Jeffrey A. Snyder, M.D., F.A.C.S.
Updated October 1, 2007
We strive to provide high quallity care in a friendly setting. To help us reach our goal, the following policies are in place for our practice. Please read and INITIAL next to every policy. Thank You.
1. ____ OFFICE VISITS: All office visits are to be scheduled. Please call our office before coming in. If you believe you have an urgent situation, please call us first before coming in. If you are more than 15 minutes late, you may be asked to reschedule.
2. ____ CANCELLATIONS/NO SHOW: To provide high quality care and in fairness to other patients and the Doctor, we require at least 24 hours notice to cancel appointments. There will be a $50 fee for the second missed or late cancelled appointment without 24 hour notification, which will be due and payable from YOU. There will be a $150.00 charge for a missed procedure appointment. The practice reserves the right to dismiss patients with three missed or cancelled appointments.
3. ____ TELEPHONE CALLS: We strive to return phone calls in a timely manner. We ask you to reserve after hour calls for urgent matters only, save routine questions for office hours.
4. ____ PERSONAL INFORMATION: All information will be verified each visit. If you have changed any information (address, phone number, insurance, etc.), it is your responsibility to notify the front desk. We will bill your insurance as a courtesy if the appropriate information is provided.
5. ____ PAYMENT REQUIREMENTS: CO-pays are required for service at all times. We accept cash, personal checks, Visa and MasterCard. We reserve the right to refuse payment in the form of a check if there are checks returned on your account. In the event that we must re-bill you, there could be a re-billing charge.
6. ____ HEALTH INSURANCE: As a service to you, we will accept "assignment of benefits" and will bill your insurance carrier, provided proper paperwork is provided to us. Every effort will be made to closely estimate your co-payments and deductibles, which are due at the time of service, but the ultimate responsibility for the unpaid balance rests with you. Please understand that insurance is a contract between you and your insurance carrier. If an insurance carrier has not paid within 60 clays of billing, any unpaid fees are due and payable in full from you.
7. ____ NON-COVERED CHARGES: Any charges not paid by your insurance carrier will require payment in full at time services are provided or upon notice of insurance claim denial. Financial policies are extended payments may be discussed with our office manager. The billing policy can only be overridden with the Doctor's approval.
This acknowledges that I have read and had the opportunity to ask questions about these policies.
Patient Signature __________________________________________________
Date _________________________
Genitourinary Surgical Consultants
4500 East 9th Avenue
Suite 530
Denver, CO 80220
Tel: 303.320.0200
Fax: 303.320.4111
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