Patient Info

Your First Visit

    • Make Your First Visit Easy. Bring The Following:
  • Patient Identification
  • Insurance Cards
  • Completed Patient Forms (link to patient forms page)
  • Related X-Rays
  • Records From Referring Physician
  • List of Medications

Be prepared to share your medical history with our providers. This will include any medical conditions you have or may have had in the past, surgical history, any medications (prescription or over-the-counter) you are currently taking (include name, dosage and frequency), and any allergies you have to medications or foods.

Financial Policy

Urology Associates participates in the Medicare and Mississippi Medicaid programs as well as other commercial insurance products. If the Clinic participates in your insurance plan you will be responsible for all copays, deductibles, and coinsurance amounts at the time of service. You will also be responsible for any services not covered by your insurance plan. You must bring your insurance card(s) to every visit.If the Clinic does not participate in your insurance, we will file your insurance as a courtesy but you will be responsible for all charges not paid by your insurance. You will be required to pay a $200 deposit on your first visit which will be applied against your charges.If you do not have any insurance you will be required to pay a $200 deposit on your first visit which will be applied against your charges. This must be paid before you are seen. All future charges should be paid at time of service unless you work out other payment arrangements with our billing staff. We do offer patients with no insurance coverage a discount when charges are paid in full at time of service. Please ask any of our billing or check out staff about this discount.You understand that you are financially responsible for all Clinic charges unless covered and paid by your third party insurance as explained above. If you should default on your financial responsibility, you understand that your account may be turned over to a collection agency. If that occurs, you may be charged for all reasonable collection fees incurred by the Clinic.


Please provide complete and accurate insurance information. Please bring all insurance cards and show them to the receptionist; usually these will be copied and placed on file with your records. It is your responsibility to notify us of any special requirements of your insurance carrier, such as the need for second opinions, pre-admission certification, or pre-procedure certification and of any change in your coverage.Insurance is filed for you free of charge to your insurance company.Our insurance clerk is on staff to assist you and will handle any questions or problems you might have regarding your insurance. The insurance clerk may be reached by calling 662-377-7105. Please do not ask your physician to fill out forms while you are in the examining room.We do participate in the following plans:

  • Medicare
  • Mississippi Medicaid
  • Blue Cross / Blue Shield
  • Healthlink
  • United Healthcare
  • Aetna
  • Cigna
  • Humana

Patient Information Forms

The information requested on the confidential patient forms is not intended to be an invasion of your privacy. It is necessary in order for the doctor to treat you, for the filing of your insurance, and for us to be able to reach you when necessary. Please fill out the form completely and accurately. We will be glad to provide assistance if requested.View and print these forms using Adobe Acrobat Reader® (PROVIDE LINK HERE)Once you have the Adobe Acrobat Reader® installed, click on these links to view and print the following forms

Privacy Practices



PLEASE REVIEW IT CAREFULLY. State and Federal laws require us to maintain the privacy of your health information and to inform you about our privacy practices by providing you with this Notice.  We must follow the privacy practices as described below.  This Notice will take effect on September 23, 2013 and will remain in effect until it is amended or replaced by us.It is our right to change our privacy practices provided law permits the changes.  Before we make a significant change, this Notice will be amended to reflect the changes and we will make the new Notice available upon request.  We reserve the right to make any changes in our privacy practices and the new terms of our Notice effective for all health information maintained, created and/or received by us before the date changes were made.You may request a copy of our Notice of Privacy Practices at any time by contacting our Privacy Officer, Marilyn Wilkerson.  Information on contacting us can be found at the end of this Notice.TYPICAL USES AND DISCLOSURES OF HEALTH INFORMATIONWe will keep your health information confidential, using it only for the following purposes


We may use your health information to provide you with our professional services.  We may also disclose and/or share your healthcare information with other health care professionals who provide treatment and/or service to you.  These professionals will have a privacy and confidentiality policy like this one.  Health information about you may also be disclosed to your family, friends and/or other persons you choose to involve in your care, only if you agree that we may do so.  We may contact you to provide you information about treatment alternatives or other health-related benefits and services that may be of interest to you.


We may use and disclose your health information to seek payment for services we provide to you.  This disclosure involves our business office staff and may include insurance organizations or other businesses that may become involved in the process of mailing statements and/or collecting unpaid balances. If you pay for services out-of-pocket and in full, you may request that we not disclose protected health information related solely to those services to an insurance company or health plan, and we must comply with that request unless we are otherwise required by law to disclose that information.


We may use or disclose your health information to notify, or assist in the notification of a family member or anyone responsible for your care, in case of any emergency involving your care, your location, your general condition or death.  If at all possible we will provide you with an opportunity to object to this use or disclosure.  Under emergency conditions or if you are incapacitated we will use our professional judgment to disclose only that information directly relevant to your care.  We will also use our professional judgment to make reasonable inferences of your best interest by allowing someone to pick up x-rays or other similar forms of health information and/or supplies unless you have advised us otherwise.

