Tennessee's Premier Urologic Health Care Specialists.

Important Information For Patients

Appointments

In fairness to other patients, please be here at the time scheduled. Kindly provide us with at least 24 hours’ notice if you cannot keep your appointment. If we are delayed by unexpected problems, we will make every effort to notify you at home or when you arrive at the office. Please arrive 30 minutes prior to your scheduled appointment.
Doctors-appointment
New Patients
We accept new patients with urologic problems on an appointment basis. Urgent problems (bleeding, abdominal pain with fever, inability to void, kidney stone, etc.) will be seen immediately in the office or emergency room. Less urgent problems will be scheduled as is mutually convenient. Please clearly describe your problem when calling for a first appointment.
Referred Patients
Physicians often refer patients to us for consultation. Depending on the type of problem, we may initiate diagnostic studies or treatment. Most patients will continue under the care of their primary physician after a diagnosis and treatment plan have been established. At times, we may continue to follow your urologic problems ourselves. Your referring physician will always receive a prompt report of our findings and recommendations for treatment.
Follow-Up Visits
If your condition needs continued observation, follow-up care will be arranged through our office or with your primary physician.

What to Bring to Your First Appointment

At Tennessee Urology Associates we request that new patients bring the following items to ensure the best quality care is being received: Current list of ALL medications Any Clinical Notes from Referring Physician Driver’s License Insurance Card If able, please print and complete the documents below. Be sure to bring the New Patient Packet to your appointment. Patient Information Form Privacy Practices Patient Rights and Financial Responsibility Due to the Red Flags Clarification Act of 2010, Urology Associates is required to have an image of patients drivers’ licenses to ensure identity theft does not occur. For more information regarding the Red Flags Clarification act of 2010 please visit cms.org

Your Physician

The physician who performs your initial evaluation (or hospital consultation) will continue to follow you whenever possible. We alternate night and weekend calls. When you need emergency care after hours or when your regular urologist is unavailable during office hours, you will be asked to see another physician in our group to initiate treatment. Your regular urologist will resume care as soon as possible.

Medical Records

Please bring any medical information (x-ray reports, hospital summaries, and prescription drugs) describing your medical problem to your appointment. This can save costly repetition of expensive tests.

Emergencies

During Office Hours
Call the office and explain your problem. Your physician (unless unavailable) will arrange for an urgent office visit or emergency room visit as necessary.
After Hours and Weekends
Call the office and your call will be transferred to an operator who will contact the physician on call.
Emergency Room Visits
We prefer to arrange these for you after discussing your problem by phone. Many times, a less expensive office visit with your regular physician will suffice. If you arrive at the emergency room without contacting us first, the emergency room physician will see you and call us only if you need hospital admission. In true emergencies, this allows immediate institution of proper care. For problems not requiring hospital treatment, you will be referred to our office for follow-up.

Professional Fees

Our fees are based on the complexity of the problem or procedure and time spent. They are comparable to fees charged by similar specialists in this area. We invite your questions in advance regarding fees for any service or procedure.

