S3.amazonaws.com



Patient Financial AgreementUpon checking in for all appointments at our reception desk you will:Present a valid photo ID.Present a valid insurance card(s) CopaymentWill have contacted your Primary Care Physician to enter a referral with your insurance company if needed.If you do not have these items your appointment will be rescheduled.REFERRALS/PRIOR AUTHORIZATIONSYour insurance plan may require a referral and/or prior authorization for services in order for your carrier to reimburse for these services. It is the patient’s responsibility to contact their insurance company to determine referral and/or prior authorization requirements before receiving services. If the visit requires a referral, you must obtain the referral from your primary care physician prior to your appointment. If prior authorization is needed for your treatment, notify our office prior to your appointment so our staff can work with you to obtain this. Please note that referrals and prior authorizations are not a guarantee of coverage.NON-COVERED SERVICES/DEDUCTIBLESPlease make sure that you read and understand the information provided to you by your insurance company including your membership handbook. Each insurance company offers multiple plans. You need to check with your insurance plan to find out the limits to your coverage and/or the deductibles attached to these services. It is your responsibility to know your membership benefits, eligibility, limitations and exclusions for your plan. Please note: If we bill your insurance and payment is denied for a valid reason, the payment remains your responsibility.RADIOLOGY/LABORATORYSome lab tests and radiology services are provided by a third party company. We want to make you aware that you may be billed separately for these services. If you have questions about these bills you can contact your insurance company. Some insurance plans require you to use specific laboratories or radiology facilities. Your insurance company can tell you these arrangements.PAYMENTWe accept cash, checks, MasterCard or Visa:Please make checks payable to Pioneer Valley Urology, P.C.If you pay for services with a check and it is returned a fee of $35.00 will be added to your account.Patients experiencing difficulty paying deductibles, outstanding balances, or other amounts due should contact the billing office at 413-241-3154Visit our Patient Portal for 24-7 access to our account statement and to make online payments.Pioneer Valley Urology is committed to providing you with the highest quality urology care. The above is an agreement between Pioneer Valley Urology and you, the patient/responsible party, to ensure payment for the services you receive. By executing this agreement, you are agreeing to pay for all services that are received as stated above.___________________________________________________Date___________________________________________________________________________________________________ Patient/Responsible Party Name (Print)Patient/Responsible Party Signature ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download