➡We ask that you present your insurance card at each visit. It is your responsibility to provide us with the correct information to bill your insurance. If you have a change of address or contact information, please notify us 2 weeks in advance. It is your responsibility to know your plan benefits and verify you are seeing an in- network provider.

➡If we do not participate with your insurance company and you have out-of-network benefits, we can verify those benefits with your insurance as a courtesy to you. You will be expected to make payment in full at the time service is rendered. If your insurance denies our charges or refuses payment for services rendered, the insurance portion may be transferred to the patient portion and billed to the responsible party on the patient’s account. If we do not participate with your insurance and you do not have out of network benefits, please be sure to make private pay arrangements with us prior to your first visit.

➡We will collect your co-payment, patient responsibility, private pay fees, and/or collect for non-covered services prior to a scheduled procedure. If you have a balance from a previous service, we will also collect that payment. We accept cash, cashiers checks, Visa, MasterCard, Discover, and American Express. Check payments will not be accepted. Patient care is our top priority, however payment is due for services rendered. If your account becomes delinquent, we reserve the right to refer your account to a collection agency.

➡Insurance Billing: If we participate with your plan, we will bill your insurance for you. Your plan provider can verify if we are in-network with your insurance plan. If your plan requires you to have an authorization to see us, you need to obtain that prior to visiting our office. Your insurance is a contract between you (in some cases, your employer) and your insurance company. We are not a party to that contract. It is very important that you understand the provisions of your policy. If your insurance company pays only a portion of the bill or rejects your claim, any contact or explanation should be made to you, their policy holder. Reduction or rejection of a code or claim which the American Medical Association considers payable does not relieve you of your financial obligation. Remember, whether you do or do not have insurance, you are ultimately financially responsible for payment of your charges.

➡Our office uses secure electronic auto-reminders, electronic patient messaging, and secure attachments. Should you wish to opt out of these services, please notify us in writing here.

➡Your health information may be entered into a quality database to assist the physicians in understanding of the patients condition and/or help with medical research. Medical documentation and medical images may be taken and used in publications for educational purposes. The patients identity will never be used or revealed in any descriptive texts accompanying pictures and/or videos. By allowing us to do so, our providers are able to improve in quality care.

➡We welcome visits by surgeons to observe and learn from our physicians. I (d0) (do not) consent to the possible presence of a medical observer in the operating/procedure room during my surgical care should my surgeon make such a request. I understand that said observer is not in any way associated with PARC Surgical Center. I hereby release PARC Surgical Center, the physicians, its agents, assigns, and successors, from any and all liability, which may result from the presence of a scientific observer.

➡No show or missed appointments: When an appointment is scheduled, time is specifically allocated for you. If the appointment is not canceled in advance, we cannot offer that time to another patient. We require a minimum of 48 hours advance notice if you believe you need to cancel or change your appointment. Failure to do so will result in a $50.00 fee applied to your account.

➡Rescheduling Surgery: Due to the large block of time reserved for your procedure, as well as the international nature of our business, last minute cancellations can create access-to-care problems, as well as significant expenses to the facility, surgeons, and anesthesiologists. If you need to cancel or change your surgery date, please contact our office at least 1 month in advance. If you do not give us notice, and fail to appear for a scheduled surgery date, you will have a $1,000.00 “no-show” fee assessed to your account. If you call to reschedule or cancel a surgery with less than 1 month prior notice, you will be charged a $500.00 change fee. These fees are not covered by insurance and must be paid in full prior to rescheduling the surgery. We understand that extenuating medical circumstances may occur and fees in these instances may be waived subject to management approval.

➡If you have a young child and want to have our staff sit with him during your consultation with the doctor, we are happy to help. By choosing to do so, you agree to release and hold harmless Hypospadias Specialty Center from any and all claims, demands, suits, costs, and/or charges in connection with or arising out of the services
we provide. Please note: this is not a babysitting service. Parents are not permitted to leave the premises during consultations.

➡Choice of Law and Forum required provision (HB270): The patient, including patient’s representative and heirs or beneficiaries, and Hypospadias Specialty Center, including the employees and agents, rendering or providing medical care, health care, or safety or professional or administrative services directly related to health care to patient agree: That all health care rendered shall be governed exclusively and only by Texas law, and in no event shall the law of any other state apply to any health care rendered to the patient; and in the event of a dispute, any lawsuit, action, or cause of which in any way relates to health care provided to the patient shall be brought only in a Texas court in the county/district where all or substantially all of the health care was provided or rendered, and in no event will any lawsuit, action, or cause of action ever be brought in any other state. The choice of law and forum selection provisions of this paragraph are mandatory and are not permissive.