(770) 232-9252 6920 McGinnis Ferry Road | Suite 340 | Suwanee, GA 30024
Please be advised that you are responsible to pay your deductible, co-insurance, out of pocket maximum, and any outstanding balance on your account before surgery.
Every effort is made to provide you with an accurate estimate of what your portion of the bill will be. This is only an estimate. You may owe additional monies after your insurance company processes your claim.
Please remember that insurance coverage is an agreement between you and your insurance company. We agree to file your claim for you and to accept the contractual rate for payment if we are a participating provider with your insurance plan. While we make every attempt to pre-certify and pre-authorize your surgery with your insurance company, ultimately, if for any reason your Insurance company does not pay your claim, we will look to you for payment.
If you have the gastric band and we filed your insurance for surgery, we will continue to try to pre-certify your files. If we are unable to obtain prior authorization or in the event your insurance company does not pay for your files, you are responsible for payment at the time service is rendered. If you change insurance companies we may not bill insurance for your files. If you are a self-pay patient, you are responsible to pay $150.00 for each fill or de-fill at the time of service, regardless of the level of satiety achieved after each fill.
Please note that we do not accept personal checks for surgery. AU funds must be cash, cashier's check, certified funds, money order, Visa or MasterCard.
I have read, understand, and agree to the financial policy of Johns Creek Surgery, PC. d/b/a Atlanta Bariatrics.
For your surgery your surgeon may request the services of a Surgical Assistant. There is a separate fee for these services and they will not be included in either your surgeon's fee or the hospital charges.
The surgical assistant service will file a claim on your behalf with your insurance for these surgical assistant services and although your surgeon may participate in your insurance network, the surgical assistant may not and may not be eligible for reimbursement under your insurance plan.
If your insurance denies benefits for services rendered by a surgical assistant, you will in turn be responsible for any fee charged by the assistant. This surgical assistant will bill you directly and services are due in full as per the invoice date.
Regarding the above and all other information contained in this form, i (the undersigned) acknowledge, understand, and agree as follows:
I hereby give my consent for Johns Creek Surgery, P.C. to use and disclose protected health information (PHI) about me to carry out Treatment, Payment, or healthcare Operations (TPO). Johns Creek Surgery, P.C.'s Notice of Privacy Practices provides a more complete description of such uses and disclosures.
I have the right to review the Notice of Privacy Practices prior to signing this consent. Johns Creek Surgery, P.C. reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Private Practices may be obtained by forwarding a written request to:
Johns Creek Surgery, P.C.
Attn: Privacy Officer
6920 McGinnis Ferry Rd.
Suwanee, GA 30024
With this consent, Johns Creek Surgery, P.C. may call my home or other alternative location and leave a message on voicemail or in person in reference to any items that assist the practice in carrying out healthcare operations, including laboratory results among others.
With this consent, Johns Creek Surgery, P.C. may mail or e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements.
I have the right to request that Johns Creek Surgery, P.C. restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.
By signing this form, I am consenting to Johns Creek Surgery, P.C.'s use and disclosure of my PHI to carry out TPO.
I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent, If I do not sign this consent, or later revoke it, Johns Creek Surgery, P.C. may decline to provide treatment to me.
By signing this, I confirm that I have been offered a copy of Johns Creek Surgery, P.C.'s Notice of Privacy Practices. I understand that it is my responsibility as a patient to read the infonnation contained in the document.
I understand that I will need to provide a security access code to Johns Creek Surgery, PC in order for Johns Creek Surgery PC to speak to someone on my behalf about my medical condition, appointment reminders or billing issues. My security access code is:
I understand that anyone calling on my behalf will need to know my security code before any information including appointment reminders can be discussed with them.
I understand that no information will be released to anyone who cannot provide the security access code that have designated.
In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as correspondence to the individual's office instead of their home.
Instructions: Please print the form.
The Privacy Rule generally requires healthcare providers to take reasonable steps to limit the use or disclosure of and requests for Personal Health Information (PHI) to the minimum necessary to accomplish the intended purpose. These provisions do not apply to uses or disclosures made pursuant to an authorization requested by the individual. Healthcare entities must keep records of PHI disclosures. Information provided below, if completed properly, will constitute an adequate record. Note: In an emergency, uses and disclosures may be permitted without prior consent Disclosures for treatment, payment or care given by this or another healthcare facility do not need to be logged. Disclosures that must be logged Include: JudiclaULaw Enforcement, Public Health, Funeral Director, Public Safety, etc.
A copy of this form will be filed in the above-named patient's PHI.
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