Patient Registration

Welcome to our office. In order to serve you properly, we will need the following information. Please Print —All information will be kept strictly Confidential.

The above information is true to the best of my knowledge. I understand that it is my responsibility as the patient to determine whether or not the services requested from Johns Creek Surgery, P.C. will be covered by my insurance plan(s), and I understand that I am financially responsible for any balance. I authorize my insurance benefits to be paid directly to the physician. I also authorize Johns Creek Surgery, P.C. or my insurance company to release any information required to process my claims.

Patient Questionnaire

The following information is very important to your health. Please take time to fully and completely fill out this Important information.

Financial Policy

In order for our office to maintain accurate billing, we do require that an image copy of your current insurance card be on file in our system. it is imperative that you as the insured be aware of exactly how your policy has been written with your insurance company and how your individual benefits work. Most insurance plans require a separate deductible for surgical procedures and you will be required to pay this deductible at the time of service. I understand that Johns Creek Surgery, PC will assist me with coverage issues, benefits and eligibility and pre-certification, if needed, however, I am ultimately responsible for payments for all services rendered to me. If your insurance company has not paid our office within 45 days, you will be billed from our office and we will ask that you contact your insurance carrier directly to help expedite your claim.

• Our office has a Returned Check Fee of $50.00.
• If your account is delinquent and is turned over to a collection agency for processing, we will automatically assess your account an additional 38% over the original amount due.
• Outside facility laboratories are used for all blood work, biopsies and collective cultures. These facilities handle filing of their own charges with your insurance carrier directly. Depending on how your benefits are paid to the lab you will be responsible for any charges not covered by your carrier. These charges are not inclusive to any charges from Johns Creek Surgery PC.

Referrals

I understand that it is my responsibility to obtain a referral prior to being seen by Johns Creek Surgery, PC if my insurance company requires one. I understand that it is my responsibility to find out from my insurance company if a referral is needed for my plan. I understand that I am responsible for payment if my insurance company denies my claim because I did not obtain a referral.

Medicare and Medicaid

I understand that Johns Creek Surgery, PC does not accept Medicaid for any services. Medicare does not cover gastric band fills or dietitian services and these charges will be my responsibility.

Dietitian appointments

I understand that Johns Creek Surgery, PC will not bill my insurance company for dietitian services. I also understand that payment for dietitian services are due at time of service. All phone consultations must be paid in full prior to being scheduled with the Dietitian. I may request an itemized statement to submit to my insurance company for reimbursement.

Insurance Changes

I understand that if I change my insurance company, plan or coverage while undergoing Bariatric I General surgery, Johns Creek Surgery, PC may not bill or accept my insurance. I agree to notify Johns Creek Surgery, PC immediately of such changes. I Understand that I may revert to a self-pay status and be responsible for all charges in the event of an insurance change.

Co-Payments

I understand that my co-payment, deductibles, co-insurance is due at each office visit unless I am in a surgical global period. I understand that Johns Creek Surgery, PC does not bill or waive co-payments. I also understand that if I am unable to make payment at time of my appointment, my appointment will be rescheduled.

Appointments and Cancellations

Providing complete and thorough medical care to our patients is our number one goal. Our providers and staff members work very hard to maintain this goal and we ask that patients make every effort to adhere to the appointment time that has been reserved for you. We kindly ask that you give us 24 hours' notice in the event that you are unable to keep your appointment In order for us to schedule and care for other patients.

There is a $100.00 cancellation fee for surgeries that are cancelled less than 3 business days from the scheduled day and time of surgery unless the cancellation is due to insurance denial or medical necessity.

Prescription Refill Policy

Providing patients with the highest standard of care requires that patients also take part in the process of monitoring their conditions. It is imperative that patients return for follow up visits in order to monitor certain conditions and also to allow us to closely watch areas that are of concern. In the event that you have received a prescription medication from our office, please make sure to ask either the provider or the medical assistant when you will need to return for a follow up visit in order to refill your prescription medication.

• We do not refill oral medications over the phone.
• We will not refill any prescriptions issued by another provider without an evaluation by one of our providers.

Surgery Center Referral

I understand that my physician may refer me to Atlanta General and Bariatic Surgery Center for outpatient surgery. I understand that the Doctor has a financial interest in this surgery center and acknowledge that this information has been disclosed 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 information 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 I 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.

HIPAA Privacy Authorization Form
Authorization for Use or Disciosure of Protected Health Information

(Required by the Health Inautauce Portarnitty and Accountability Act, 45 C.F.R. Parts 160 and 164)

I hereby give my consent for Johns Creek Surgery, PC to use and disclose protected health information (PHI) about me to carry out treatment, payment, or healthcare operations. Johns Creek Surgery, PC 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, PC reserves the right to revise its Notice of Privacy Practices at any time A revised Notice of Privacy Practices may be obtained by forwarding a written request to; Johns Creek Surgery, PC, Attn: Privacy Officer, 6920 McGinnis Ferry Road Suite 340, Suwanee, GA 30024.

This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct. With this consent, Johns Creek Surgery, PC may call my home or other alternative location provided 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. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

With this consent, Johns Creek Surgery, PC may mail ore-mail to my home or other alternative location provided any items that assist the practice in carrying out healthcare operations. However, the practice Is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. I may revoke my consent In writing except to the extent that the practice has already made disclosures in reliance upon my prior consent and may no longer be protected by federal or state law. If I do not sign this consent, or later revoke it, Johns Creek Surgery, PC may decline to provide treatment to me.

By signing this form, I am consenting to Johns Creek Surgery, PC use and disclosure of my PHI to carry out healthcare operations. Please see Patient Record of Disclosures for details.