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Urological Associates of the Piedmont
Adult and
Pediatric Urology
Offices
in Culpeper and Warrenton, Virginia
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1100 Sunset Lane Suite 1211A
Culpeper, Va. 22701
540-825-2900 |
410 Hospital Drive,
Warrenton, Va. 20186
540-347-1314 |
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Insurance Terms &
Conditions
( Please read, sign, and return to our
office )
(Printable form)
| 1. Professional services are rendered and charged
to the patient, not the insurance company. |
2. Patients are expected to pay for services when they are rendered.
If we participate with your insurance company, charges will be
submitted to the insurance company. You are responsible for
providing
co-payments and referral forms (if they are required by
your insurance company). |
3. Insurance claims not paid within 90 days will be the
responsibility of the patient. We will ask that you pay the charges
and follow-up with your insurance company once you are billed at
this office. |
4. "I hereby authorize and request that payment be made directly to
Urological Associates of the Piedmont, P.C. (David M. Pfeffer, M.D.and
Thomas S Mitchell, M.D; this would
include services rendered in the hospital or in the office. I
recognize and accept personal responsibility for any balance due." |
5. "I hereby authorize Urological Associates of the Piedmont, P.C.
(David M. Pfeffer, M.D.and Thomas S Mitchell, M.D. to furnish any or all information which the insurance
may request concerning my present illness or injury." |
6. "I herby authorize Urological Associates of the Piedmont,
P.C. (David M. Pfeffer, M.D.and Thomas S Mitchell, M.D.to submit my lab specimen, i.e. urine sample, blood
sample, which may be necessary for further diagnostic testing, to an
outside laboratory. This laboratory will be supplied with a copy of
my insurance card along with general billing information to be
submitted by the laboratory for their charges. I also understand
that I will be the responsible party for any balance." |
7. After a reasonable amount of time and an attempt has been made to
collect any balance with Urological Associates of the Piedmont, P.C.
(David M. Pfeffer, M.D.and Thomas S Mitchell, M.D I understand that I will be responsible for any
collection fees or attorney fees if this account should go to a
collection agency. All returned checks will be assessed a
$25.00 processing fee. |
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| Patient Signature: ________________________
Date: _______________ |
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