Healthcare Operations:

We will use and disclose your health information to keep our practice operable.  Examples of personnel who may have access to this information include, but are not limited to, our medical records staff, outside health or management reviewers and individuals performing similar activities.

Required by Law:

We may use or disclose your health information when we are required to do so by law.  We will use and disclose your information when requested by national security, intelligence and other State and Federal officials and/or if you are an inmate or otherwise under the custody of law enforcement.

Judicial and Administrative Proceedings and Law Enforcement Purposes:

We may disclose your health information in response to a court order, subpoena or request from law enforcement personnel only as permitted by federal and state law.

Abuse or Neglect:

We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes.  This information will be disclosed only to the extent necessary to prevent a serious threat to your health or safety or that of others.

Public Health Responsibilities and Health Oversight Activities:

We will disclose your health care information to report problems with products, reactions to medications, product recalls, disease/infection exposure and to prevent and control disease, injury and/or disability.  We may disclose your healthcare information to a health oversight agency for oversight activities authorized by law.

Marketing Health-Related Services:

We will not use your health information for marketing purposes unless we have your written authorization to do so.

National Security:

The health information of Armed Forces personnel may be disclosed to military authorities under certain circumstances.  If the information is required for lawful intelligence, counterintelligence or other national security activities, we may disclose it to authorized federal officials.

Appointment Reminders:

We may use or disclose your health information to provide you with appointment reminders, including, but not limited to, voicemail messages, or letters.

Department of Health and Human Services:

We may disclose your health information when required by the U. S. Department of Health and Human Services as part of an investigation or determination of our compliance with relevant laws.

Coroners, Medical Examiners and Funeral Directors:

We may disclose your health information to a coroner, medical examiner or funeral director as permitted by law.

Workers’ Compensation:

We may disclose your health information as authorized by laws relating to workers’ compensation or similar programs.

Business Associates:

We may disclose your health information to a business associate with whom we contract to provide services on our behalf, subject to the business associate’s agreement to appropriately safeguard the health information of our patients.

Authorized Uses and Disclosures:

We will not use or disclose your protected health information for any other purpose without your written authorization.  Specifically, we will not use or disclose your protected health information without your written authorization in the following circumstances: (1) most uses and disclosures of psychotherapy notes; (2) uses and disclosures of protected health information for marketing purposes, including subsidized treatment communications; and (3) uses and disclosures that constitute a sale of protected health information. Once given, you may revoke your authorization in writing at any time except to the extent that we have taken an action in reliance on the authorization.  To revoke an authorization, you or your authorized representative may contact Marilyn Wilkerson, Privacy Officer, at Urology Associates, P O Box 829, Tupelo, MS  38802, Telephone: 662-377-7100.



Upon written request, you have the right to inspect and get copies of your health information (and that of an individual for whom you are a personal representative.)  There will be some limited exceptions.  If you wish to examine your health information, you will need to complete and submit an appropriate request form.  Contact our Privacy Officer for a copy of the Request Form.  You may also request access by sending us a letter to the address at the end of this Notice.  Once approved, an appointment can be made to review your records.  We will provide electronic access upon request.  A copying fee will be charged.  If you prefer a summary or an explanation of your health information, we will provide it for a fee.  Please contact our Privacy Officer for a fee and/or for an explanation of our fee structure.


You have the right to amend your healthcare information, if you feel it is inaccurate or incomplete.  Your request must be in writing and must include an explanation of why the information should be amended.  Under certain circumstances, your request may be denied.

Non-routine Disclosures:

You have the right to receive a list of non-routine disclosures we have made of your health care information.  You have the right to receive an accounting of the disclosures of your medical information made by Urology Associates during the last six years, except for disclosures for treatment, payment or health care operations, disclosures which you authorized and certain other specific disclosure types.  The right to receive this information is subject to certain exceptions, restrictions and limitations.


You have the right to request that we place additional restrictions on our use or disclosure of your health information.  We do not have to agree to these additional restrictions, except to an insurance company or health plan for services you have paid for in full and out of pocket, but only if we are not otherwise required by law do so.  Otherwise, if we do agree to your request for restrictions, we will abide by our agreement except in emergencies.  Please contact our Privacy Officer if you want to further restrict access to your health care information.  This request must be submitted in writing.

Notice of Breach:
In the event of a privacy or security breach of your unsecured protected health information, we will promptly notify you in accordance with applicable state and federal law.


You have the right to file a complaint with us if you believe we have not complied with our Privacy Policies.  Your complaint should be directed to our Privacy Officer.  If you believe we may have violated your privacy rights, or if you disagree with a decision we made regarding your access to your health information, you can complain to us in writing at Urology Associates, P O Box 829, Tupelo, MS  38802, Attn:  Marilyn Wilkerson.  Request a Complaint Form from our Privacy Officer.  We support your right to the privacy of your information and will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services Office for Civil Rights.


  • Practice Name:  Urology Associates
  • Chief Executive Officer: Kyle Fallin
  • Telephone:  662-432-07000
  • Address:  P.O. Box 829, Tupelo, MS  38802