We are committed to providing you with the best possible care and are pleased to discuss our professional fees with you at any time. Your clear understanding of our Financial Agreement is important to our professional relationship. Please ask if you have any questions about our fees, financial policy or your financial responsibility.
Patients must fill out patient information forms prior to seeing the doctor. We will request to photocopy your insurance card (s) for your file.
- CO-PAYMENTS – by law, we MUST collect your carrier designated co-pay. This payment is expected at the time of service. Please be prepared to pay the co-pay at each visit.
- OUT OF NETWORK PLANS – Since we do not participate with your plan, payment will be expected at the time of service, unless prior arrangements have been made. This includes co-insurance, deductible and non-covered amounts. We will send a courtesy bill to the carrier on your behalf.
Private Insurance Authorization for Assignment of Benefits/Information Release: I, the undersigned, authorize payment of medical benefits to
OKC Kids Urology, PLLC for any services furnished. I understand that I am financially responsible for any amount not covered by my contract. I also authorize any medical information about me to be released to my insurance company (for their agent) including information concerning health care, advice, treatment or supplies provided to me. This information will be used for the purpose of evaluating and administering claims of benefits.
- SELF PAY PATIENTS – Payment is expected at the time of service unless other financial agreements have been made prior to your visit.
- RETURNED CHECKS – I understand there will be a $25.00 fee for returned checks.
- CANCELLED APPOINTMENTS – I agree and accept the Clinic’s right to charge a $35.00 fee for appointments canceled with less than 24-hour notice or if the patient fails to show up for the scheduled appointment.
- MEDICARE – We will submit claims to Medicare. The patient will be responsible for the deductible and the 20% co-insurance, which can be billed to a secondary insurance if you have one.
Medicare Lifetime Signature on File: I request that payment of authorized Medicare benefits be made on my behalf to OKC Kids Urology, PLLC for any services furnished to me. I authorize any holder of medical information about me to CMS (and it’s agents) to determine these benefits payable for related services. This information will be used for the purpose of evaluating and administering claims of benefits.
- DIVORCED/SEPARATED PARENTS OF MINOR PATIENTS – the guarantor is responsible for payment of services rendered. OKC Kids Urology PLLC cannot be involved with separation or divorce disputes. You are responsible for the timely payment of your account. Our financial staff will work closely with you and your carrier to avoid sending any account to an outside agency to collect payment. We reserve the right to send delinquent accounts to an outside collection agency.
We accept cash, check, Mastercard, Visa. Thank you for taking the time to review our policies. Please feel free to ask questions or share any special concerns with us.
