Patient Resources

We would like to welcome you to Atlantic Urology Associates and the Center for No-Scalpel Vasectomy. We thank you for the opportunity to be involved in your care. Our Physician and staff are committed to providing you with an unsurpassed healthcare experience. 

Below is information and downloadable forms that will make your visit with us pleasant and efficient. Thank you again for choosing our practice and we look forward to seeing you.

 

What to bring to the appointment

  • Current Insurance card
  • Driver's License or other Picture ID
  • Approved Form of payment (see below)  
  • Credit card for "Credit Card on File" (CCOF) swipe if going through Aetna or Blue Cross/Blue Shield 
  • Print out, fill out, and bring New Patient form (see link below)
  • Any relevant radiology, pathology, laboratory, medical or surgical reports
  • Primary care physician referral form, if required by insurance

Forms

Please download, print, and complete the following forms you will need for your appointment.

Practice Policies:

  • Aetna, and Blue Cross/Blue Shield Patients: Effective November 1, 2015 we implemented a CREDIT CARD ON FILE (CCOF) policy for patients with these insurances.  In addition to collecting the estimated patient responsibility at the time of service, patients with these in-network insurances will also be asked to sign the CCOF agreement and present a credit card to be entered into a secure HIPPA and PCI compliant off-site server. Any balance, or overpayment, to PATIENT RESPONSIBILITY will be billed, or refunded, to the CCOF after the insurance company does final adjudication of the claim (EOB).  For more information please see Dear Patient Letter, Financial Policy, AUTH CCOF  
    Patients using in-network commercial insurance are responsible to check with their insurance company that their "coordination of benefits", premiums, precertification's, and referrals are all in order. CCOF will be charged for balances resulting from these deficiencies. Questions regarding your coverage and benefits should be directed to your employer or insurance company. We do not bill, nor accept, insurance secondary to primary commercial insurance. 
  • "Out of network" insurance or patients without insurance (self-pay): We ask for full payment at time of service. No CCOF required. Patients with "out of network" benefits will be provided with a statement that they can submit to their insurance company for reimbursement.
  • Cancellation/no show Policy: ; 
    • A $75.00 charge is applied if patient does not give us a minimum of 24 hour (not including weekends) notice of need to cancel an office visit appointment. 
    • A $150.00 charge is applied if patient does not give us a minimum of 72 hour (not including weekends) notice of cancellation of a procedure appointment. 
  • Payment types accepted: We accept cash, money orders, debit card, Visa, American Express and Master Card. If paying on day of service by credit card, your credit card must be present to swipe at time of visit even if we have a credit card on file (CCOF).  
  • Please notify the office promptly any time there is any change in your contact info, insurance information, or CCOF information. Charges will apply for incorrect or lapsed information.
  • Our Notice of Privacy Practices

Hospital Affiliations