Gem City Hand and Microsurgeons
Responsible Party Information
Insurance Information
Please list the family members or other persons, if any, whom we may inform about your general medical conditions and your diagnosis (including treatment, payment, and healthcare operations).
Please list the family members or significant others, if any, we may contact in case of emergency.
I hereby authorize the above physician(s) at Gem City Hand and Microsurgeons to release any information regarding services rendered by him and allow a photocopy of my signature to be used to file insurance.
NEW PATIENT CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION OF TREATMENT, PAYMENT OR HEALTHCARE OPERATIONS
Understand that as part of my health care, Gem City Hand and Microsurgeons originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information services as:
I understand and have been provided with a Notice of Privacy Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:
I understand that Gem City Hand and Microsurgeons are not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations.
I further understand that Gem City Hand and Microsurgeons reserve the right to change their notice, and in accordance with Section 164.520 of the Code of Federal Regulations, should Gem City Hand and Microsurgeons change their notice, they will send a copy of any revised notice to the address I have provided (whether U.S. mail or, if I agree, email)
I understand that as part of this organization's treatment, payment, or healthcare operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via fax. I fully understand and accept the terms of this consent.
Financial Policy
Thank you for choosing Gem City Hand and Microsurgeons to serve your healthcare needs. We are committed to your successful treatment. The following is a statement of our Financial Policy, which we require that you read and sign before any treatment. Our practice firmly believes that a good physician-patient relationship is based on understanding and good communication. We believe that an informed consumer is a more satisfied patient. Therefore, we want to communicate our Patient Financial Policy to you in writing so that you will know what to expect during your visit.
Insurance
All patients must complete our patient registration form and provide current information before being seen by the doctor. We are in-network with many insurance companies, but it is your responsibility to check with your insurance company to determine if we are in-network with your plan. In the event that your insurance does not cover your visit or treatment within a reasonable time (45-60 days), the balance may be transferred to the patient's responsibility. Please be aware that some of the services provided may be non-covered services by Medicare and/or other medical insurance guidelines.
If you have elected to use our practice out of your network, please check with your insurance company regarding your benefits levels. If you have questions regarding your coverage, please speak with your insurance company. It is your responsibility to understand your benefit coverage.
All co-pays, deductibles, and balances are due at the time of service. If you are scheduled for surgery, we will check your benefits. If you have a deductible and/or coinsurance amount, you will be asked to pay all or a part of the amount prior to surgery. If payment cannot be made prior to surgery, your surgery may need to be rescheduled.
*Please note that we are a separate entity from the facility and anesthesia. We cannot provide deductible and coinsurance amounts for these entities. It is your responsibility to check with the facility and anesthesia to find out what your out-of-pocket expenses will be with them.
We will submit claims to a secondary insurance plan. However, if the secondary insurance does not pay within a reasonable time (45-60 days), the balance my be transferred to the patient's responsibility, and it will be your responsibility to follow up with secondary insurance.
We will appeal disputed claims with insurance companies to the extent that additional documentation is required from us in order for your claim to be processed. While the filing of insurance claims is a courtesy that we extend to our patients, all charges are your responsibility to follow up with the secondary insurance.
High Deductible Health Plans (HAS & HRA Participants)
Please inform us prior to your visit if you are a participant in a High Deductible Health Plan, a Health Savings Account (HSA) or a Health Reimbursement Account (HRA). You must be prepared with the plan information and pay the patient responsible portion from the HSA or HRA a the time of service. If you scheudle surgery, we will check your benefits prior to the surgery. You may be responsible for all or part of your deductible and coinsurance amounts prior to the surgery being performed.
Patient Responsibility
If you do not have insurance, or if you are a participant in an insurance for which we are not a provider, we require that you be prepared to pay our fees at the time services and rendered. Please inquire with our staff about self-pay cash discounts for payment at the time of service. If you are covered by insurance, you will be reduced to our contracted allowable amount.
We realize that temporary financial problems may affect timely payment on your account. If such problems arise, or in circumstances where a claim is pending, it is recommended that a payment plan be initiated. We encourage you to promptly contact our billing office for assistance in the management of your account.
Outstanding Balances
Balances are due within 30 days of receiving a statement from our office. If payment is not made within 60 days of receipt of the statement, or if previous payment arrangements have not been made with our office, a $10 late fee will be added each month to your balance. Balances over 90 days old will be turned over to our collection agency.
Payment Details
We accept cash, checks, and most major credit cards. We do not accept Care Credit. You can also make payments on our website at www.gemcityhandandmicrosurgeons.com or over the phone with your credit card information.
Any returned checks are subject to a $35.00 fee. Returned checks must be resolved before any future appointments can be scheduled.
I have read and understand the above financial policy and agree to the terms as stipulated by Gem City Hand and Microsurgeons.
Opioid Prescribing Policy
It is the goal of Gem City Hand and Microsurgeons to provide the best care possible for our patients. In order to reach this goal, it is necessary to provide information to keep our patients informed. Although this letter probably addresses only a few of those who read it, we feel it important to have this policy available to you.
Due to the highly addictive nature of narcotic (opioid) pain medications, the physicians of Gem City Hand and Microsurgeons strictly limit their use in accordance with DEA (Drug Enforcement Agency) and Ohio State Medical Board guidelines. Narcotic pain medication includes but is not limited to Vicodin, Lortab, Percocet, Hydrocodone, Oxycontin, Oxycodone, etc.
If the physician deems it appropriate, narcotic medications will only be authorized and prescribed for up to 12 weeks following surgery. If you feel you need narcotic medication for longer than 12 weeks, you may be referred to your primary care physician or a pain management physician.
Patients may not receive opioid medications from more than one practitioner.
Please safeguard your narcotic prescriptions.
Photo/Imaging Consent
For valuable consideration, I hereby irrevocably consent to and authorize the use and reproduction by you, or anyone authorized by you, of any and all photographs, videotaped images and/or audio tracks which you have taken of me, negative or positive, for any purpose whatsoever, without further compensation to me. All negative and positives with the prints and audio/video tapes shall constitute the property of Gem City Hand and Microsurgeons soley and completely.
I am 18 years of age or older.
If the person signing is under 18, consent should be given by a parent or guardian as follows:
I hereby certify that I am the parent or guardian of
The patient named above. For value received, I hereby give my consent without reservation to the foregoing on behalf of him or her.
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