Urology, P.A. and The Continence Center logo

Urology Professional Association

and

The Continence Center

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Patient Information

Initial Visit

On your initial visit please bring:

Also, be prepared to share your medical history with our physicians. This will include any medical conditions you have or may have had in the past, surgical history, any medications (prescription or over-the-counter) you are currently taking (include name, dosage and frequency), and any allergies you have to medications or foods.

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You must pay your copay and any co-insurance at each visit.

Financial Policy

Urology Professional Association (Clinic) participates in the Medicare and Mississippi Medicaid programs as well as other commercial insurance products. If the Clinic participates in your insurance plan you will be responsible for all copays, deductibles, and coinsurance amounts at the time of service. You will also be responsible for any services not covered by your insurance plan. You must bring your insurance card(s) to every visit.

If the Clinic does not participate in your insurance, we will file your insurance as a courtesy but you will be responsible for all charges not paid by your insurance. You will be required to pay a $200 deposit on your first visit which will be applied against your charges.

If you do not have any insurance you will be required to pay a $200 deposit on your first visit which will be applied against your charges. This must be paid before you are seen. All future charges should be paid at time of service unless you work out other payment arrangements with our billing staff. We do offer patients with no insurance coverage a discount when charges are paid in full at time of service. Please ask any of our billing or check out staff about this discount.

You understand that you are financially responsible for all Clinic charges unless covered and paid by your third party insurance as explained above. If you should default on your financial responsibility, you understand that your account may be turned over to a collection agency. If that occurs, you may be charged for all reasonable collection fees incurred by the Clinic.

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Fees

An estimate of fees to be expected will be given to you upon request.

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Insurance
Please provide complete and accurate insurance information. Please bring all insurance cards and show them to the receptionist; usually these will be copied and placed on file with your records. It is your responsibility to notify us of any special requirements of your insurance carrier, such as the need for second opinions, pre-admission certification, or pre-procedure certification and of any change in your coverage.

Insurance is filed for you free of charge for hospital admission or surgery and is mailed to your insurance company or directly to your employer if it is a group policy. (Exception: For the filing of certain disability policies covering loans, mortgages, etc., there will be a small fee.)

Our insurance clerk is on staff to assist you and will handle any questions or problems you might have regarding your insurance. The insurance clerk may be reached by calling 662-377-7105. Please do not ask your physician to fill out forms while you are in the examining room. We do not participate in the Champus Program. We do participate in the following plans:

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Patient Information Forms


The information requested on the confidential patient forms is not intended to be an invasion of your privacy. It is necessary in order for the doctor to treat you, for the filing of your insurance, and for us to be able to reach you when necessary. Please fill out the form completely and accurately. We will be glad to provide assistance if requested.

You can view and/or print the necessary patient forms for your appointment by following these easy instructions. In order to view and/or print the forms, you must have the Adobe Acrobat Reader®, which you probably already have on your computer. If not, you can easily and quickly download a free version of Adobe Acrobat Reader® by going to their website Download Reader.

When viewing the forms in Adobe Acrobat Reader®, the text might appear somewhat fuzzy; this is normal (the forms will print out clearly). To print, just click on the printer icon in the Adobe Reader toolbar above the document.

Once you have the Adobe Acrobat Reader® installed, click on these links to view and print the following forms:

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Privacy Practices
Urology Professional Association, wishes to present a document outlining their privacy practices.

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This is where you can feature something special about the practice, highlight a new service, link to a news article, etc.

This is where you can feature something special about the practice, highlight a new service, link to a news article, etc.