• Your insurance cards
• Forms we have sent you
• Related x-rays
• Records from referring physician
• List of medications

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.

Financial Policy

Payment Policy: Medical Services provided by Urology, P.A. and the payment for those services are transactions between you and the Physicians. Like any other business activity, you are responsible for payment of services on the day those services are rendered.

Insurance: Payment for out-of-pocket charges (deductibles, co-payments, non-covered charges) is expected on the date of service. As a service to you, we will file insurance on your behalf and make every reasonable effort to obtain payment according to your coverage. Regardless of the type of insurance coverage you have, you are ultimately responsible for paying your medical bills. If your insurance company rejects the claim or delays payment, we will bill you after 30 days for those charges.

No Insurance Coverage: Upon arrival in our office for your appointment, patients without insurance coverage will meet with a patient representative to discuss the details of our payment options and requirements, including CareCredit, a flexible financing program. At that time, you will be expected to pay a $100.00 deposit prior to services being rendered. If pre-payment cannot be made, your appointment may be rescheduled.

Payment Options: We accept cash, personal checks, Visa, Master Card and CareCredit, a financing plan we are pleased to offer as a separate line of credit to cover your healthcare needs.

Credit Policy If your account has an unresolved or outstanding balance, you will be expected to prepay for your visit and make a payment on the unresolved balance or your appointment may be rescheduled.

NOTE: Unresolved balances may be placed with an outside collection agency.

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

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:

• Medicare
• MS Medicaid
• Blue Cross/Blue Shield
• HealthLink
• Baptist Health Services Group

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:

• view/print Patient Information Form
• view/print Financial Policy
• view/print Patient History Form
• view/print Review of Systems Form

Privacy Practices
Urology, P.A., wishes to present a document outlining their privacy practices.

Main Office 830 So. Gloster St. East Tower - 4th Floor Tupelo, MS 38801 Ph: 662.377.7100 VIEW MAP»
The Continence Center 830 So. Gloster St. East Tower - 4th Floor Tupelo, MS 38801 Ph: 662.377.7279 VIEW MAP»

S a t e l l i t e s
Amory 1105 Earl Frye Boulevard Outpatient Pavilion Amory, MS 38821 Ph: 662.377.7100 VIEW MAP»	Hamilton, AL 1200 S. Military Dr. Hamilton, AL 35570 Ph: 205-921-6395 VIEW MAP»

For office hours, visit our locations page.