Past Medical History (for your safety, you must answer all of the questions below to the best of your knowledge)

Please list ALL home medications (prescription, over the counter medicines, vitamins, herbal/dietary supplements).

**Make sure you list each medicine separately in its own box.  A new box will appear for each medicine.**

Are you taking now or have you ever taken:

Do you have any chronic medical problems?

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act (HIPAA). I understand that by signing this consent I authorize OFS, LLC (OFS) to use and disclose my protected health information to carry out:

• Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment)
• Obtaining payment from third party payers (e.g. my insurance company);
• The day-to-day healthcare operations of your practice

I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that OFS has the right to change its Notice of Privacy Practices and that I may contact the practice at any time to obtain a current copy of the Notice of Privacy Practices.

Federal law states that OFS cannot share your health information without your permission except in certain situations. If you sign this form, you are giving OFS permission to treat the person(s) you name as your Personal Representative, and to share your health information with that person. You can name more than one person as your Personal Representative. This Personal Representative Designation will remain in effect until the Revocation section is signed and submitted to OFS. Revocations or changes to this designation will not apply to information that has already been released by OFS. I understand this designation is voluntary and is being made at my request. I name the following person(s) to act as my Personal Representative:

OFS values you as a patient and respects the privacy of your personal and medical information that is disclosed to us in the course of our treatment relationship with you. The law allows us to send written communications to you about treatment and health care operations, including products and services we offer. This is a normal part of our provider-patient relationship, and no permission is required for us to do so. We believe such communications are a valuable part of our relationship with you. However, certain types of communications cannot be sent to you unless you provide written authorization to receive them such as information regarding additional services or products that we offer in our office.

Thank you for choosing OFS, LLC. We are dedicated to providing exceptional care of our patients and their loved ones. We ask that you read this document thoroughly before signing. We will be glad to answer any questions you may have regarding the information provided here.

Payment

• Just as we make every effort to accommodate you when you are in need of medical/dental care, we expect that you will make every effort to pay your bill promptly. Payment is due at the time services are provided or upon receipt of a statement from our billing office.
• You must present a current insurance card and valid identification at each visit. If you do not present a current insurance card, you will be responsible for payment in full at the time of your visit. You will receive reimbursement from OFS, LLC if your insurance pays the claim at a later date.
• Co-payments, deductibles, and fees for services not covered by your insurance policy, if known, are due at the time the service is rendered. If you owe additional money after your visit, you can expect to receive a statement. Statements are mailed out on a monthly basis. Payment is expected within 10 days of receipt of your statement.
• If your insurance carrier is not one with which we participate, you are responsible for payment in full. Insurance plans consider some services to be “non-covered,” in which case you are responsible for payment in full.
• Self-pay patients should be prepared to pay his/her balance in full at the time of service.
• For your convenience we accept cash, personal checks, and credit cards (Visa, MasterCard, American Express, and Discover). We also accept Care Credit (a medical/dental financing option) and can help you see if you qualify. Payment in full is required for all surgeries and consultations at time of service (including x-rays and CT scans).
• Outstanding balances or failure to pay co-payments upon check-in may result in reschedule of non-emergent appointments.
  Refunds
• There may be either an account balance or credit due to you upon completion of treatment. Refund checks are issued from this office on a bimonthly basis. If you feel a refund is due, please contact our billing office.

