Fees: Our fees for professional services are consistent with those in the community. An estimate of US's fees for proposed services may be obtained upon request. US’s fees do not include hospital charges, outside lab charges or other specialty physician charges such as anesthesiologists, pathologists and radiologists.

Registration and Financial Information: To process claims on your behalf, we must have your complete insurance coverage(s) information, your employment, and your guarantor (another individual responsible). Please bring your drivers license or other picture ID to your first visit. We will update and/or confirm the accuracy of this information at each office visit or other significant service. Please bring your current insurance card with you for every visit. It is your responsibility to inform us in a timely manner of any changes to your billing information. If an insurance company denies payment for incomplete or wrong information, it is your responsibility to make payment in full. If your insurance requires a referral form or authorization, it is your responsibility to obtain this from your primary care provider prior to your appointment.

Payment at the Time of Service: We will bill your insurance for services. Please be prepared to pay your co-payment (and any non-covered services) at the time of each visit. We will also collect all previous outstanding patient balances during checking in at your office visit.

Elective Procedures: We require payment in full by time of service for all elective procedures and related consultations (vasectomies, vasovasostomy, etc.).

Credit Cards: As a convenience, US accepts Visa, MasterCard and Discover credit cards. We offer the option to pay the balance of charges due after insurance payments on your credit card. You may authorize this in advance, or call the Business Office directly when you receive your statement.

Self Pay: If you do not have insurance, we will collect $100 at the time of check-in for your first visit and $50.00 at the time of check-in for each subsequent visit. You will be billed and fully responsible for total charges that exceed this original payment. You may request a prompt payment discount when you pay for the services within 15 days of receiving a statement from us. Please note this cash discount is not available for elective procedures.

Payment Plans: The Business Office staff will establish payment plans for patient balances greater than $500. You can send in monthly payments or the Business Office staff can arrange monthly credit card charges with your authorization until the balance is paid in full. Please talk to a Business Office staff member for details of our payment plan options.

Care Credit: This program allows you to obtain an interest free loan for up to 18 months on balances of $300 or more. There is also an option to obtain an interest bearing loan on balances of $1,000 or more for between 24 and 60 months. Please ask a Business Office representative for more details and an application.

Insurances, Health Plans and Medical Benefit Programs: US participates with many insurance plans. Please call your insurance company at the telephone number provided on your benefit card, and your insurance company can inform you if we participate in your insurance, or if they will authorize you to receive care from Urology Specialists Chartered as an "out of network provider". For insurances that we participate with: We will bill your insurance for you, and accept the contracted payment rates. For office services we will collect your co-payment at time of service. If you have HSA/HRA insurance we will collect $100 for new patient visits and $50 for existing patients. Insurance payment rates may include a portion to be paid by the patient, and if so we will bill you. If the insurer does not provide payment in full according to the contracted amount, the balance of charges is the responsibility of the patient. You are responsible for any amounts the insurance plan deems not covered (or a non-covered benefit), up to the entire amount. For insurances that we do not participate with or "out of network provider" or "non-par provider": We do see patients whose insurance US does not participate with or who lists US as out of network. We will provide a receipt and documentation enabling you to seek reimbursement by your insurance. As a courtesy to our patients, we will submit claims to non participating insurers or health plans; however we can not extend a discount. Payment in full is required. You are responsible for any amounts your insurance does not pay. If we do not hear from your insurance company: If we do not receive payment or rejection from your insurance company in a timely manner, we will transfer the balance to your responsibility. We request your assistance in following up with your insurance company to resolve any non-payment issue.

Our providers recommend care based on the patient's best interest, which is independent of insurance coverage issues. We cannot know the benefits and exclusions of each patient's coverage. Contact your insurance company or employer for this information.

Additional Information and Fees

• There will be a $25.00 fee assessed for all checks returned unpaid by banks.
• Prescription renewals are best completed during your office visit. If you need a prescription refill between office visits, it is best to request from your pharmacy who will contact us for authorization. If appropriate to refill the prescription, we will provide this authorization within 24-48 hours, Monday through Friday between 8:00 a.m. to 4:00 p.m.
• We request at least a 24 hour advance notice if you will be unable to keep your scheduled appointment (please call 605-336-0635 as soon as possible). Our policy is to charge $25.00 for missed appointments unless canceled at least 4 hours in advance.
• Completing disability insurance forms and employer forms is not a medical service and is not paid by insurance. There is a $25.00 fee for completing these forms. Please allow at least one week for completion. Please provide a pre addressed envelope for mailing or a FAX number if requested.
• There are also fees for copying medical records except when for continuation of care. A legal release is required. Please allow at least one week for records to be released.

We thank you for choosing our physicians, physician assistants, and staff as a partner for your healthcare needs. As always, providing high quality healthcare to you is and remains our primary purpose.

If you have any questions about this information, please feel free to call our Business Office at 605-336-1940 for more information.