UGNM Financial Responsibility Information and Agreement
The doctor's service is provided directly to you and you are responsible for payment of these services. We do not provide service on the assumption that charges will be paid by your insurance company. If we are not participating providers with your insurance company, we require that payment be made at the time services are rendered. As a courtesy to our patients, we will submit a claim to your insurance company for you. However charges remain your responsibility.
Co-payments and deductibles that have not been satisfied are required at the time services are rendered.
If referrals are required by your insurance plan, it is your responsibility to obtain a proper referral from your primary care physician. If you do not secure a proper referral for the services provided, charges may be your responsibility.
In the last year and particularly since the start of the Affordable Care Act (Obamacare) many insurance companies have separated out the co-pay for the office visit from any other services, procedures or ultrasounds. In this case, charges for anything other than the office visit itself will go toward the deductible and are due at the time of service if your deductible has not been met. Most policies have much higher deductibles than they have in the past. Know how your policy works so you don’t have any surprises.
If a surgical procedure is performed, our office needs to collect any co-pays or deductibles prior to your procedure. We will bill your insurance company directly and withhold any further action for forty-five days. We strongly encourage you to get involved with the insurance company’s payment process.
Informing our patients about our financial policy assists us in providing the best services to our patients. Thank you for taking the time to read this policy statement. Should you have further questions or comments; please contact our billing staff or manager.
WE ARE HERE TO HELP YOU!
I understand and agree to comply with this financial policy:
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Signature Date
Assignment of Insurance Benefits
I hereby authorize direct payment to the Urology Group of New Mexico of any insurance benefits otherwise payable to me or on my behalf for services performed by any Urology Group provider. I understand that my insurance is billed as a courtesy and I am financially responsible for all charges not covered by this assignment of benefits.
Authorization for Release of Information
I authorize Urology Group of New Mexico to release medical information concerning my care and treatments to my primary care provider or to the third party payers for the purpose of processing claim payment.
Collection Agency Accounts
In the event that this account is placed with a collection agency, I agree to be responsible for the collection fees, reasonable attorney's fees and court costs.
No Show Policy
I understand that if I do not give a 48 hour notice to reschedule/cancel it will result in a $50.00 fee. I understand if I do not keep two (2) consecutive appointments without calling to cancel or reschedule I will be terminated from the practice. Upon request, my medical records will be transferred to another provider with a possible fee.
My signature acknowledges the understanding and acceptance of all of the above policy statements.
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Patient or Guardian Signature Date
HIPAA ACKNOWLEDGEMENT
I acknowledge that I have been given an opportunity to review and/or have received a copy of the notice of privacy practices as required by HIPAA, that I may contact the office for questions or complaints regarding these privacy rights, and the practice will offer updates for any amendments or changes.
I also authorize my physician and his/her staff to communicate information regarding appointments, medical result, and billing issues to:
Print Name______Relationship______
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Date
Patient or Guardian Signature
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Date Witness
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Date