Insurance

• Professional services are delivered and charged to you the patient not to your insurance carrier. Your health and/or dental insurance policy is a contract between you and your health insurance company or employer. We cannot accept final responsibility for collection of your insurance benefits as we are not a party to your insurance contract.
• Please note it is your responsibility to know if your insurance has specific rules or regulations, such as the need for referrals, pre-certifications, pre-authorizations and limits on outpatient charges regardless of whether or not our physicians participate. If you are uncertain about your current health insurance policy benefits you should contact your plan to learn the details about your benefits, out-of-pocket fees and coverage limits.
• Our doctors belong to many insurance plans. Before your appointment, please be sure your doctor is in-network and the services are covered under your plan. If your insurance carrier is not one with which we participate, you are responsible for payment in full at time of service.
• Please be aware of and provide any required referrals or authorizations in advance of the appointment of service. If you do not provide these before care is rendered you will be responsible for the cost of care. When in doubt, contact your plan directly for clarification.
• As a courtesy and for your convenience, we do file insurance claims on your behalf. If problems arise regarding coverage issues, we will attempt to work with your insurance company to help resolve them prior to making it your responsibility. Please be advised that you are nevertheless ultimately financially responsible for payment of medical services rendered by OFS, LLC.
• Pursuant to Alabama Law, insurers are required to pay a properly submitted claim within 45 days. You have a responsibility to provide information to our office so a claim can be properly submitted. If your insurance company has not paid a claim on your behalf within 60 days, the balance will be transferred to your account and you will be responsible for payment in full. If we receive payment at a later date, you will be reimbursed.
• When possible, insurance benefits will be verified before treatment and patient/guarantor will be notified of any changes to the estimate of your portion due at time of surgery. If we contact your insurance carrier regarding benefits or authorization on your behalf, we are not responsible for inaccurate information provided to us by your carrier. The information about your plan that we relay to you is in good faith.
• Please be aware that this requires a significant amount of time on the part of our staff. We ask for you patience and cooperation when dealing with your insurance company. Upon your request, we will submit a printed predetermination of benefits; however, be aware that it takes, on average, 4 to 6 weeks to receive a response.

 

Laboratory Billing

• All laboratory service(s) done outside of the office (laboratory, pathology, prosthetics, etc.) will not be included in the charges for OFS, LLC unless specifically noted in your Treatment Estimate. These tests, procedures and services are billed separately to either your insurance company or to you. All charges not covered by your insurance are your responsibility. You should direct any questions regarding a bill or statement from an outside laboratory to that business.
• OFS, LLC reserves the right to send all necessary lab specimens to the lab of its choosing.

Guarantor

• Any patient over the age of 19, or an emancipated minor, will be held financially responsible for all charges incurred. If another party is responsible for payment of your account, you must pay your balance in full and negotiate repayment with them outside of our office. This policy includes individuals negotiating divorce agreements.
• Parent and guardians are responsible for payments for their dependents at the time services are rendered. Minors and dependents must present a valid insurance card and guarantor’s valid identification at each visit if a claim is to be filed.
• The accompanying parent or adult is responsible for payment in full at the time of service. In case of divorce, it is the parents responsibility to work out the payment of your child’s medical care between the custodial and noncustodial parent.

Fees

• A 1.5% service charge (18% annually) is added to any balance over 60 days old.
• Attorney and collection fees incurred in an effort to enforce payment by this agreement will be paid by the delinquent payer whose failure to pay required such costs and services to be incurred.
• Please be aware that in case of a returned check, a $30 charge will be collected in order to cover the cost incurred from our bank and your account will be placed on a “cash-only basis.” We will accept payments only be cash or credit card until the balance is cleared.
• There is an administrative fee of $15 for completing forms and must be paid in advance.
• Pursuant to Alabama Law Section 12-21-6.1, to copy medical records per patient request or for participation in a Deposition or Phone Consultation on your behalf, you will be charged a $5 processing fee plus $1 per page up to 25 pages, $0.50 per page for 25+ pages and actual cost of mailing the record if necessary. Radiology fee for a CD of x-rays and /or CT scans is an additional $2 fee.

Collections

• Failure to settle your account balance within 90 days of service, will result in your account moving into a collections status.
• Past due accounts may hinder your ability to have appointments scheduled and may result in your dismissal from the practice.

Statement of Financial Responsibility
I, the undersigned, have read the above and understand that I am responsible for all medical, dental and surgical charges incurred by myself or my dependents. I authorize the release of any medical information necessary to process any claims that are processed on my behalf by OFS, LLC. I understand that my medical/dental insurance contract is between my insurance company and myself and that the failure of the insurance company to pay my claim does not absolve my financial responsibility to OFS, LLC. I understand that a verification of benefits and estimate of treatment are provided in good faith and are only estimates. I am ultimately responsible for all fees related to my provided service. All court and attorney fees or other fees associated with the collection of my account are my financial responsibility.