Thank you for choosing Kansas City Urology Care, PA as your urology health care provider. We are committed to providing you with the highest quality medical care, in a supportive, empathetic and respectful manner. If you have special needs, we are here to work with you.

The following information is provided to avoid any misunderstanding or disagreement concerning payment for professional services. Your clear understanding of our “Patient Financial Policy” is important to our professional relationship. Please ask if you have any questions about our fees, our policies or your responsibilities. Carefully review the following information and return this form to us with your signature and today’s date.


It is the patient’s responsibility to provide the clinic with current insurance information since our practice participates with a variety of insurance plans. Your insurance policy is a contract between you and your insurance company. We consider an insurance card similar to a credit card because you are asking us to bill another party (your insurance) for charges for the services you have been provided.

As a courtesy, we will file your claims for you. However, we will not become involved in disputes between you and your insurance carrier. This includes, but is not limited to, deductibles, co-payments, non-covered charges and “usual and customary” charges. We will supply information as necessary. You are ultimately responsible for the timely payment of your account.

If we DO participate with your insurance company, all services performed in our office will be submitted to them, unless we have received prior notification of non-covered services. All copays and deductibles are the patient’s responsibility. Copay’s are due at the time of service.

If we DO NOT participate with your insurance company, we will file the insurance claim and accept the payment, but we will not accept the contractual adjustment. That balance will be the patient’s responsibility and any balances that are not covered will be the patient’s responsibility.

Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover. It is your responsibility to know if a certain procedure is not covered, please check your insurance handbook.

It is your responsibility to bring any required referrals for treatment at, or prior to the visit. If you do not have the referral, your visit may be rescheduled, or you may be financially responsible.


Your insurance company requires us to collect co-payments at the time of service. Waiver of co-payments may constitute fraud under state and federal law. Please help us in upholding the law by paying your co-payment at each visit. For your convenience we accept cash, check, or credit card (MasterCard, VISA, AMEX or DISC). If you do not bring proper payment to your visit, you may be asked to reschedule your appointment except in the case of a medical emergency.

Patients with NO Medical Insurance

If you do not have group or individual medical insurance, payment for professional services is expected at the time of service. As a courtesy, the practice offers a 30% discount of billed charges, to anyone with no insurance if paid at the time of service. This discount is available ONLY ON the actual date of service.

If unable to pay at the time of service, at the discounted rate (30% of billed charges), we require a $100 down-payment toward all billed services, which will be at the full fee amount. If you have questions, we would recommend that you contact our billing department (913-341-7985) prior to your appointment.

Waiver of Patient Responsibility

It is the policy of the practice to treat all patients in an equitable fashion related to account balances. The practice will not waive, fail to make reasonable collection efforts, or discount co-payments, co-insurance, deductibles, or other patient financial responsibility in accordance with state and federal law, as well as participating agreements with payers. Full or partial financial responsibility may only be waived in accordance with the Kansas City Urology Care’s Charity Care Policy.

Un-Paid Balances & Payment Arrangements

If your insurance company has not paid the balance in full or you are unable to pay the balance in full, you will receive a statement notifying you of the amount due, you may call our billing office at (913)-341-7985 to set up payment arrangements if necessary. If you fail to make payment in full, within 120 days, for the services that are rendered to you, your outstanding balance may be considered for further collection activity.

Late Arrivals

A late arrival, not considered to be the responsibility of Kansas City Urology Care, will be registered and worked into the schedule as soon as possible. If the patient is more than 30 minutes late, the appointment may be rescheduled.


Kansas City Urology Care, PA may charge a $50 “no-show” fee in the event that you do not show for your appointment and in which you do not cancel or reschedule with 24 hours’ notice. This will be applied to your account.

Returned Checks

The charge for a returned check is $30 payable by cash or money order. This will be applied to your account in addition to the insufficient funds amount. You may be placed on a “Cash Only” basis following any returned check.


Our practice does not treat minors without the presence of a parent(s) or guardian(s). If the patient is a minor (under 18 years of age), the parent(s) or guardian(s) is responsible for full payment and will receive the billing statements.

Divorce Decrees

Kansas City Urology Care is not party to any divorce decrees, so any outstanding balance is still the responsibility of the patient or the legal guarantor of the patient, in the case of a minor.

Special Form Fees

If you require any special forms to be completed (for example; FMLA, Work Comp or Disability) by a physician, the patient/guarantor will be responsible for any fees related to the service.

Medical Record Copies

Your medical record is the property of Kansas City Urology Care, PA. If you would like to request a copy of your medical records, for yourself or to be mailed to another provider, please contact your physician’s office to obtain the proper Medical Records Request form.

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Kansas City Urology Care may charge a reasonable cost-based fee pursuant to 45 CFR 164.524. Kansas City Urology Care has developed a fee structure that is slightly below the Missouri and Kansas Department of Health Services maximum standards:

  • • Clerical fees $18.50
  • • For the first 250 pages $ 0.50 per page (maximum $125.00)
  • • For each page after 250 $ 0.45 per page
  • • Plus actual postage

Kansas City Urology Care must emphasize that as healthcare providers, our relationship is with you, not your insurance company. While filing the insurance claims is a courtesy we extend to our patients, all charges are strictly your responsibility from the time services are rendered. Therefore, it is often necessary for you to inquire and explore your benefits with your insurance carrier. We do realize that temporary financial problems may affect timely payment, but if such problems do arise, we encourage you to contact us promptly for assistance in the management of your account at 913-341-7985.

Kansas City Urology Care believes that a good patient-to-physician relationship is based upon understanding and good communication. Thank you for understanding our “Patient Financial Policy”. We appreciate the opportunity to provide you with your urological care. Your assistance and cooperation will be most appreciated.

Financial Policy

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