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(646) 355-3711

URBAN MEDICAL GROUP OFFICE POLICY​

Our goal is to provide and maintain a good physician-patient relationship. Letting you know in advance of our office policy allows for a good flow of communication and enables us to achieve our goal.  If you have any questions, do not hesitate to contact a member of our staff.


Appointments

We value the time we have set aside to see and treat you. We do not double book appointments. If you are not able to keep an appointment, we would appreciate 24-hour notice. There is a charge of $50 for missed appointments and a charge of $200 for missed upper endoscopy and colonoscopy procedures.


If you are late for your appointment (>15 minutes), we will do our best to accommodate you. However, on certain days it may be necessary to reschedule your appointment.


We strive to minimize any wait time; however, emergencies do occur and will take priority over a scheduled visit. We appreciate your understanding.Before making an appointment, check with your insurance company as to whether the visit will be covered as a healthy and/or sick visit.  As per the Affordable Care Act (ACA), most insurances do cover annual preventative services. However many insurances do not cover sick visits and you may be responsible for any allowed charges.


Insurance Plans

Please understand:

It is your responsibility to keep us updated with your correct insurance information. If the insurance company you designate is incorrect, you will be responsible for payment of the visit and to submit the charges to the correct plan for reimbursement. If we are unable to verify your insurance status the day prior to the visit you will need to submit a credit card to cover the visit if your insurance is inactive or not current.


We may be your primary care provider, make sure our name or phone number appears on your card. If your insurance company has not yet been informed that we are your primary care provider, you may be financially responsible for your current visit. If you have been referred from your primary care provider it is your responsibility to obtain the required referrals prior to your visit.


It is your responsibility to understand your benefit plan with regard to, for instance, covered services and participating laboratories.


For example:

Not all plans cover annual healthy (well) physicals, sick visits, sports physicals, laboratory tests, or other visits. If these are not covered, you will be responsible for payment.


If you are being seen for an annual well or preventive physical, then you may be responsible for charges if you discuss any current medical issues as per your insurance contract.


Urban Medical Group wants to give you the best medical care irrespective of your individual issuance contracts, and as a result we will always discuss any medical concerns that you have during your visits. However, Urban Medical Group cannot verify for each patient what is and what is not covered in terms of preventive and sick visits. You must call your insurance carrier for those details.


It is your responsibility to know if a written referral or authorization is required to see specialists, whether preauthorization is required prior to a procedure, and what services are covered.


Referrals/Prior Authorizations

Advance notice is needed for all non-emergent referrals, typically 3 to 5 business days.It is your responsibility to know if a selected specialist participates in your plan.Remember, we must approve referrals before they are issued.Prior authorizations for non-emergent procedures, imaging, and medications typically take 3-5 business days.


Financial Responsibility

According to your insurance plan, you are responsible for any and all co-payments, deductibles, and coinsurances.


Co-payments are due at the time of service. We are required by law to obtain your copay for the visit as per our agreement with your insurance carrier and you are also obligated to pay your copay as per your contract with your carrier. Failure to do so would be considered fraud by you and our practice.


Self-pay patients are expected to pay for services in FULL at the time of the visit. If we do not participate in your insurance plan, payment in full is expected from you at the time of your visit.


Patient balances are billed immediately on receipt of your insurance plan’s explanation of benefits. Your remittance is due within 30 business days of your receipt of your bill.


If previous arrangements have not been made with our finance office, any account balance outstanding longer than 28 days will cause a termination of your patient portal benefits and credentials. Any balance outstanding longer than 90 days will be forwarded to a collection agency.


If you are financially unable to pay your entire balance within the specified time, then a payment plan may be possible for a given situation.


For scheduled appointments, prior balances must be paid prior to the visit.If you participate with a high-deductible health plan, we require a copy of the health savings account debit or credit card, or a copy of a personal credit card to remain on file.We accept cash, checks, Visa, AMEX, Discover, and MasterCard credit and debit.


A $20 fee will be charged for any checks returned for insufficient funds.    


Forms

There is no extra charge for a medical form given at the time of your visit. This is considered part of the visit. Any additional school, camp, sports, work or other medically related forms are subject to a $10-per-form fee if not part of your visit. Payment is due when the forms are dropped off. We require a 3-day turnaround time.


Transfer of Records

If you transfer to another physician, we will provide a copy of your medical records at the price per page listed in the notice of privacy and practices policy. We need 48 hours notice.We provide records of your visits (including consultations from specialists) rendered here at Urban Medical Group. For any previous records, you must request them directly from your previous providers.I acknowledge that I have read and understand the office policies of Urban Medical Group PLLC by signing below.


Patient Name:  

Patient Signature:

Date: