Urology Partners Financial Policy
Tanglewood Professional Center Riverwalk Professional Park Lakewood Ranch MOB II
Avenue West 200 3
Avenue West, Suite 210 6310 Health Park Way, Suite 100
Bradenton, Fl 34209 Bradenton, Fl 34205 Lakewood Ranch, Fl 34202
Phone: (941) 792-0340 | Fax: (941) 794-2251 | Email: firstname.lastname@example.org
Bryan Allen, MD
Sean Castellucci, DO
Edward Herrman, MD
Ricardo R. Gonzalez, MD
G. Austin Hill, MD
Alan K. Miller, MD, FACS
Mark Weintraub, MD
Mitchell Yadven, MD
Urology Partners believes communicating our financial policy is good healthcare practice.
Charges incurred for services rendered are the patient’s responsibility regardless of
insurance coverage. Your insurance coverage is a contract between you & your insurance
company. We file your insurances as a courtesy. Please realize that having secondary
insurance does not necessarily mean that your services are covered 100%. Secondary
insurances typically pay according to coordination of benefits with the primary insurance
It’s your responsibility to provide us with accurate insurance information & to inform us of
changes in your coverage as they occur.
You are responsible for all copays, coinsurance, deductibles & non-covered services.
We are obligated to collect your copay, coinsurance and/or deductible at the time of
service per your insurance. We accept cash, debit card, check, MasterCard, Visa, America
Express, Discover & Care Credit. Statements are sent out bi-monthly, & we ask that balances
due be paid when you receive your statement or at your next appointment, whichever is
sooner. Be aware patient payments are typically applied to the oldest balance first. There is
a $25.00 service charge for returned checks. Payment will then need to be made in cash, money
order or credit card for the balance due.
Uninsured patients are required to pay in full at time of service. We will collect a $200.00 deposit for office visits at check-in for
any new uninsured patient as well as for all insured patients who have not met their deductible. The average new patient
appointment is approximately $250.00 & does not include the cost of any additional testing. Remaining balances in excess of the
deposit paid at check in will be collected at check-out.
• Uninsured patients – Charges must be paid in full prior to procedure date.
• Insured patients – Out of pocket charges must be paid in full prior to the date of the procedure.
Patients may accrue large balances for services provided. In some cases, with proof of financial hardship, an adjustment may be
considered to reduce the cost of services. However, please understand that we cannot waive deductibles, coinsurances or copays
that are required by your insurance. This is a violation of our contracts with the insurance plans. Care Credit® is accepted at our
office and applications are provided at the front desk. Please be aware that balances not paid within 90 days will sent to an
outside collection agency, unless payment arrangements have been made.
Once all pending claims have been processed a refund may be due. If a refund is due, a request will be sent to 21st Century
Oncology to process and mail a refund check to the address on file. This process typically takes 30-45 days.
Please note, repeated missed appointments may results in a $25.00 fee and/or discharge from the practice.
Completing disability forms, FMLA forms & other requested insurance forms requires prepayment of $15.00 per form. Please understand that in
order to complete forms your medical record must be reviewed, forms completed & signed by the physician & copied into your medical record.
Please provide us with pertinent information, especially dates of disability & return to work. We request you allow 5 business days for this process.
For any billing inquiries, please contact our billing department, 941-792-0340 and select the prompt for billing inquiries.
I understand & agree to Urology Partners Financial Policy.
Signature of Patient/Person Legally Responsible Date
Print Name of Patient/Person Legally Responsible Date
Name of Patient and Relationship to Patient DOB of Patient
(if signed by Person Legally Responsible)
click to sign
click to edit