YOU MUST PROVIDE YOUR INSURANCE CARD AND PICTURE IDENTIFICATION TO THE RECEPTIONIST FOR PHOTOCOPYING AT EACH APPOINTMENT. IN THE EVENT THAT NO INSURANCE IS AVAILABLE, OR IT HAS BEEN DETERMINED THAT THE PATIENT IS INELIGIBLE FOR COVERAGE OF SERVICES, THIS ACCOUNT WILL BE DETERMINED TO BE SELF-PAY AND PAYMENT IN FULL IS DUE AT THE TIME OF EACH SERVICE.
I hereby authorize Children's Urology of Virginia to release medical information to my physicians and/or insurance company(ies). I further authorize direct payment from my Insurance Company(ies) to Children's Urology of Virginia.
I understand that I am responsible for obtaining all necessary referrals prior to the scheduled appointment. All co-payments required by my Insurance Plan will be paid at the time of service. I further acknowledge that all deductibles, co-insurance and non-covered items as determined by my insurance plan will be due and payable upon notice either sent by US Mail in the form of a statement and/or telephone communication from Children's Urology of Virginia.
After the first missed appointment without 24-hour notice given to Children's Urology of Virginia, I will be responsible for a $50.00 No Show fee.
If an appointment for surgery is missed without 24-hour notice given to Children's Urology of Virginia, I will be responsible for a $100.00 No Show fee. If the child is unable to undergo the surgery due to illness, this fee will be waived.
All returned checks shall be assessed a $40.00 bank processing fee for which I will be responsible.
I further agree that if this account is not paid when due I will be responsible for a collection expense of 35% of the balance, plus any court costs incurred by Children's Urology of Virginia, in addition to interest accrued after the initial 90 days of debt at 1.5% monthly.
You will be required to sign this agreement on the day of your first appointment. To help expedite the registration process, you can print & sign this document and bring with you on the day you come into the office.