OFFICE AND FINANCIAL POLICIES

 

Thank you for choosing our practice. This agreement is provided to you to clarify our payment policies. Please read it, ask us any questions you may have, and sign in the space provided. A copy will be provided to you.

Insurance: Please bring your insurance with you at the time of your appointment.

We are members of most, but not all, plans. You are responsible for verifying that we are providers for your plan . With insurance plans where we have agreed to participate in the network as a provider, your carrier requires that all co-pays be paid prior to any services being rendered. The co-pay requirement cannot be waived by our practice, as it is a requirement placed on you by your insurance carrier. If you do not have your co-pay at the time of your visit, you must provide us with a written waiver from your insurance carrier specifically authorizing Urological Specialists to waive this requirement.

You are responsible for any co-insurance, deductibles, or non-covered services not paid by your insurance with the state’s required time limitation for paying health care claims. You will receive a statement from our office/billing service indicating what your insurance has paid. Any balance remaining is due upon receipt.

Claims submission: We will submit your claims for you to your insurance company and we will, within reason, attempt to help you get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request.

Coverage changes: Insurance companies have very strict requirements with regard to filing deadlines for reimbursement of claims. Please notify us immediately of any insurance changes. If your insurance company does not pay your claim in 90 days, the balance will automatically be billed to you.

Medicare: We accept Medicare assignment. As a Medicare patient, you are responsible only for the difference between the approved charge and the amount Medicare pays and, of course, your deductible. If you have supplemental insurance, we will bill it directly for you.

HMO or POS: Regarding insurance plans where we participate as a provider, your insurance carrier requires that you obtain a referral from your Primary Care Physician (PCP) before receiving services from another provider, please bring that referral with you. It is your responsibility to know your insurance requirements. Any services received without a referral or proper authorization will be your responsibility.

 

No Insurance/Self Pay: Payment will be due at the time of service. If you are unable to pay your balance in full, you will need to make prior arrangements with our office.

Workers’ Compensation: If your injury is due to an accident in your work place,

please be sure to contact your employer and inform them of your injury. We will need to receive required information from your employer before we can process any of your medical claims. Failure to properly report this injury to your employer may result in your claims being denied. Denied claims may become your financial responsibility.

Payment: We accept cash, check, Mastercard/Visa and Discover.

All billing questions should be directed to K.L.O. Professional Billing: 630-789-2550.

Disability or insurance forms: There will be a charge of $15.00 - $35.00 for the completion of medical forms. Charges are based on the number of pages and complexity of information requested. Payment is due at the time that you pick up the forms. Please allow 7-10 for the completion of these forms. If you would like the forms mailed to you or the insurance, payment will be due prior to mailing.

Canceled appointments: WE REQUIRE AT LEAST A 24 HOUR CANCELLATION NOTICE. THIS WILL ALLOW US TO PROVIDE THAT TIME SLOT TO ANOTHER PATIENT. THERE IS A PENALTY FEE OF $25.00 IF YOU FAIL TO CANCEL AN APPOINTMENT AND A $100.00 PENALTY FEE IF YOU FAIL TO CANCEL AN OFFICE PROCEDURE (cystoscopy, prostate biopsy, etc.).

 

Medical records: We will provide you a copy of your medical records upon request. You will need to sign a letter of release. Please allow 7-10 days for us to copy your records. If you wish for your records to be mailed, there may be an additional fee to cover the mailing costs. You may be charged for additional copies of your medical records, rates charged within Illinois state statues.

Return checks: A $30.00 charge will be added to your account for any check returned by your bank for any reason.

711 W. North Ave., Suite #212 • Chicago, IL 60610

phone: (312) 867-7430 • fax: (312) 867-7431

www.chicago-urology.com