Financial Policy and Billing Consent

This consent is required by the Health Insurance Portability and Accountability Act of 1996 and HIPAA Omnibus Final Rule 2013, to inform you of your rights for privacy with respect to your health care information.

Consent Related to Privacy Notice

I have had a chance to review the Practice Privacy Notice as part of this registration process. I understand that the terms of the Privacy Notice may change and I may obtain these revised notices by contacting the practice by phone or in writing. I understand I have the right to request how my protected health information (PHI) has been disclosed. I also have the right to restrict how this information is disclosed, but this practice is not required to agree to my restrictions. If it does agree to my restrictions on PHI use, it is bound by that agreement.

Consent for Care

I, ______________________ (Patient Name), with my signature, authorize Advanced Urology Institute and any employee working under the direction of the physician, to provide medical care for me, or to this patient for which I am the legal guardian. This medical care may include services and supplies related to my health (or the identified person) and may include (but not limited to) preventive, diagnostic, therapeutic, rehabilitative, maintenance, palliative care, counseling, assessment, or review of physical or mental status/function of the body and the sale or dispensing of drugs, devices, equipment, or other items required and in accordance with a prescription. This consent includes contact and discussion with other health care professionals for care and treatment.

Consent for Release of Information and Assignment of Benefits

I also authorize this practice to furnish information to the identified insurance carrier(s) for any and all payment activities. I consent to assign all payments for services directly to this practice. I further consent to the use for any practice operational needs as identified in the Practice Privacy Notice.

Financial Policy

We appreciate you choosing us for your healthcare. We will adhere to the following financial policy in order to consistently deliver high-quality care and services. The patient/responsible party assumes responsibility to ensure that the financial obligation is fulfilled for the health care services received.

  • I understand that I am responsible for all co-payments, amounts applied to deductibles, and other amounts that may be deemed my responsibility by the payment sources, as required by my contract with my insurance plan and state regulations.
  • I understand that if I have an insurance co-payment, and/or deductible, I am expected to make payment when checking in for my appointment.
  • I understand that my contract with my insurance entity may or may not cover some services. All insurance policies are not the same. They vary by employer group. Advanced Urology Institute is not responsible or able to know every policy available. It is my responsibility to verify applicable coverage prior to receiving the services. For example, not all health plans include screenings as a benefit. If I seek care outside of the contract terms, I am aware that I may be responsible for all charges that are incurred.

PAYMENT IS DUE AT THE TIME SERVICES ARE RENDERED. We accept cash, personal checks, MasterCard, Visa, Discover, and American Express as payment for office services deductibles, copays, and co-insurance.

PRIVATE INSURANCE COMPANIES THAT WE “ARE NOT” A PROVIDER WITH: You will be responsible for payment in full at the time of service and our office will file the claim form as a courtesy with your insurance company.

Self-Pay

For our patients who do not have insurance coverage, we will require a $175 deposit each visit that will go towards your date of service. The patient is solely responsible for all charges from the date of service rendered.

Our billing office is available to discuss your account and set up payment options after all charges have been processed.

Surgical Services

Payment of co-pays, deductibles, and co-insurances will be collected prior to surgery. If requested, a written estimate of charges will be given to you along with the patient’s estimated balance owed after insurance has paid. We will file with third payers for the assigned insurance balance only.

Hospital Services

Payment of co-pays, deductibles, and co-insurances will be collected before hospitalization. If requested, a written estimate of charges will be given to you along with the patient’s estimated balance owed after insurance has paid. We will file with third payers for the assigned insurance balance only.

Non-Payment Accounts

Any insurance balance will be billed to the insurance carrier. If the insurance carrier does not pay, you will be responsible for the payment. Any balances with no payment activity will be forwarded to a collection agency.

Missed Appointment

We ask for you to give 48-hours’ notice to cancel an appointment. Patients who do not call to cancel an appointment may be charged $50.00. A third no-show may result in the patient being discharged from the practice.

Forms and Records

For completion of disability and cancer policy forms, there will be a $10.00 charge for a one-sided form and a $15.00 charge for a two-sided form. Medical records requested may have a charge. If there is a charge, you will be notified in advance. Records will be released only after payment has been received.

Financial Agreement

We will gladly discuss your proposed treatment and do our best to answer any questions relating to your insurance. You must realize, however, that:

  • Your insurance is a contract between you and the insurance company. We are not a party to that contract.
  • Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover (such as elective sterilization, infertility evaluation screening lab test, etc.).

We must emphasize that as your medical care providers, our relationship and concern is with you and your health, not your insurance company.

ALL CHARGES ARE YOUR RESPONSIBILITY FROM THE DATE SERVICES ARE RENDERED. On any balance on your account over 90 days, including those that your insurance has not paid, collection action will be taken.

We realize that emergencies do arise and may affect timely payment of your account. If such extreme cases occur, please contact our billing department at (727) 441-1509.

If you have any questions about the above information or any uncertainty regarding insurance coverage, please do not hesitate to ask us. We are here to help you.

Thank you for your understanding and cooperation with this policy. It is our privilege to provide your medical care.