Physician Profile

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. Patients covered by Medicare are expected to pay 20% of Medicare's allowable charge for the office visit. Medicare will pay the other 80%. If you are covered by a secondary insurance, we will bill the secondary insurance for you.

4. 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.

5. "I hereby authorize and request that payment be made directly to Urological Associates of the Piedmont, P.C. (David M. Pfeffer, M.D., Thomas S Mitchell, M.D., and Steven G. Sutton, M.D.); this would include services rendered in the hospital or in the office. I recognize and accept personal responsibility for any balance due."

6. "I hereby authorize Urological Associates of the Piedmont, P.C. (David M. Pfeffer, M.D., Thomas S Mitchell, M.D., and Steven G. Sutton, M.D.) to furnish any or all information which the insurance may request concerning my present illness or injury."

7. "I herby authorize Urological Associates of the Piedmont, P.C. (David M. Pfeffer, M.D., Thomas S Mitchell, M.D., and Steven G. Sutton, 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."

8. 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., Thomas S Mitchell, M.D., and Steven G. Sutton, 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.

Patient Signature: ________________________ Date: _______________