In order to ensure prompt care, please read the following prior to your visit:
Please bring your insurance cards and a photo ID to each visit.
This notice describes how medical information about you may by used and disclosed and how you can get access to this information. Please review it carefully.
MANAGED CARE (HMO/PPO/POS)
Before your appointment, you may check with our billing department to determine if we are "in-network" for your insurance. Due to the uniqueness of our specialty, many physicians refer patients to us "out-of network." The fact that you have been referred here does not necessarily mean that we are in your network.
It is your responsibility to obtain any referrals or authorization required by your Insurance Plan for each visit. If you do not have this information at the time of your appointment, you will have the choice to reschedule or to personally assume the responsibility for all charges. Our office will automatically obtain all hospital surgical authorizations.
We are legally required to collect your copay at each visit prior to providing care in non-emergency situations. For your convenience, we can accept cash, check or credit card.
BILLING YOUR INSURANCE
If your insurance carrier is one with which we have a participating contract, then we will collect your copay at the time of the visit. We will then bill you for any amount remaining after the insurance has been paid.
If your insurance carrier is not one with which we have a participating contract, even if it is an HMO and you have a referral or authorization, then payment for the office visit/consultation portion of any appointment is due at the time of service. After your payment, we will send an insurance claim to your carrier so they can reimburse you for any amount due.
USUAL & CUSTOMARY RATES
You have chosen to be evaluated & treated by top quality, highly specialized physicians. Please understand that usual & customary rates are arbitrarily set by insurance companies in an attempt to withhold payment from physicians. We are unable to honor requests to accept "usual & customary" rates as payment in full.
Please keep us informed of any changes in your insurance.
METHOD OF PAYMENT
Our office accepts cash, check, money orders, and credit card payments. If you are not able to pay your portion in one payment, you must arrange for a payment plan with our billing service.
If you do not have insurance, please contact our office prior to your visit to make payment arrangements.
If your account is turned over to a collection agency, you will be charged the principle amount plus 33.33 % of the unpaid balance as collection fees. In addition, you will be assessed reasonable attorney fees and any cost arising out of any litigation concerning the collection of this account.
Completion of forms, such as FMLA (Family Medical Leave Act) or writing letters of medical necessity are very time consuming and are not a service covered by your insurance plan. There is a $25 basic charge for any letter or form of 1-3 pages and $10 per page after the 3rd page. Revisions to a prepared letter will carry a $15 fee.
There will be a $25 charge for each missed physician or physical therapy appointment payable prior to your next appointment. This fee is not covered by insurance carriers.
Due to the intimate nature of questions and the exam required to assess bladder & pelvic floor problems, the presence of children will prevent our ability to properly care for you. Please make childcare arrangements prior to your visit.