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Privacy Notice/Financial Policy/Signature on File

Clear understanding of our Privacy Notice/Financial Policy/Signature on File is important to our professional relationship. Please ask if you have any questions about our fees or your financial responsibility.
CLICK HERE TO DOWNLOAD A PRINTABLE PDF VERSION OF THIS NOTICE 

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT OUR PATIENT MAY BE USED AND DISCLOSED. PLEASE REVIEW THIS DOCUMENT CAREFULLY.

WHO WILL FOLLOW THIS NOTICE

This notice describes how we may use and disclose our patient’s protected health information to carry out treatment, payment and health care operations and for other purposed that are permitted or required by law. It also describes the right to access and control our patient’s protected health information and to give the patient this notice stating our legal duties and privacy practices with respect to protected health information.

We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our notice at any time. A revised notice will be effective for all protected health information that we maintain.  A revised Notice of Privacy Practices will be made available to the patient by either contacting our office and requesting that one be sent in the mail or asking for one at the time of the patient’s next appointment.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION
ABOUT OUR PATIENT

For Treatment: We may use and disclose protected health information to provide, coordinate or manage medical treatment and related services. We may disclose health information to doctors, nurses, technicians, office staff or other personnel who are involved in taking care of our patient and his/her health.

For example, different personnel in our office may share information about our patient and disclose information to people who do not work in our office in order to coordinate care, such as phoning or electronically submitting prescriptions to the pharmacy; scheduling and authorizing outside diagnostic testing.

For Payment: We may use and disclose health information so that the treatment and services received at this office or hospital may be billed and paid. 

For example, we may need to give our patient’s insurance carrier information about a service so that the insurance carrier will pay us or reimburse you for the service. We may also tell the insurance carrier about upcoming treatment that may require prior approval and to determine whether the plan will cover the treatment.

Appointment Reminders: We may use health information to generate an appointment reminder that will be sent to the patient by telephone, email, text message or other means in order to inform our patient of the date, time and location of the next appointment.

Required by Law: We will disclose health information when required to do so by federal, state or local law.

COMPLAINTS

If you believe our patient’s privacy rights have been violated, you may file a complaint with the Secretary of Department of Health and Human Services. To file a complaint with our office, you may address it to “Privacy Officer, Pediatric Urology Associates, 247 Route 100, Suite 1002, Somers, NY 10589”.  We will not retaliate for filing a complaint. 

FINANCIAL POLICY

We are committed to providing our patient the best possible care and are pleased to discuss our professional fees at any time. Clear understanding of our financial policy is important to our professional relationship. Please ask if there are any questions about our fees, financial policy or your financial responsibility.

ALL patients must have a current and completed information form on file. We will always request a copy of the current insurance card to be scanned into the patient's account.

Referrals:  If the member's plan requires a referral from the primary care or referring physician, it is YOUR responsibility to obtain it prior to the appointment and have it available at the time of the visit.  If a valid referral is not available at the time of service, a SIGNED WAIVER form will be required and payment in full will be expected, at the time of service

If a valid referral is provided to us within 24 hours, we will submit a claim for services rendered. If a valid referral is not provided after the time of service, NO refund will be due back.

Copayments:  Contractually, we are required to collect a copayment as designated by the member's insurance plan. This payment is expected at the time of service. Please be prepared to pay your copayment at each visit. We will allow one visit in which a copayment is not paid. Thereafter, we will reschedule the patient. If a copayment is not collected, payment is expected within 10 business days following the date of service.

Deductibles/Coinsurance: You will be responsible for any balance the member's plan designates and stated on the member's explanation of benefits.
In the case of surgery, if your plan requires a deductible, it must be paid prior to the surgery date.

Contractual adjustment of charges will be made to the account as designated by the insurance carrier. Payment for deductibles and coinsurance will be the member's responsibility with no exception. 

If we do not "participate" with your plan, payment in full will be expected at the time of service, unless financial arrangements have been made prior to the visit. If an unanticipated diagnostic testing/in office procedure is performed during the visit, we will allow 45 days for payment of the diagnostic testing/in office procedure only. A courtesy claim will be sent to the insurance carrier on behalf of the patient. 

Termination of Insurance Coverage: If the patient's coverage is 'retro-terminated', payment of all balance(s) due will be expected within a reasonable time. 

Divorced/Separated Parents of Minor Patients: The parent who consents to the treatment of a minor child is responsible for payment of services rendered. Pediatric Urology Associates will NOT be involved with separation or divorce disputes.

** Timely payment is expected from the responsible party. Pediatric Urology Associates reserves the right to reschedule or deny a future appointment on delinquent accounts. Should it be necessary for Pediatric Urology Associates to use an outside agency to collect payment, any additional costs incurred will be added to the balance due.**

Notification of In-Network Surgical Benefits:  As a medical specialty practice, our physicians may perform diagnostic, and in some cases, minor surgical procedures in the office when necessary to provide the patient a thorough evaluation of the presenting complaint. Some insurers offer health benefit plans that apply the cost of these procedures to in-network surgical deductibles and/or coinsurance. Although a procedure is diagnostic by definition, some insurers may consider it "surgical" because of its coding classification by the American Medical Association.

Pediatric Urology Associates will pre-authorize all diagnostic testing and in-office procedures; however, there is always a chance that financial responsibility for these services will not be known prior to the claim being processed. We encourage the member to contact the insurer should there be any concern about financial responsibility prior to the visit. Should there be an unanticipated service rendered, we encourage you to question to the provider prior to consent. We will allow time at the visit for the carrier to be contacted by the member.  


SIGNATURE ON FILE

By signing this statement, the responsible party is authorizing Pediatric Urology Associates to complete any necessary insurance claim forms on behalf of the patient. You are hereby authorizing the release of any medical/other information which may be needed in order to process said claim(s).

Your signature will be kept on file and shall be referred to when insurance claim forms are submitted.

I further acknowledge that in the event my account remains past due and is referred to outside collection, such as a collection agency or law firm, I agree, to pay 9% per annum from the date of the last charge or payment on account in addition to the past due balance, and to pay costs and fees for such collection enforcement including 45% collection enforcement fee, in addition to the past due balance due and owing.

NAME OF PATIENT: ____________________________
NAME OF LEGAL GUARDIAN: ____________________________
SIGNATURE: ____________________________
PRINT NAME: ____________________________
DATE: ____________________________

I understand and agree to the above terms. I further acknowledge that in the event my account remains past due and is referred to a collection agency/law firm due to termination of coverage or additional financial responsibility deemed by my carrier, I agree to authorize said entities to communicate with my insurance company regarding my past due account and further authorize said entities to obtain and review my credit report.

WE ACCEPT CASH, CHECKS, MASTERCARD, VISA, DISCOVER AND AMERICAN EXPRESS

(Guardian/Responsible Party Signature): ____________________________
DATE: ____________________________




CLICK HERE TO DOWNLOAD A PRINTABLE PDF VERSION OF THIS NOTICE