Patient Information

What to Bring to Your Appointment

  • Your insurance card
  • Physician referral forms if required by insurance
  • A list of current prescriptions and/or over-the-counter medications you are taking, including dose and frequency
  • Pertinent information about your medical and surgical history
  • Any recent x-rays or appropriate records you may have

Fees & Insurance

Our fees are based on the level of knowledge, time, tests involved, to provide diagnosis and treatment. The fees of our top procedures are available upon request. To keep our records current, please come prepared to show your insurance card each time you visit the office. We participate with the majority of area insurances. Please check with your insurance company to confirm your coverage. If you do not have insurance coverage, you will be expected to pay $50 at the time of your visit.

Co-payments and charges applicable to your deductible are expected to be paid at the time of your visit. We accept payments in cash, by check and major credit cards. Online payment is available via our patient portal or website at www.urologycenterpc.net. For surgery and other diagnostic procedures, payment arrangements may be made with our billing department. You will receive a monthly statement whenever there is a balance due.

 

We encourage you to call our billing department at (402) 397-5255 with any questions you have on your account.

Patient Bill of Rights and Responsibilities

We believe our patients, or their appointed representative, have certain rights as well as certain responsibilities.

Below is a summary of these rights and responsibilities.

As A Patient, You Have The Right To:

RESPECTConsiderate, respectful care at all times and under all circumstances with recognition of your personal dignity.

PRIVACY – Personal and informational privacy and security for self and property.

REPRESENTATIVE – Have a representative (parent, legal guardian, person with medical power of attorney) exercise the Patient Rights when you are unable to do so.

CONFIDENTIALITY Confidentiality of records and disclosures and the right to access information contained in your clinical record. Except when required by law, you have the right to approve or refuse the release of records.

INFORMATION – Information concerning your diagnosis, evaluation, treatment and prognosis., know the identity and professional status of individuals providing service.

INTERPRETER SERVICES  To know that interpretation services are available.

CONSENT OR REFUSAL – Make decisions about medical care, unless contraindicated for medical reasons, including the right to accept or refuse medical or surgical treatment after being adequately informed of the benefits, risks and alternatives, without coercion, discrimination or retaliation. To consent or refuse to participate in any unusual, experimental or research project without compromising your access to services.

ADVANCED DIRECTIVERight to formulate an advance directive.

PAIN MANAGEMENT
Competent, caring healthcare providers who act as your advocates and treats your pain as effectively as possible.

PHYSICAL RESTRAINTBe free from unnecessary use of physical or chemical restraint and or seclusion as a means of coercion, convenience or retaliation.

TRANSFERSKnow the reason(s) for your transfer either inside or outside the facility.

NON-DISCRIMINATION
Impartial access to treatment regardless of race, age, sex, ethnicity, religion, sexual orientation, or disability.

FINANCIAL RESPONSIBILITY – Accept personal financial responsibility for services provided. Receive an itemized bill for all services in a timely manner. Be informed of the source of reimbursement and have the opportunity to make financial arrangements with our billing staff.

OWNERSHIP – Know about any business relationships among the facility, healthcare providers, and others that might influence your care or treatment.

CONCERNSReport any concerns regarding the quality of services provided to you or file a grievance with the facility by contacting the Administrator or Outpatient Surgery Manager, via telephone or in writing.

As A Patient, You Are Responsible For:

To keep your appointment or notify us in advance if you will be unable to do so.

Provide accurate demographic information including phone number, address, insurance information and employer information.

Provide, to the best of your knowledge, accurate and complete information about your present health status, medications, allergies and past medical history and reporting any unexpected changes to your physician(s).

To cooperate fully in the treatment plan determined with your doctor.

To be respectful of our staff and other patients in the facility.

Providing an adult to transport you home after surgery and an adult to be responsible for you at home for the first 24 hours after surgery if you are having a general anesthetic.

To let us know if you do not understand or cannot follow our healthcare instructions.

To let us know of your desire to refuse treatment, leave the facility against the advice of the physician, and/or do not follow the physician’s instructions relating to your care.

To be prompt in the payment of your account and to comply with any payment plans set up for you.

Provide any information any living will, power of attorney, advanced directive, etc. that could impact your care.

Advance Directive

Regardless of any advance directives set forth in a living will, health care power of attorney or other written statement, any unexpected medical emergency, in this facility, will be managed with resuscitative or other stabilizing measures followed by a transfer to a hospital’s emergency department. If you have an executed advance directive, please bring a copy with you at the time of your appointment. We will place the directive in your medical records. If you need assistance in obtaining an advance directive form, please contact us for assistance.

Your Right to File a Complaint

If you believe your rights as a patient have been violated, you may file a complaint with our administrator.

To file a complaint with our office, contact our administrator at:

Laura Forehead, Administrator
402-397-9800 x 1213

Peggy Poe, Outpatient Surgery Manager
402-397-7178 x 1113

____________________

If you do not receive a response following an adequate amount of time
to address your concerns, you may file a complaint with:

The State Of Nebraska – Department of Health and Human Services

dhhs.ne.gov/Pages/complaints.aspx

OR

Office of the Medicare Beneficiary Ombudsman

http://www.medicare.gov/claims-and-appeals/medicare-rights/get-help/ombudsman.html