Payment

We ask for payment at the time of the visit. Repeated billing is expensive, and adds to the cost of your medical care. If you cannot settle your account while in the office, please mail payment to our office as soon as possible. We are happy to arrange for regular monthly payments (with no interest charges) if you desire. Please let our staff know how you plan to settle your account. All financial and medical information is kept strictly confidential. You are responsible for full payment of your account in 90 days. Please contact our Billing Office at 865-690-0602.
Past Due Accounts
Any account not paid in full within 90 days of the original billing is considered past due and is subject to collection proceedings. Please let us know immediately if there are any circumstances preventing payment of your account within the 90 days.
Patient Rights and Financial Responsibilities
In order to reduce confusion and misunderstanding between our patients and the practice, we have adopted the following financial policy. If you have any questions, please discuss them with our billing staff or Office Manager. We are dedicated to providing the best possible care and service to you. Your complete understanding of our financial policies is an essential element of this service.
  1. Unless other arrangements have been made in advance by either yourself or your health coverage carrier, payment is due at the time services are rendered. For your convenience, we accept VISA, Master Card, American Express and Discover. We also accept cash, checks and money orders.
  2. If you are unable to pay your co-payment and/or balances, your appointment may be rescheduled.
  3. Your insurance policy is a contract between you and your insurance company. As a courtesy, we will file your insurance claim for you if you assign the benefits to your doctor. In other words, you agree to have your insurance company pay the doctor directly. If your insurance company does not pay the practice within a reasonable period, we will have to look to you for payment. If we later receive a check from your insurer, we will refund any over-payment to you.
  4. We have made prior arrangements with many insurers, managed care companies, and other health plans to accept an assignment of benefits. We will bill those plans with whom we have an agreement. We will require you to pay any applicable co-payments, deductibles, co-insurance and any outstanding balances at the time of service.
  5. All health plans are not the same and do not cover the same services. In the event your health plan determines a service to be “not covered”, you will be responsible for the complete charge. Payment is due upon receipt of a statement from our office.
  6. For all services provided in the hospital by our doctors, we will bill your health plan. Any balance due is your responsibility and we will bill you for these balances.
  7. For all services rendered to minor patients, we will look to the adult accompanying the patient and the parent or guardian with custody for payment.
  8. In order to provide the best possible service and availability to all our patients, please call as early as possible if you know you will need to reschedule your appointment. A service fee may be applied for no-shows.
  9. A $35.00 service fee will be charged for all returned checks.
  10. FMLA and Disability paperwork is completed for a charge of $25. Medical records can be copied for a charge of $20. Please allow sufficient time for this to be completed.
  11. For male patients only, we will require you to pay all outstanding balances before Sildenafil or Trimix is sold to the patient.

Insurance

Pre-certification and authorization for hospital admission is now a requirement of many insurance plans. If we are not aware your plan requires pre-certification before you enter the hospital, benefits may be reduced depending on your policy. It is your responsibility to let us know if your plan requires pre-certification for hospitalization. We will file your insurance and ask that you be reimbursed. You will receive monthly statements until your account is paid in full.
PPOs (Preferred Provider Organization)
If your insurance is a PPO, you must check with your carrier to see if we participate in the PPO before receiving care. If you choose to see us for medical care, and we do not participate in your PPO, you most likely will not receive full plan benefits without prior approval.
HMOs and POSs
Most HMOs and POSs require approval of your primary care physician before specialty care is rendered. If you chose an HMO or POS for your medical care and wish to see one of our physicians (whether as a new patient or as a patient followed regularly in our office), you must have advanced approval for the visit by your primary care physician. Patients must always contact their primary care physician for any medical problems and should not call our office unless specifically instructed to do so by one of our physicians.

Financial Policy

Tennessee Urology Associates and other wholly owned subsidiaries (individually or collectively "Tennessee") are dedicated to providing quality patient care and are also aware that financial concerns are part of your welfare.

Before your visit, Tennessee is required to verify your member eligibility with your insurance company. In addition, for your protection and in accordance with federal regulations, Tennessee is required to verify your identity (valid driver's license or other form of acceptable photo identification). Your failure to provide an acceptable form of photo identification may cause denial of services. Please inform the front office staff if you have any concerns regarding your insurance benefits or if do not have insurance coverage (you are "self-pay"). If you are self-pay, and are unable to satisfy your financial obligations to Tennessee, you may want to contact your local health department to see if you are eligible for Medical Assistance. Please feel free to contact our Patient Liaison at 866-681-2335 to discuss your payment options in advance.

Please read the following carefully and sign below.

Copayments, Coinsurance, and Outstanding Balances: Copayments, coinsurance and outstanding balances not covered by insurance are due prior or at the time services are rendered. Payment can be made by check, cash, MasterCard, VISA, American Express and Discover. Additionally, you may be eligible to finance amounts which you owe for services rendered through a third-party financial institution. Inability to pay at the time of service may result in having to reschedule your appointment.

Referrals: It is your responsibility to obtain a referral from your primary care physician. Referrals must be presented at the time services are rendered, if applicable. If you need to have a referral faxed to us, our office will provide you with our fax number. If your insurance plan requires you to have a referral or other authorization, and you fail to provide that to us, your appointment will be rescheduled or your claim for that date of service will be processed via opt-out benefits, if applicable.

