To expedite your visit to our office, it is important that you complete this new patient paperwork prior to your first appointment. You can fax the paperwork in to 904-727-7976 or you may bring it with you at your first appointment.

New Patient-Male

New Patient-Female

 

***Remember to bring any labs, imaging and make sure you have a referral if needed by your insurance company.
***Please complete the packet prior to your arrival.

Make sure to read the below information regarding our Insurance and Patient Responsibilities.

INSURANCE:

Patients at Kasraeian Urology are required to provide all insurance information to registration personnel. Kasraeian Urology billing offices will send claims on behalf of the patient to all insurance plans, but patients are ultimately responsible for following all insurance plan guidelines and any outstanding balances as a result from non-covered or out-of-network services, co-insurance, co-payment, deductibles, etc.

It is in each patient’s best interest to know and understand their insurance plan benefits and their responsibility for any deductibles, co-insurance, or co-payment amounts prior to any visit. Not all services are covered under all health plans. If a patient’s health plan does not cover a service or procedure, the patient is responsible for payment of these charges.  To find out what a health plan covers and what the financial obligation may be, the patient should call the customer service or member services department of the patient’s insurance carrier (the phone numbers are on the insurance card). The patient’s employer’s human resources department may also be a source of information and assistance.  It is each patient’s responsibility to know their insurance carrier’s patient responsibilities and procedures. If proper procedures are not followed, the patient may be liable for full payment of the bill. If the insurance carrier requires a referral and/or prior authorization, contact the primary care physician prior to seeing a specialist.

 

Patients who have coverage through a Health Maintenance Organization (HMO): In order to visit a specialist, patients covered through a HMO must first obtain a HMO referral from the patient’s primary care physician. It is the patient’s responsibility to obtain the referral from the patient’s primary care physician prior to the patient’s visit with Kasraeian Urology specialist. If a patient does not have a HMO referral, Kasraeian Urology will make every attempt to assist the patient in obtaining the referral. If Kasraeian Urology is unable to obtain the referral, the patient may be required to reschedule the appointment or the patient may be responsible for full payment of the bill at the time of service. Whether the visit with the specialist is medical necessity and covered under the patient’s policy will be determined by the HMO and not Kasraeian Urology. The co-payment made at the front desk is for the visit or encounter with the specialist only. Other services may have the patient’s deductible and/or coinsurance applied.

 

Patients who have coverage through other insurance: The co-payment made at the front desk is considered a patient’s initial expense to visit with Kasraeian Urology specialist. However, procedures performed during the visit will most likely not be covered by the patient’s co-payment made at the front desk. After a patient’s insurance carrier has received and processed a bill for services rendered to the patient, only then will a determination be made regarding the patient’s financial responsibility, which may include co-insurance, co-payment, deductibles encounter fees, etc.

 

Non-covered Services: In the event that a patient’s insurance carrier determines a service is not covered under the plan, the patient will be responsible for the complete charge and is due upon receipt of a bill from Kasraeian Urology. Services most often not covered under health plans and denied by insurance carriers typically include fertility and related workup to include mesa and vasectomy reversals, sexual dysfunction and related workup (including erectile dysfunction), and some laparoscopic procedures. Kasraeian Urology strongly encourages each patient to contact their insurance provider prior to their visit to verify coverage for such services. The customer service number is located on the insurance card.

 

In Office Procedures: As a courtesy to our patients, Kasraeian Urology will accept and file claims for numerous insurance carriers. However, Kasraeian Urology will not know in advance how each insurance carrier will process the charges for procedures provided to the patient. The majority of medical procedures performed by Kasraeian Urology are not subject to prior authorization by the insurance carrier. Kasraeian Urology will make an effort to notify patients of potential charges for scheduled procedures. Kasraeian Urology strongly encourages each patient to contact their insurance provider prior to a

scheduled procedure to verify coverage for such services. For unscheduled procedures which are determined to be necessary by the physician at the time of a schedule visit, Kasraeian Urology is not responsible for contacting the patient’s insurance carrier and determining whether or not such services are covered under the patient’s health plan.

 

Potential Surgical Charges: Patients may be required to schedule a surgical procedure for a later date. If surgery is necessary, a Kasraeian Urology scheduler will be available to assist the patient with pre-authorization and schedule any necessary pre-operation testing. Kasraeian Urology will bill a patient’s insurance carrier for all surgical procedures. The balance, if any, shall be the patient’s responsibility and is due upon receipt of a bill from Kasraeian Urology. Should a Kasraeian Urology physician visit a patient in a hospital or perform surgery, please keep in mind that all physician fees are separate and distinct

from surgical assists, hospital, anesthesia, lab or pathology fees.

 

Approved Provider: It is important that each patient understand what will or will not be cover by the patient’s health plan. Any time a patient calls Kasraeian Urology to schedule an appointment, the patient should first verify that the health plan is accepted. If a patient’s primary care physician refers a patient to a specialist, the patient should verify that the specialist is an approved provider under the patient’s health plan. While it is likely that Kasraeian Urology has an agreement to provide services with a patients’ insurance carrier, health plans continue to change and are typically renegotiated each year. It is each

patient’s responsibility to know if a physician is an approved provider under the health plan. Patients are also responsible for knowing which locations the health plan may require the patient to obtain labs, x-rays and other ancillary services and to obtain any referrals that may be necessary.

 

Medicare Patients: Kasraeian Urology accepts assignment on Medicare insurance claims. Please remember that Medicare pays 80% of approved charges. The patient will be responsible for the remaining 20% co-insurance, any yearly deductible, and any items deemed medically unnecessary by Medicare. If a patient has a secondary insurance that covers the coinsurance and deductible, Kasraeian Urology will file on the patient’s behalf.

 

PRIVATE PAY:

 

Private pay or insurances not accepted by Kasraeian Urology: All private pay patients are required to make a deposit prior to seeing a Kasraeian Urology physician. We strongly suggest that, prior to the service being performed, all private pay patients inquire about the cost of care or services that will be provided. At the end of the visit, private pay patients will be expected to pay for additional charges, if any. Private pay patients will also be entitled to receive a refund of any overcharges.

 

Out of Network: If a patient has a health plan for which Kasraeian Urology does not have a prior agreement, the patient is considered out of network. Out of network patients will be responsible for any and all co-insurance and deductibles. Kasraeian Urology strongly encourages each patient to contact their insurance provider prior to a scheduled procedure to verify coverage for such services. As a courtesy, Kasraeian Urology will prepare and send the claim on behalf of the patient on an unassigned basis. This means that the patient’s insurance carrier will send the payment directly to the patient. Consequently,

the charges for the patient’s care and treatment will be due at the time of