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JOHN J. BASILE, MD, PC SUNIL V. PATEL, MD Adult and Pediatric Urology
Dear valued patient, There is a growing trend among insurance companies to refuse payment for any office visit that relates to the evaluation and/or treatment of erectile dysfunction. This would include any visit to the office that results in prescribing the drugs Viagra/Levitra/Cialis, Caverject, or similar medications. Many insurance companies refuse to pay for an entire office visit if your main reason for seeking treatment is not related to erectile dysfunction. More astonishing, even if the reason for your visit is the treatment of erectile dysfunction, and you have been provided a referral by your managed care physician, your insurance company may still refuse to pay for your entire visit. We are distressed by this practice, and we will continue to make every effort to evaluate and treat your conditions in an effective and appropriate manner. Due to the large number of insurance companies we deal with, we will be unable to determine at the time of your appointment whether or not your insurance will cover these services. We strongly recommend that you become familiar with your individual policy, so that you are aware of any such limits on your coverage. Due to this growing trend by insurance companies to refuse payment for the evaluation and treatment of erectile dysfunction, it has become necessary for this office to institute a new policy concerning payment for these services. Effective immediately, if erectile dysfunction is discussed or treated, or if a prescription or samples of medications used in the treatment of erectile dysfunction is provided to you during an office visit, you must agree to be responsible for payment in full for the services provided. As a courtesy to you we will not require you to pay this sum at the time of your visit, and we will submit your bill to your insurance company for you. However, if we are denied payment for any or all of the visit, you will be responsible for payment of this amount in full within 30 calendar days upon notification. If you opt not to discuss erectile dysfunction during the office visit, we will try to expedite scheduling another office visit to deal solely with this issue. In addition to co-payments, if applicable, the charges for office visits are as follows:
If you are a new patient to this practice who presents without insurance, insurance card or if applicable, a referral form, you will be required to pay our usual and customary fee of $250 for a new patient consultation at the time of the visit. If any checks are returned for insufficient funds, there will be an additional penalty fee of $25, which must be paid within 30 days upon return of your insufficiently funded check. Should financial need arise, we can work out a payment plan, but the entire amount must be paid in full within 90 days. We regret that we have to resort to these steps and truly feel that the insurance companies have overstepped their bounds with regard to reimbursement issues. If you have any questions or concerns about this issue, please do not hesitate to discuss them with us.
Your signature below will serve as your acknowledgement of your responsibility for payment of services rendered, and your understanding of the contents of the above information.
Print name Date Signature
Dear Patient: These pills are now available for treatment of erectile dysfunction. They may or may not benefit your individual situation. You are instructed to take one 50 mg Viagra, or 10 mg Levtra, or 10 mg. Cialis approximately one hour prior to desired intercourse. If the pill is not completely effective and if no significant side effects are recognized, you may try taking two 50 mg (100 mg) Viagra pills, two 10 mg (20 mg) Levitra pills, or two 10 mg (20 mg) Cialis pills after a 24-hour period has elapsed. The main side effects of these pills, in order of incidence, are as follows:
These side effects will generally resolve on their own within 24 hours. If any serious side effects occur, you are not to take any additional pills. Do not take Viagra, Levitra or Cialis within 24 hours of penile injection therapy or intraurethral suppository use. There have been reported cases of priapism (prolonged erection). If your erection lasts longer than four hours, call this office or go to the nearest emergency room. This medication is contraindicated (DO NOT TAKE) if you are taking a nitrate medication (e.g., Nitroglycerin, Isordil, Isosorbide), see below list of commonly prescribed nitrates. You should not take Viagra, Levitra, or Cialis if you have angina or chest pains. Should you develop chest pains, angina, or require the need for Nitroglycerin usage, (DO NOT TAKE ANY VIAGRA, LEVITRA, OR CIALIS) without the permission of your urologist or cardiologist. The other relative contraindications are a possible increase in plasma, or blood level, of the Viagra or Levitra if you are taking Cimetidine (Tagamet), Erythromycin or anti-fungal medication (pills, not creams). This list is incomplete. Before taking Viagra, Levitra, or Cialis, ask your pharmacist regarding other possible drug interactions including alpha blocker usage (Hytrin/Terazosin, Cardura/Doxazosin, Flomax/Tamsulosin). If Viagra, Levitra, or Cialis is successful, call your pharmacy or any pharmacy in the area that your insurance contracts with until you are able to find one that has the medication in stock. Refills will be provided with the prescription, but after a one-year period you will be required to make an appointment before any additional refills will be provided. Insurance coverage: I have no way of knowing whether or not this prescription will be covered by your insurance plan. Therefore, I totally divulge myself of any responsibility regarding payment for this medication. This is your responsibility. If you have any questions, call your insurance company prior to calling us with the request for a prescription.
I have read this form and I hereby give informed consent for the administration of the samples and/or the prescription for Viagra, Levitra, or Cialis pills. My doctor has given me a chance to ask any questions, and I express a complete understanding of the above.
Commonwealth Urology
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