Insured Patients: For those insurance companies with which we are contracted (where we are considered a participating provider), we will submit a claim on your behalf for the services we provide. Any copayments, coinsurance or outstanding balances must be paid in full prior to or at the time of service. We recommend that patients contact their insurance carrier for specific questions related to your Explanation of Benefits.

For those insurance companies with which we are not contracted, have no out-of-network benefits and we are unable to determine if services will be covered, we will require payment in full for all services provided at the time of service. We will provide you with an itemized statement indicating the services rendered, our fees, and your payment received. You can submit this statement to your insurance company for reimbursement.

Self-Pay Patients: Payment for service is due in full at the time of service unless other arrangements have been made with our Patient Accounting Department prior or on the day of service.

There is a separate policy for self-pay elective surgeries – Elective Surgery Scheduling and Payment Policy.

Diagnostic Testing: During the course of your medical treatment with Tennessee Urology, including your office visit and/or surgical procedure, your urologist may request that a tissue, blood or urine specimen be obtained for the purpose of diagnostic testing. This testing is being performed in order to assist your urologist in the diagnosis and management of your urologic condition. Depending upon the requirements of your insurance coverage, these specimens may be processed at Tennessee’s Urology’s in-house pathology laboratory or at a third-party laboratory, for example Quest or LabCorp. The costs of these laboratory tests vary depending upon the nature and complexity of each test. The cost for a diagnostic test, including the cost that you will be required to pay, if any, depends on your insurance carrier and the type of insurance coverage you have. Please note: 1) All charges for specimens processed at Tennessee Urology’s laboratory will be included in the statement you receive from Tennessee Urology. 2) Charges for specimens processed at a third-party laboratory will be billed to you directly by that laboratory.

No Show / Same Day Cancellation Policy: A $25 missed appointment fee will be charged to you for any missed appointment where you fail to cancel a scheduled appointment at least 24 business hours prior to the time of that scheduled appointment. The fee will be your responsibility to pay and will not be billed to your insurance company.

Account Balances: Our billing office will provide you with a monthly statement of all account activity including our charges, payments and contractual adjustments from your insurance carrier along with payments made by you. Please be aware that you will be charged a returned check fee for all payments, made by a personal check, that have been returned by your backing institution uncashed due to insufficient funds or stopped payment. Please note that failure to pay outstanding balances that are your responsibility may result in having to reschedule future appointments until balances are resolved. In addition any unpaid delinquent balance may (a) delay scheduling of future appointments (b) result in your account being forwarded to a collection agency or collection attorney of our choice, which may result in additional fees to you including attorney’s fees equal up to 40% of your outstanding balance, (c) reporting you to one or more third-party credit reporting agencies, and (d) termination from the practice.

Contact Information: All contact information obtained by the Practice from you may be used for the purposes of collecting all outstanding balances owed to Tennessee.

Billing Matters / Grievances: For billing matters, you may contact one of our Patient Accounting Liaisons at 866-681-2335. Grievances must be received in writing within 60 days of receipt of a billing statement or conversation with Tennessee staff regarding the matter in question.

THE FOLLOWING PROVISION APPLIES TO ALL PATIENTS EXCEPT THOSE WHO ONLY HAVE MEDICARE WITH NO SECONDARY COVERAGE. IF YOU ARE COVERED 1) BY MEDICARE AND HAVE SECONDARY COVERAGE, OR 2) IF YOU ARE COVERED BY A MEDICARE ADVANTAGE PLAN, YOU MUST INITIAL HERE.
I hereby authorize and request my insurance company to make payment directly to Tennessee Urology Associates and any wholly owned subsidiaries of any benefits that may be due for covered services and supplies rendered to me by Tennessee Urology Associates.

AUTHORIZATION TO PAY BENEFITS TO PHYSICIAN

I authorize the release of medical or other information necessary to process health insurance claims. I also request payment of benefits to myself or to my provider, Tennessee Urology Associates when he accepts assignment.

AUTHORIZATION TO RELEASE MEDICAL INFORMATION

I hereby authorize my provider, Tennessee Urology Associates to release any information necessary for my course of treatment.

Signature:_______________________________________ Date:_______________________