Pediatric Urology Associates, P.C.
Selwyn B. Levitt, M.D., F.A.A.P., F.A.C.S., William A. Brock, M.D., F.A.A.P., F.A.C.S., Edward F. Reda, M.D., F.A.A.P.,F.A.C.S.
Israel Franco, M.D., F.A.A.P., F.A.C.S., Steven C. Friedman, M.D., F.A.A.P.,F.A.C.S., Lane S. Palmer, M.D., F.A.A.P.,F.A.C.S.
Jordan Gitlin, M.D., Jaime Freyle, M.D, Bhagwant Gill, M.D., Emily Cupelli, M.A., C.P.N.P., Therese Collett, M.S.,
Sylvia Toro, M.S., C.F.N.P., Joan Volpe, M.S.N., C.P.N.P., Kathryn Weinlein, M.A., F.N.P.C.
OUR FINANCIAL POLICY
Pediatric Urology Associates is committed to providing you with the best possible care and we are pleased to discuss our professional fees with you at any time. Your clear understanding of our Financial Policy is important to our professional relationship. Please ask if you have any questions about our fees or your financial responsibility.
Patients must complete all Information Forms prior to seeing the physician. A copy of your insurance card(s) will be made for your file
Co-Payments – By law, we must collect your carrier designated copay at the time of service. Please be prepared to pay that copay at each visit
Non-Copay Plans – If your plan does not require a copay and we participate, we will accept the designated fee. You are responsible for any deductible and balance your plan indicates on their explanation of benefits
Referrals – If your plan requires a referral from your primary care physician it is YOUR responsibility to obtain it prior to and have it with you at the time of your visit. If you do not have a valid referral with you or on file, you will be required to RESCHEDULE YOUR APPOINTMENT
Self Pay – Payment is expected at the time of service unless other financial arrangements have been made prior to your visit
Usual and Customary – Is a term developed by the insurance carrier industry to reflect “average charges” from specific physicians in designated geographic localities. The usual and customary amount noted on the explanation of benefits does not accurately reflect individual charges. Therefore, the usual and customary charges does NOT supercede our fees
Account Balances – You are responsible for timely payment of your account. Pediatric Urology Associates reserves the right to reschedule or deny a future appointment on delinquent accounts
WE ACCEPT CASH, CHECKS, MASTERCARD AND VISA
THANK YOU for taking the time to review our policies. Please feel free to ask questions or share with us any specific concerns.
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(Responsible Party Signature) (Date)