PATIENT INFORMATION

In case of emergency, please provide information for the nearest relative or designated contact person not at the patient's address:

By signing below, I acknowledge that the above information is true to the best of my knowledge.

ALL PATIENTS: DO YOU HAVE, OR HAVE YOU EVER HAD ANY OF THE FOLLOWING SYMPTOMS? 

CHECK ALL THAT APPLY

In order to ensure our patients receive the highest quality healthcare, certain fees may be assessed and collected at the time of service as indicated below. Patients will be notified about any fees in advance of service. Please read and sign this form to acknowledge your understanding of our administrative and patient financial policies.

WALK-IN POLICY
All patients requesting an unscheduled same-day appointment without previously informing our office will incur a $50 fee.

CANCELLATION POLICY
We ask that you notify our office of cancellation within 24 hours of your scheduled appointment if you are unable to attend, or 48 hours prior to Urolift procedure. Failure to notify our office will result in the following fees:

Consultation or Follow Up Appointment Cancellation or No Show: $50.00 fee
Surgical or Procedural Appointment Cancellation or No Show: $200.00 fee
Urolift Appointment Late Cancellation or No Show: $500.00 fee
Diagnostic Tests Cancellation or No Show (Cystoscopy, UDS, Duplex Doppler): $100.00 fee

 

REQUEST FOR MEDICAL RECORDS POLICY
Any request for copies of your medical record created by your physician will be charged $25 for the first 25 pages. Any additional pages will be charged at $1 per paqet not to exceed $75.00.

REQUEST FOR PRESCRIPTION/SERVICE APPEALS
Any request for your physician to write a letter of appeal on behalf of a denied drug/service will incur a $25 fee.

ALL INSURANCE COPAYS WILL BE COLLECTED AT THE TIME OF SERVICE (IF NOT PAID AT VISIT $5.00 STATEMENT FEEL WILL BE BILLED)

I have read and understand the Administrative Policies and Associated Fees of this medical practice and that all fees are payable at the time of service. I agree to pay such fees as applicable.

Medicare and commercial insurance companies only pay for services deemed "reasonable and necessary." In some circumstances, insurance companies may not consider testing or treatment prescribed by your physician as "reasonable and necessary." In such cases, insurance companies may not approve or may not adequately reimburse to provide those services.

 

SERVICES LIKELY TO BE DENIED:

• Prostaglandin or papaverine intracavernosal injections ($25.00 Each)
• Testosterone, intramuscular injection $25.00
• Testopel / Testosterone Pellets ($100.00 per Pellet)
• ED Medication or Troche
• Xiaflex@ intralesional injection for Peyronie's disease
• Botox@
• Semen analysis
• HIV testing
• Diabetes or cholesterol screening
• COVID-19 Antibody Testing
• Circumcision and or Frenuloplasty

I hereby authorize my physician to release to my insurer, governmental agencies, or any other entity financially responsible for my medical care, all information (including diagnosis and the records of any examination or treatment rendered) needed to substantiate payment for such medical services along with information required for pre-certification, or authorization/referral to other medical providers.

In the event that my health plan determines a service to be not payable, I will be responsible for the complete charge and agree to pay the costs of all services provided. I also agree that should I fail to assume that financial responsibility and credit action is necessary, I will pay any additional costs above the amount of the physician's charges.

 

FOR MEDICARE/MEDICARE PATIENTS ONLY: EXTENDED PAYMENT REQUEST

I request that payment of authorized Medicare or other insurance benefits be made on my behalf to my physician for any services furnished me by him/her. I authorize any holder of medical or other information about me to release to the Health Care Financing Administration and its agents or other insurance carriers any information needed to determine these benefits or the benefits for related services.

This one-time signature will be maintained on file as verification for all subsequent services, which are provided to you by your physician.

A copy of this authorization may be used in place of the original.

I hereby authorize the release of my medical records and request release to:

Dr. Daniel J. Cosgrove

16311 Ventura Blvd., Suite 800
Encino, CA 91436
Phone (818) 906-0635 • Email: info@advantageurology.com • FAX (818) 906-7303

We often get inquiries from spouses/partners, family members and/or friends, and other physicians or medical professionals about the status of our patients. Please be advised that due to Federal Law, we will not release any information about our patients without their prior written consent.

Protected Health Information (PHI) is any health information in the medical record that can be used to identify an individual and that was created, used, or disclosed in the course of providing a health care service such as diagnosis or treatment. For any health information other than test results, a valid HIPAA compliant release must be completed. You (The Patient) may authorize release of PHI through certain forms of electronic communication. To ensure your privacy, we will not leave messages containing PHI on any device without your permission.

By signing below, I consent to the use of this information in providing/coordinating my medical services only.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. "Protected health information" is information about you, including demographic information, that my identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

Uses and Disclosures of Protected Health Information
Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician's practice, and any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of your physician's practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required By Law, Public Health issues as required by law, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration requirements, Legal Proceedings, Law Enforcement, Coroner, Funeral Directors, and Organ Donation, Research, Criminal Activity, Military Activity, and National Security, Workers' Compensation, Inmates Required Uses and Disclosures under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.

Other Permitted and Required Uses and Disclosures Will Be Made Only With Your Consent, Authorization or Opportunity to Object unless required by law.

You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician's practice has taken an action in reliance on the use or disclosure indicated in the authorization.

Your Rights
Following is a statement of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes, information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Our request must state the specific restriction requested and to whom you want the restriction to apply.

Your physician is not required to agree to a restriction that you may request. If your physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a proper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically.

You may have the right to have your physician amend your protected health information. If we deny your request for amendment you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.

We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.

Complaints
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.

This notice was published and becomes effective on/or before August 1, 2015.