FINANCIAL POLICY LAKESHORE UROLOGY,PLC
We recognize the need for a definite understanding between you and your physician concerning
healthcare and the financial concerns. Our commitment is to provide the very best healthcare to
our patients while recognizing the need to limit services to only those medically necessary. The
responsibility for payment of fees for these services is the direct obligation of the patient.
Please be sure we have the most current demographic and insurance information at all
times. It is your responsibility to provide us with this information. The information you
provide us must match the information you provide the insurance carrier. Filing insurance claims
with the wrong information delays processing and increases patient’s financial responsibility.
You must realize, however, that your health benefit plan is an arrangement between you,
the enrollee and the insurance company, HMO or your employer. While we will try to be
helpful, and we may participate in the plan, your health benefit plan determines your coverage,
any requirements for prior authorizations or referral and establishes the limit on your coverage
for medical services. We cannot know the benefits and exclusions of each patient’s policy. It is
the patient’s responsibility to know and understand your coverage and benefits.
It is your responsibility to know if your insurance has specific rules or regulations, such as the
need for referrals from primary care physicians, pre-certification, limits on outpatient charges,
specific physicians and/or hospitals to use. You should be knowledgeable of any
deductibles, co-payments and/or coinsurance. You agree to accept responsibility for
co-payments, deductibles, and medical care and other services that are provided to you which
are not specifically covered by your insurance plan or not covered due to the absence of
authorizations/referrals you are obligated to obtain under your insurance plan. The services,
plans, and benefits under your insurance plan may be subject to and governed by applicable
contracts and government regulations.
You are required to present your insurance card every visit.
Bills from Hospital and Labs:
When you have certain laboratory testing collected in our office, the specimen is generally sent
to an outside lab or hospital for analysis. When this occurs you may receive a separate bill from
*Payment Policy Schedule:
Co-payments - Full payment at the time of service.
Coinsurance - Full payment at the time of service
Non-covered Service - Full payment at the time of service.
Self Pay Surgeries - Payment is handled on a case-by-case basis. Generally, a 50%
deposit is required 10 days prior to surgery with the balance
due at the time of the surgery.
Surgery Cancellations - Any cancellation or rescheduling of a scheduled surgical
procedure without a valid medical reason less than 5 business
days prior will incur a $100.00 cancellation fee. This fee is not
covered by insurance.
Referrals/Authorizations - Should your insurance carrier require a referral or
authorization, it is your responsibility to obtain or request one
prior to your appointment. The office will not issue a referral or
authorization for a service already performed or back date a
referral or authorization.
Returned Checks - If you make a payment by check to the office and it is returned
to us for any reason, you will incur a $25.00 fee. Additionally,
no appointments or services will be provided for non-emergent
care, until the balance is paid in full.
Past Due Accounts - It is our intention to collect all payments for services rendered
on time. Our policy is to send three statements should there be
an existing balance, however if your account becomes past due
the office will take the necessary steps to collect this debt. Any
and all additional costs associated with the collection of the
debt may become your financial responsibility.
* The fees/charges quoted above are subject to change at any time.
We realize that temporary financial problems may affect timely payments on your account. If
such problems do arise, we encourage you to contact us promptly for assistance in the
management of your account. If you have any further questions about the information above or
any uncertainty regarding our financial policy, please do not hesitate to ask us. We are here for