Documentation/Form Index

 

 

*Important* New Patient Forms

Prostate Symptom Score
Incontinence Questionaire
Instructions For Removing Your Foley Catheter
UROFLOW Test
UTI Questionaire 
Female Cystitis

 

 

 

RECORDS RELEASE:

 Each patient has the right to his/her medical record.  It is Windham Urology's policy that we have a written request from the patient stating they would like either their entire record sent or just the pertinent information.  It is our policy that we have at least two (2) weeks notice so that we have the time to copy the records and either mail or fax them to the appropriate person/entity.  It is also our policy that we will send an entire record free of charge one time.  Any second requests will bring a fee.   It is our policy that any patient who wants to view their own medical record may do so in the presence of one of our physicians.

 

FINANCIAL POLICY

In an effort to be compliant with Medicare regulations and to keep office billings costs to a minimum the Windham Urology Group has adopted the following financial policy.

You the patient are expected to know what your insurance carrier covers.  If a referral is needed to be seen by a specialist – we must have this prior to your scheduled appointment; what laboratories participate with your insurance carrier; as well as if any co-insurance; co-pays and or deductibles are due.  It is not the responsibility of W.U.G.

As a courtesy, we will bill your insurance carrier however; you the patient are ultimately responsible for all charges incurred.

If we participate with your insurance carrier we accept their allowed amount as payment in full with the exception of any co-pays: co-insurance amounts: or deductibles due.

All co-pays; co-insurance amounts and deductibles are expected to be paid in full at the time of service.

If you do not pay your co-payment at the time of service and we have to send out a bill a $10.00 billing fee will be added to the amount due to cover costs.

If you have an insurance that we do not participate with, you are responsible for payment in full at the time of service.

If you do not have medical insurance coverage, payment for any & all charges incurred is due in full at the time of service unless prior arrangements have been made with the billing office.

If you make a payment contract with Windham Urology Group and do not honor your obligation, your account will be turned over to our collection agency without further notification from us and potentially dismissed from the practice.

PAST DUE ACCOUNTS:  If your account becomes past due, we will take necessary steps to collect this debt.  If we have to refer your account to a collection agency, you agree to pay all of the collection costs which are incurred.  If we have to refer collection of the balance to a lawyer, you agree to pay all lawyers' fees which we incur plus all court costs.  In case of suit, you agree the venue shall be in Windham County, Connecticut.

RETURNED CHECKS: There is a fee (currently $25.00) for any checks returned by the bank.

WAIVER OF CONFIDENTIALITY:  You understand if this account is submitted to an attorney or collection agency, if we have to litigate in court, or if your past due status is reported to a credit reporting agency, the fact that you received treatment at our office may become a matter of public record.

WORKERS COMPENSATION:  We require written approval/authorization by your employer and/or worker's compensation carrier prior to your initial visit.  If your claim is denied, you will be responsible for payment in full.

 

 

 

63 Canterbury Road., Brooklyn, CT 06234
Phone: 1-860-412-0491
Fax: 1-860-412-0496