Urologic Physicians P.A.

VASECTOMY SCHEDULING SHEET

DATE OF PROCEDURE ______________________

TIME OF PROCEDURE _________________________

TIME TO REPORT TO FACILITY _______________________

NAME OF YOUR PHYSICIAN:

PLACE:

Preoperative Instructions:

_____ Do not eat or drink anything after midnight, the night before your procedure.

_____ You may have a light breakfast the morning of your procedure. If you are scheduled in the afternoon, you may have a light lunch.

_____ See your family physician for a history and physical within one week of your scheduled procedure date.

_____ You must have someone drive you home after the procedure.

_____ Do not take any aspirin, blood thinning or anti-inflammatory medication for at least 7-10 days before procedure (this includes but is not limited to Advil, Aleve, Ecotrin, Bufferin).

*Please see next page for postoperative instructions.

**If you have any questions regarding your scheduled procedure, or need to reschedule or cancel, please call our office and speak with a patient coordinator at 952.920.7660.

Vasectomy Payment Information

Each insurance company has its own policy regarding payment for elective sterilization. We are giving you this information in order to help you determine what your costs for this procedure will be before it is performed. We are unable to give you a definite cost because each insurance company has underlying plans that have different rules. When we call to ask we are told that the information being given is only an estimate and that a determination cannot be made until a claim is filed (after the procedure is performed).

Some insurance companies pay for the entire procedure whether performed in the hospital or in our office. They may require that you pay a small out of pocket fee or copay. Others have no benefits for elective sterilization. There are plans that pay for the entire procedure if performed in our office but will pay only a limited amount when done in the hospital. We do not participate with all insurance plans which raises your out of pocket expense. We are always willing to file the claim for you and do not require a prepayment. We only ask that when your cost is determined that you pay us promptly upon receiving your bill.

We ask that you call your insurance company BEFORE your procedure to have them help you determine what your best or cheapest option is. We are willing to work with you to help cut your costs. If your cost is that same wherever the procedure is done (office or hospital) we will perform it in the hospital. If our reimbursement is cut when done in the hospital we will perform it in the office. If your out-of-pocket expense is significantly higher when done in the hospital and you let us know that we will perform it in the office.

Here are the questions that you need to ask your insurer:

Here is some information that you may need to tell the insurer:

TO OUR MEDICAL ASSISTANCE PATIENTS: You must sign a consent form 30 days before your procedure. If you do not do so, we will not be paid. If we do not find the signed consent in your chart prior to your procedure, you will be cancelled.

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Urologic Physicians, PA

Main Phone: 952.920.7660
Billing/Business Office: 952.920.2046

Main address
6363 France Ave. South
Suite 500
Edina, MN 55435

Satellite offices
303 E Nicollet Blvd
Suite 310
Burnsville, MN 55337
 2545 Chicago Ave S
Suite 502
Minneapolis, MN 55404
 1515 St Francis Ave
Suite 250
Shakopee, MN 55379