Private Pay Patients:
As a private pay patient you will be asked to make a deposit
prior to seeing the doctor. It is very important that
you ask about the cost of care or services that your physician
is recommending prior to the service being performed.
At the end of your visit, You understand that You will
receive a refund or expected to pay for additional charges.
Minor Patients:
For all services rendered to minor patients, we will look
to the adult accompanying the patient and the parent or
guardian with custody for payment. Assignment of Benefits
You hereby assign all medical and surgical benefits, to
include major medical benefits to which You am entitled.
You hereby authorize and direct your insurance carrier(s),
including Medicare, private insurance and any other health/medical
plan, to issue payment check(s) directly to THE PROSTATE
CENTER OF AUSTIN for medical services rendered to yourself
and/or your dependents regardless of your insurance benefits,
if any. You understand that You am responsible for any
amount not covered by insurance.
Consent
for Treatment:
You understand your right to participate in your treatment
process. You am mentally competent and do hereby consent
to necessary examination, procedures and or treatments
prescribed by your physician, his/her assistants or designee
as is necessary in his/her judgment.
Authorization to Release Information:
You hereby authorize THE PROSTATE CENTER OF AUSTIN to:
(1) release any information necessary to insurance carriers
regarding your illness and treatments; (2) process insurance
claims generated in the course of examination or treatment;
and (3) allow a photocopy of your signature to be used
to process insurance claims for the period of lifetime.
This order will remain in effect until revoked by me in
writing.
You have requested medical services from THE PROSTATE
CENTER OF AUSTIN on behalf of yourself and/or your dependents,
and understand that by making this request, You become
fully financially responsible for any and all charges
incurred in the course of the treatment authorized. In
the event of default, You understand that the Urology
Team may use an outside collection company and or report
returned checks to the Attorney General office for the
State Of Texas.
You further understand that fees are due and payable on
the date that services are rendered and agree to pay all
such charges incurred in full immediately upon presentation
of the appropriate statement. A photocopy of this assignment
is to be considered as valid as the original.
You understand that our records contain protected health
information about you and as such are highly confidential.
When appropriate, this office may use medical records
for non-treatment purposes (research, public health, and
some operational activities).
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