OFFICE POLICY: Your co-pays, deductibles or percentages are due at the time of service. We file insurance claims on your behalf. However, you are responsible for all deductibles and charges not covered by insurance. Please keep us informed of all changes to your coverage. All collection costs and attorney fees are your responsibility if not paid as agreed. I have read the above and accept financial responsibility for this account.

AUTHORIZATION: By signing this, I authorize release of any/all medical records regarding my care to another physician/facility. I understand that this medical information may be used for Diagnostic, Insurance, Legal and other reasons as deemed necessary by James Oral and Maxillofacial Surgery to ensure the best medical care on my behalf.

CONSENT: I certify that the above information is true and correct to the best of my knowledge. I give my permission for Dr. Theodore James to examine, photograph, administer and perform such minor operative procedures as may be deemed necessary in the diagnosis and/or treatment of my oral, and/ or maxillofacial problems.

Thank you for choosing us as your Oral Surgeon Provider. The purpose of this policy is to empower you by giving you a clear understanding of your financial responsibility with regard to any and all shared costs, co-pay amounts, deductibles, and any balance not paid by your insurance or employer plan.

SELF PAY
If you are uninsured, all fees are required at the time of service. We accept all major credit cards.

INSURED
We will bill your insurance for you, but patient deductibles, co-payments and coinsurance are due at the time of service. All major credit cards are accepted for your convenience. Your insurance may pay more or less than we expect and you will be responsible for any remaining balance. If we have not had a response from your insurance company within 30 days (as required by state law), you will be sent a bill for the remaining balance. We request that you take an active role in getting your insurance company to pay your claim.

INSURANCE DENIALS / SURGERY
As a safeguard, our facility will contact your insurance company to pre-authorize, pre-notify, and/or pre-certify any surgery(s) you may choose to have. This action is required by most insurance carriers but it does not result in a guarantee of payment. Please be advised that unless contractual arrangements affect your liability for payment, you are responsible for your bill. Your insurance company may claim that your recommended surgical procedures lack medical necessity, are investigational, or use another form of denial tactic. By signing this form, you agree that should your insurance company deny payment for services that you have chosen to have, you will take responsibility for all charges incurred.

DELINQUENT ACCOUNTS
You agree to pay cost and/or reasonable attorney’s fees if any delinquent balance is placed with agency or attorney for collection or suit. If it becomes necessary to collect an account by legal action, the responsible party will need to pay ALL fees involved.

RETURNED CHECKS
If payment by check is returned for Non-Sufficient Funds, you will be charged a $20.00 fee along with the total of the check to be paid in full.

3% SERVICE CHARGE
Please note that a 3% service charge will be applied to all credit or debit card transactions and online payments.

DIVORCE
In case of a divorce, Dr. James is not party to the divorce settlement. If your ex-spouse is obligated to pay, that is up to you to enforce, not the doctor.

MISSED APPOINTMENTS
We require 24 hours’ notice for the cancellation of an appointment except in an emergency situation. After one missed appointment without 24 hours’ notice, you will be charged a $250.00 missed appointment fee.

OVERPAYMENTS
Overpayments will be returned to the patient/guarantor after completion of all insurance billing.

Thank you for trusting us with your care. Please feel free to contact our office at (208) 207-9093 with any questions you may have regarding financial responsibilities.

Uses and Disclosures Not Requiring Your Authorization

In the following circumstances, we may disclose your health information without your written authorization:

• To family members or close friends who are involved in your health care
• For certain limited research purposes
• For purposes of public health and safety
• To Government agencies for purposes of their audits, investigations, and other oversight activities
• To Government authorities to prevent child abuse or domestic violence
• To the FDA to report product defects or incidents
• To law enforcement authorities to protect public safety or to assist in apprehending criminal offenders
• When required by court orders, search warrants, subpoenas, and as otherwise required by law

Patient Rights

As our patient, you have the following rights:

• To have access to and/or a copy of your health information
• To receive an accounting of certain disclosures we have made of your health information
• To request restrictions as to how your health information is used or disclosed
• To request that we communicate with you in confidence
• To request that we amend your health information
• To receive notice of our privacy practices