Patients Forms:

Purpose of Request

I authorize the Practice to disclose or provide my protected health information to the following individual, who is authorized to act as my personal representative for the purposes of receiving all of my protected health information. I will inform my personal representative of the last four digits of my social security for identification purposes when inquiring about my health information. As my personal representative, they may exercise my right to inspect, copy, and request amendments to my protected health information. They may also consent or authorize the use or disclosure of my protected health information:

Name of Personal Representative:

Description of Information to be Disclosed

I authorize the Practice to disclose all of my protected health information to my designated personal representative

Expirations or Termination of Authorization

This authorization will remain in effect until terminated by you, your personal representative or another individual (s) of legal entity authorized to do so by court order or law.

Right to Revoke or Terminate

As stated in our Privacy Notice, you have the right to revoke or terminate this authorization by submitting a written request to our Privacy Manager. This can be done in-person or by mailing a request to:

Consultants in Gastroenterology

Attn: Privacy Manager 131 Summerplace Drive West Columbia, SC 29169

Redisclosure

I understand the Practice has no control over the person(s) I have listed as my personal representative. Therefore, any protected health information disclosed under this authorization will no longer be protected by the requirements of the Privacy Rule and will no longer be the responsibility of the Practice.

Consultants in Gastroenterology and the South Carolina Endoscopy Centers are committed to providing the highest quality of care. The cost of care is expensive and a financial policy is a part of every medical practice.

PATIENT RESPONSIBILITY

Patients are ultimately responsible for all charges for services provided by Consultants in Gastroenterology and South Carolina Endoscopy Centers and payment is due when services are rendered. If a procedure is scheduled, a non-refundable deposit may be required. This deposit will be applied to any deductible or co-pay that needs to be met. We have the right to deny treatment that is determined a non-emergency by our physicians for any outstanding balance with either Consultants in Gastroenterology or the South Carolina Endoscopy Centers. We accept payments by cash, personal check, debit card, VISA, MasterCard and American Express.

INSURED PATIENTS

As a courtesy, we will file your primary and secondary insurance. If we participate with your insurance company, any amount due after the applicable contractual adjustment will be your responsibility. If we do NOT participate with your insurance company, any unpaid balance following insurance payment will be your responsibility. Please provide us with updated and current information necessary to file your claim. If this is not obtained on the date service is rendered, you may be responsible for your bill. You are also responsible for notifying us of any changes in insurance. A copy of your card is required at each visit. If you do not have your card at the time of visit, you will be asked to sign a waiver and may be billed for the services. To verify our participation with your insurance, please call your insurance company. Different insurance companies have different co-pays and deductibles. Please be aware of your individual policy requirements. You are required to pay your co-pay and/or deductible at the time of your visit. We do participate with Medicare and file insurance that is secondary to Medicare. It is your responsibility to pay your co-insurance and/or deductible at the time of service. We are also a participating provider for South Carolina Medicaid; however, you must have your current card at the time of service. Your card must have remaining visits left to be valid. Please verify with our office regarding our participation with any HMO Medicaid plan. Please check to see if your insurance requires a referral and verify that it is obtained before your visit. If a referral is required, but not obtained, full payment may be required from the patient at the time of service. If your insurance carrier has NOT paid your claim in full within 60 days, please call your insurance company to inquire about the status.

NON-INSURED PATIENTS

All non-insured patients are required to call (803) 939-4100, ext. 150 or 169 prior to their visit to make payment arrangements. Discounts are offered for prompt payment for the uninsured patient. If arrangements are not made prior to the visit, payment in full is expected at the time of service.

RETURNED CHECKS

You will be charged a $30 fee in the event your check is returned for any reason.

CANCELLATION AND NO SHOWS

Office Visits: All cancellations must be received at least one (1) business day in advance. Patients who fail to give one (1) business day notice will be considered a "no show" and may be charged $25.

Procedures: All cancellations for procedures must be received within two (2) business days. Failure to notify the office may result in a $50 cancellation fee.

COLLECTIONS

We reserve the right to send accounts with balances over 60 days old to an outside collection agency. The agency does have the right to report the past-due balance to the credit bureau.

FOR MORE INFORMATION

If you need more information about our financial policy or have questions, about your financial responsibilities, please call us at (803) 939-4100.

I have acknowledged and read the above policy regarding my financial responsibility to Consultants in Gastroenterology and the South Carolina Endoscopy Centers.

Secondary

PLEASE HAVE OUR RECEPTIONIST MAKE A COPY OF YOUR INSURANCE CARD AND PHOTO ID. THANK YOU.