEDULING, CANCELATIONS or NO SHOWS of CONSECUTIVE APPOINTMENTS, may result in TERMINATION of our professional relationship. A notice will be sent to you to consult with another practitioner for your medication requests and continuity of care.

5) Please inform our staff if here is a change in contact, address, insurance, or primary care physician.

6) Our medical personnel specializes in endocrinology, diabetes, and other endocrine metabolic disorders. The physician, staff, and/or research clinicians and do not provide primary care services that a family doctor or internist provides. The only medical clearance we will perform are of an endocrine disorder, such as for diabetes or thyroid disease. Should you require the name of a primary care
physician, please contact your insurance company for a provider reference.

7) Your insurance contract is between you and your insurance company. We understand it may be difficult to know all the terms and benefits of your contract, and the staff at WOE will check on the copay and referral prior to your visit. If you are unsure of your benefits, you should contact your PCP or insurance prior to your visit. IF YOU REQUIRE A REFERRAL OR AUTHORIZATION TO SEE US, OUR STAFF WILL DO OUR BEST TO OBTAIN IT AND HAVE IT HERE FOR YOUR VISIT. IF YOUR PCP DOES NOT PROVIDE A REFERRAL OR AUTHORIZATION FOR OUR SERVICES, YOUR APPOINTMENT WILL BE RESCHEDULED UNTIL WE RECEIVE AN APPROVAL BY THE INSURANCE.

8) Please refrain from use of cell phones and other personal electronic devices while being examined by the physician or when being attended to by the staff of West Orange Endocrinology, P.A.

9) The provider will prescribe medications and/or devices to help control, manage or mitigate complications that arise from chronic diseases. Sometimes a prescription may require special forms or a prior authorization from our office. WOE will work to get these submitted, however oftentimes the insurance company will approve a different but similar prescription. Please consult your insurance
company or pharmacist to find out which prescription is on the insurance’s preferred formulary, and contact our office for the doctor to make an adjustment to the prescription. The provider must be in agreement that this brand of medication will be an appropriate option. Prior authorizations are at the discretion of the physician.

10) Dr. Mandry limits his practice to IN-HOUSE care and does not maintain hospital privileges. He will not be admitting or consulting during hospitalizations.

You are encouraged to verify that West Orange Endocrinology is a provider on your plan. Our practice is not on every insurance plan, and if WOE does not have a contract with your insurance, you may be seen with a fee for service, or perhaps as an out of network benefit.

If WOE does participate in a plan that requires a Primary Care Physician Referral or PreAuthorization, we will be unable to provide treatment or testing until authorization or referral is received. Not all services are a covered benefit of all insurance policies, and we recommend you understand any policy exclusions, as payment for non-covered services will be your responsibility.

MEDICARE - We accept assignment on all Medicare claims. We will also file Medicare Supplementclaims (except Medicaid). Patients covered by Medicare Part B must bring the Medicare card &Supplemental Policy card to the first visit. If you switch to a Medicare Advantage Plan, please inform us immediately.

MEDICAID - We DO NOT participate in most Medicaid or Medicaid Advantage plans.

HMO/PPO - Patients must bring the HMO/PPO card, their referral or authorization (if required), and be prepared to pay at time of service. For HMO patients, YOU are responsible for making sure your primary care physician has sent us the appropriate referral and YOU WILL BE RESPONSIBLE FOR ANY UNPAID BALANCES DUE TO LACK OF REFERRAL or AUTHORIZATION.

Private Insurances/Out of Network Insurances - We will file private insurance claims and out-of-network claims as a courtesy to our patients if we can verify benefits before time of service.

Payment for the Uninsured Portion (Deductible & Co-Insurance) is due at the time of service.

We will file PRIMARY INSURANCES ONLY. If you have multiple insurances YOU will be responsible for submitting necessary forms for reimbursement directly to you. We will only file secondary insurance if Medicare is primary.

Your insurance will send you an explanation of benefits that explains what they paid to our office. This is a record that you must keep on file.

If your insurance denies payment on your claim, you will be asked to pay for services rendered. We accept cash, credit cards, and debit cards as forms of payment. For any unpaid balances, please consult with our financial administrator to set up payments to avoid a collection fee

Patients that miss their appointments without notification at least twenty-four hours in advance of the appointment will be assessed a $50 no-show fee. Patients that show up for their appointment more than 15 minutes late may need to reschedule their appointment or have to wait until the clinician is available for their appointment. In the unlikely event that you have several consecutive no shows or
missed appointments, you may receive a letter of termination from the practice. Our staff will try to contact you regarding your noncompliance.

West Orange Endocrinology, P.A. is partnered with Share Care Health Data Services and they may be contacted at 866-967-0133 for complete medical records requests. Their record request fee are as per Florida Department of Health Statutes.

Our office charges a flat fee of $25 for the completion of any forms which require the physician to review your chart and fill out. Prepayment is required before the form will be completed. I agree to abide by the financial policy of West Orange Endocrinology, P.A.

Patients not covered by any insurance plans or covered by insurance policies that we are unable to bill directly should expect to pay for services billed at our standard rates. The following estimates are provided as a guideline and are not for contractual purposes:

New Patients should be prepared to pay up to $250 for the initial consultation.
Established Patients should be prepared to pay $85 - $100 for each follow-up visit.

Additional Services, such as diagnostic testing and labs, may be required during any visit. These additional services are not included in the estimates above and are rendered at an additional fee. West Orange Endocrinology, P.A. is independent of and does not have affiliations with third party vendors such as laboratory or other consultant firms.