Patient Registration Form

Insurance Information

By Law, All Insurance Information Must Be Disclosed

Are you currently on Medicare?*

Yes
No

Confirming your medicare status will help us determine your coordination of benefits and prevent payer conflicts. As Medicare providers we are required to submit all claims to Medicare as well as private insurance.

Are you currently on disability?

Yes
No

Dissability benefits may affect the way Medicare and/or your Private insurance process your claims. If your answer is YES kindly provide your Dissability insurance information at the office along with starting date.

Do you have insurance coverage?*

Yes, I have insurance coverage.
No, I am a self paying or uninsured patient and will pay at the time of service.

Primary Insurance Name*

Member ID Number*

Group Number

Policyholder Name

First Last

Relationship to Policyholder

Policyholder Date of Birth

Do you have a secondary insurance?*

Yes, I have a secondary insurance.
No, I do not have a secondary insurance.

Secondary Insurance Name*

Member ID Number (secondary insurance)*

Group Number (secondary insurance)

Policyholder Name (secondary insurance)

First Last

Relationship to Policyholder (secondary insurance)

Policyholder Date of Birth (secondary insurance)

Financial Policy

The following is a statement of our financial policy that we ask you to read and sign prior to any treatment.

ALL FORMS MUST BE COMPLETED AND SIGNED BEFORE SEEING A DOCTOR.

MEDICAID: I understand that the practice is not part of the Medicaid program. As such I agree to pay for all fees incurred in my medical care provided by NEW YORK UROLOGICAL ASSOCIATES, PC or any of their doctors.

PRIVATE INSURANCE: Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. Therefore, YOU ARE RESPONSIBLE FOR FULL PAYMENT AT THE TIME OF VISIT.

PARTICIPATING INSURANCE: All co‐payments and deductibles are payable at the time of visit. Your signature below authorizes payments to us for our services. You are responsible for obtaining a referral number. If you do not, you are required to pay at the time of visit as an “out of network.” If your insurance does not cover a special procedure and you would like it performed anyway, you are required to sign an acknowledgement and pay at the time of service. This waives your right to submit it to your carrier for denial.

MEDICARE INSURANCE

We accept assignment. We will electronically submit your claim. Medicare will mail an Explanation of Benefits to you. You can then submit this to your co‐insurance.

I request that payment of authorized Medicare benefits be made to me or on my behalf to NEW YORK UROLOGICAL ASSOCIATES PC for services furnished to me. I authorized any holder of medical information about me to be released to the healthcare financing administration agents any benefits for related services.

****MEDICARE BENEFICIARY NOTICE****

Medicare will only pay for services that it determines to be “reasonable and necessary” under 1872(a) (1) of Medicare law. I have been notified on the date indicated that Medicare is likely to deny payment for test/treatment if I exceeded the prescribed frequency for either the prescribed test/treatment. I agree to be personally responsible for payment if Medicare denies payment.

****RELEASE OF INFORMATION****

I hereby authorize NY UROLOGICAL to release to insurance carriers or others who are, or may be financially responsible for my medical care, all information needed to substantiate payment for my medical care. I have read the above and agree to this policy as stated.

****CREDIT CARD/DEBIT CARD ON FILE****

To make collecting CO-INSURANCE and DEDUCTIBLES after your claims have been processed more efficient we ask for a valid Credit Card to be on file. A Credit Card form will be furnished at the office.

****COMMON FEES****

Please note: We make every effort to accommodate our patients and arrange for your visit and or procedure requirements in advance. We also make every effort to collect balances for your services in a timely fashion. • A $50.00 Fee will be invoiced to all Late Appointment Cancellations/NO SHOWS. All appointment CANCELLATION must be made with at least business 24 hours prior notice.
• A $200.00 Fee will be invoiced to all late Surgery Cancellations. All surgery CANCELLATIONS must be made with at least 72 business hours prior notice.
• A $5.00 Late Payment Fee will be added to all accounts with balance older than 60 days from the first invoice. This fee will be added every month the account is unpaid.
• A $10.00 processing fee plus 75 cents per page will be charged for ALL Copy of Records not related to referrals. Records will be furnished by fax (if fewer than 30 pages), by mail or pick-upon CD as a PDF document.

Please Sign and Check Box Below*

Financial Policy Acknowledgement*

YES, I hereby acknowledge and agree to the terms of New York Urological Associates PC's financial policy .

Name

This field is for validation purposes and should be left unchanged.

Step 1 of 3

Patient Information

Medical Information

Insurance Information

By Law, All Insurance Information Must Be Disclosed

Financial Policy

Patient Registration Form

Step 1 of 3

Patient Information

Medical Information

Insurance Information

** By Law, All Insurance Information Must Be Disclosed **

Financial Policy

By Law, All Insurance Information Must Be Disclosed