Urology Center of Columbus, LLC. welcomes you to our practice. We work hard to provide the highest quality care to you. Your clear understanding of our Financial Policy is important to our professional relationship. Please remember that our contract for service is with you, and it is our policy that you are responsible for our fees regardless of insurance coverage.
FEES DUE AT TIME OF SERVICE:
- Co-Pay, Co-Insurance, Deductible and Non-Covered Services
- Self Pay
- Medical Records, Special Forms and Letters (that fall outside of the normal course of insurance claims): Urology Center of Columbus’ Notice of Privacy Practice describes how medical information about you may be used and disclosed and how you may access this information. Medical records will not be released without a written authorization. For continuity of care, your records may be released to another physician’s office or healthcare facility or in the event of an emergency. To request and receive a copy of your medical records, Urology Center of Columbus will charge to cover the photocopying and administrative costs. A schedule of fees is available upon request.
- Late Fee: A late fee of $30.00 is applied to any account for nonpayment of the balance due.
- Returned Checks or Declined Postdated credit card transactions: There is a fee of $35.00 for any checks returned by the bank or declined postdated credit card transaction.
- “No Show” Appointment Fee: We reserve the right to charge a missed appointment fee to patients who do not show for a scheduled surgery or office appointment. We require this fee to be paid before your next appointment.
- Finance Charge: A finance charge of one and a half percent (1 ½%) will be imposed on each item of your account which is overdue and has not been paid within thirty (30) days.
Insurance Plans: It is ultimately your responsibility to know the details of coverage and network status of providers for your particular insurance plan. However, as a courtesy, we will file all “In or Out of Network” insurance claims to the appropriate carrier. If your insurance company requires a referral, you are responsible for obtaining it.
Contracted Insurance: (In Network): If we are contracted with your insurance company, we will submit claims for services provided. In order for us to file your claim you must furnish us with all pertinent information along with your insurance card(s). It is the insurance company that makes the final determination. If we are unable to verify your insurance information you will be responsible for the charges at the time of service.
Non-Contracted Insurance: (Out of Network): Patients who have insurance plans that do not have an existing contract with Urology Center of Columbus, LLC are expected to pay in full at time of service.
Workers’ Compensation: We require written approval / authorization by your employer and / or workers’ compensation carrier prior to your initial visit. If your claim is denied, you will be responsible for payment in full.
Account Statements: Statements are mailed out monthly to patients who have a balance due on their accounts. Payment of this balance is expected on receipt of the statement. Any payment plans must be arranged with our billing department. Accounts overdue by more than 90 days may be referred to a collection agency. We also have the right to report your account status to any credit reporting agency such as a credit bureau. By signing this Financial Policy you give us permission to check your credit, employment history and answer questions about your credit experience with us.
Authorized Signature: I authorize the release of any medical or other information necessary to process claims. I also request payment of
government benefits either to myself or the party who accepts assignment. I authorize payment of medical benefits to the undersigned physician or supplier for all services.