New Patient Packet

Authorization To Release Medical Information
Patient Name*
Date of Birth*

MonthDayYear
Date
I authorize Atlanta Cosmetic Urology to release my medical information to another person(s)(spouse, family member, physician)

YesNo
Name
Relationship
Phone Number
I authorize Atlanta Cosmetic Urology to release my medical information to another persons/family members

YesNo
Name
Relationship
Phone Number
I authorize Atlanta Cosmetic Urology to release my medical information to another persons/family members

YesNo
Name
Relationship
Phone Number
Patient Signature*

Clear
Date*

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Date

Authorization for the Release of Protected Health Information (PHI)

This form gives us permission to send your records to another doctors office at their or your request, we will always request your permission prior to sending your records. If you leave the middle blank, we can fill it in later with the name of the facility.
Patient Name*
Date of Birth*

MonthDayYear
Date
Phone Number*
I authorize the staff from Atlanta Cosmetic Urology to release or obtain the health information as directed below:
Patient to obtain from and or release to/ OR LEAVE BLANK:
Facility
Address
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Atlanta Cosmetic Urology

371 E Paces Ferry Rd NE

Suite 550

Atlanta, Ga 30305

P (404) 400-3120 F (404) 481-2454
Healthcare information relating to the following treatment, condition, or dates.
This request applies to (all records or specify dates)
Healthcare information relating to the following treatment, condition or date.
Patient Signature*

Clear
Date*

MonthDayYear
Date

Payment Policy
Thank you for choosing Atlanta Cosmetic Urology as your Urology provider. We are committed to providing you with premiere Urological care.

Insurance

We participate in several insurance plans, including Medicare. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.

Co-payments and Deductibles

All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. If unfortunately we send your account to a Collection Agency, a $200 collections processing fee will be added to any outstanding balance.

Non-covered Services

Please be aware that some of the services you receive may be non- covered or not considered reasonable or necessary by Medicare or other insurers. You must pay for these services in full at the time of visit.

Proof of Insurance

All patients must complete our patient information form before seeing the doctor. We must obtain an up to date copy of your driver's license that is valid. We also need a copy of your valid up to date insurance to provide proof of insurance. If you fail to provide US with the correct insurance information in a timely manner, you may be responsible for the balance of a claim.

Insurance Changes

If your insurance changes, please notify US before your next visit so we can make the appropriate changes to help you receive your maximum benefits. You will be responsible if there are any issues or lapses in care.

Non-payment

If your account is over 90 days past due, you will receive a letter stating that you have 20 days to pay your account. If your balance remains unpaid, we will refer your account to a collection agency.

Missed Procedures and IV Infusions

Our policy is to charge for missed procedures and IV infusions if they are not canceled within a reasonable amount of time (24hrs before) You will be responsible for the $250.00 and this will be your responsibility and billed directly to you. I have read and understand the payment policy and agree to abide by its guidelines.
Patient Signature*

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Date*

MonthDayYear
Date

"No Show" and "Cancellation" Policy & Procedure For Office Visits and Procedures
At Atlanta Cosmetic Urology, our goal is to provide quality urological care in a timely manner. We have implemented a no show and cancellation policy which enables us to better utilize available appointments for our patients in need of urological care. The following policy is regarding patients who fail to keep their scheduled office visit appointment, procedure appointment.
Please be courteous and call our office promptly if you are unable to attend an appointment. This time will be reallocated to someone who is in urgent need of treatment. Available appointments are in high demand and your early cancellation will give another person the possibility to have access to timely urological care.
- Patients who fail to show for their scheduled appointment or cancel their appointment on the same day of the scheduled appointment, shall be subject to a "No Show/Cancellation" fee of $50.00. In the event of an actual emergency and prior notice could not be given, consideration will be given, and a one-time exception may be granted.
- Patients who fail to show for their scheduled office procedure (urodynamics or in office surgery) appointment or did not notify the office within 1 week of their scheduled appointment time, shall be subject to a "No Show/Cancellation" fee of $300.00 insurance covered procedures, and $1500 for self pay procedures.
These fees are not covered by insurance and is therefore the sole responsibility of the patient.
How to Cancel Your Appointment: To cancel or reschedule appointments please call our office at 404-400-3120. If you have any problems getting through, you can leave a message with your name, appointment date and cancellation reason or request for rescheduling.
Patient Signature*

