Limitation of Practice:
Patient understands that Drs. Jenkins, Dr. Morrow’s & Dr. Gayheart’s practice is limited to Oral and Maxillofacial Surgery.
Patient hereby gives my consent, if needed, for drawing blood samples for diagnosis or in case of accidental puncture of exposure to medical personnel during my course of treatment either in the offices or in the hospital. These tests may include AIDS testing.
Insurance Claims Filing:
In all cases, the patient is responsible for payment of their account. As a courtesy, Jenkins, Morrow & Gayheart will file a claim to the patient’s insurance carrier.
Assignment and Release:
Patient hereby authorizes and assigns applicable insurance benefits to be paid directly to the physician. Patient is financially responsible for non-covered services. Patient authorizes release of information necessary to process insurance claims. Patient authorizes photographs, diagnostic dental models restricted for medical, dental, education or insurance purposes and information release to other practitioners in good faith effort for my medical care. Patient authorizes disclosure of medical record information to JCAHO surveyor in connection with performance of his/her duties as a surveyor.
Payment of your deductible as well as an estimate of your share (co-payment) of the fee is due at the time services are rendered. Payments can be made in the form of cash, check, Visa, MasterCard or Care Credit. If the insurance pays more or less than the estimated amount you will be billed or reimbursed accordingly. Patient balances are due 30 days after insurance coverage payment has been made.
If, for any reason, the patient cannot make scheduled payments, the patient must immediately contact the office of Jenkins, Morrow & Gayheart to make acceptable arrangements. Drs. Jenkins, Morrow and Gayheart reserve the right to refer all unpaid accounts to collection agencies. Any fees associated with collection, including collection agency contingency fees and/or court costs, will be added to the patients account balance. After accounts are placed with collection agencies all patient visits and procedures will be conducted on a cash only basis.
• Drs. Jenkins, Morrow and Gayheart reserve the right to assess a service charge, not to succeed $20.00 per month, to a patient account for any unpaid balance over 30 days after the insurance coverage has been paid.
• A 2% credit card processing surcharge will be applied to all credit card payments.
• Patients whose Ins companies utilize the 3rd party payer ZELIS will also be subject 2% surcharge.
Health Information Privacy Policies and Procedures:
In compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I acknowledge that I have been informed of the Privacy Policies and Procedures of Jenkins, Morrow & Gayheart, PLLC. (We have a copy at the front desk.) I understand that I may obtain a copy of these procedures from the receptionist at the front desk upon request.