Clear
Date*

MonthDayYear
Date
Patient Printed Name*

Billing and Financial Policy

The following sets out the general billing policy of Atlanta Cosmetic Urology, LLC.
Please review this information and initial/sign where indicated.
I understand that it is my responsibility to provide the clinic with current, accurate billing information and to notify the clinic of any changes in this information.*
Initial
ACU participates in many insurance plans, including Medicare. I understand that knowing my insurance benefits is my responsibility.*
Initial
ACU will verify my benefits as a courtesy to me prior to a scheduled appointment, procedure or surgery. I understand verification of benefits in not a guarantee of payment by my insurance carrier. Moreover, ACU will do its best to provide me with an estimate of costs for the services rendered to me based on the current contracted rates. I understand that an estimate of an amount owed is just that, an estimate. I man still have a balance owed once insurance processes my claim. I agree to pay any additional amounts owed by me after my claim is processed by my insurance. *
Initial
ACU will obtain the necessary prior authorizations prior to rendering treatment. I understand that prior authorization is not a guarantee of payment. If my insurance denies payment for a claim previously authorized, the clinic will appeal the denial or payment one time. After a second denial, I must work with the clinic and my insurance to appeal the denial again If my claim is denied for a third time, I may be responsible for any and all balances due to the clinic. *
Initial
I understand that I am responsible for payment of my account at the time of service for, but not limited to deductibles, non-covered services, medically unnecessary services, and copayments.*
Initial
I understand that at times, the provider may order additional testing at the time of service for any additional or ultrasounds provided on the day of service. ACU may provide costs of services as a courtesy to me, however, it is ultimately my responsibility to determine whether or not these additional tests or services are covered by my insurance.*
Initial
I understand that I will be charged a $50.00 no show fee for each missed office appointment that is not canceled within the minimum 24 hour notice. I will be charged a $300.00 or $1500 no show fee for a missed surgery/procedure not canceled/ rescheduled with a minimum two week notice.*
Initial
I understand if I present insufficient funds check (NSF check) for payment on my account that I will be charged a $30 NSF fee. I understand fee. I further understand that to rectify my account, I may be required to pay with cash, credit card, money order or cashiers check for future office visits and services.*
Initial
I understand if my account is delinquent and/or unpaid for 60+ days, I will be responsible for payment in full prior scheduling non emergent future visits, procedures or surgeries.*
Initial
I understand that there may be a fee to copy and mail medical records. I agree to pay for this small fee, should I require my records be copied and mailed to me or to another party.*
Initial
Signature*

Clear
Print name*

Tele-Health
Patient Name*
Telehealth is the contact with a provider via telephone/online portal. Health related services and/or informtion my be distributed.
1. I consent to engage in a telemedicine consultation with my healthcare provider.
2. I understand how the video conferencing technology will be used to affect such a consultation, and video conferencing will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider.
3. I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that my health care provider or I can discontinue the telemedicine consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
4. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than my health care provider and consulting health care provider in order to operate the video equipment. The above-mentioned people will all maintain confidentiality of the information obtained. I further understand that i will be informed of their presence in the consultation and thus will have the right to request the following: (1) Omit specific details of my medical history/physical examination that are personally sensitive to me. (2) Ask non-medical personnel to leave the telemedicine examination room: and or (3) Terminate the consultation at any time.
5. I understand the alternatives to a telemedicine consultation is an in person office visit, and in choosing to participate in a telemedicine consultation, I understand that some parts of the exam involving physical tests may be conducted by individuals at my location at the direction of the consulting health care provider.
6. In an emergent consultation, I understand that the responsibility of the telemedicine consulting specialist is to advise my local practitioner and that the specialist's responsibility will conclude upon the termination of the video conference connection.
7. I understand that billing will occur from both my practitioner and as a facility fee from the site from which I am presented.
- By signing this form, I certify:
  - That I have read or had this form read and/or had this form explained to me.
  - That I fully understand its contents including the risks and benefits of the procedure(s)
  - That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.
Patient Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Payment Policy

"No Show" and "Cancellation" Policy & Procedure For Office Visits and Procedures

Billing and Financial Policy

Tele-Health