New Patient Form

I authorize the release of all information relating to all claims and benefits submitted on behalf of myself or dependents. I authorize my insurance company to pay and hereby assign all benefits, if any to Southeastern Orthopaedics, otherwise payable to me. I authorize James Barber, MD or Joel Hernandez, PA-C to medically treat myself or my dependents including any labs or tests he feels necessary.

This is the authorization for use and disclosure of personal health information. Southeastern Orthopaedics or its business associates may use or disclose your personal health information, including medical records and charges, for the purpose (s) of patient referrals, payment of medical bills for your insurance company, and overall related to patient care. You may request a detailed description of your rights and permitted uses and disclosures under HIPAA. Copies of the most current Privacy Notice will be available upon request or on our website myseortho.com and posted in our main lobby. Please list below the person (s) we may share or communicate your personal medical information. I understand that the authorized persons (s) I listed above may re-disclose my health information and is no longer protected by federal privacy regulations. You have the right to revoke this authorization by submitting a signed written request to our office, your revocation request will be effective upon receipt. Any specific violations may be reported in writing to: Southeastern Orthopaedics, Attn: Privacy Officer. The authorization will remain in effect until two years from the date signed. By signing this consent form, you give SEO permission to use and disclose protected health information about you for treatment, payment, and healthcare operations. A copy of this Notice of Privacy Practices is available to you prior to signing this consent form.

• Payment Policy: All copays and previous balances will be collected at the front desk during the checkin process. You will receive 3 statements from our office for the account patient balances. All balances are due within 60 days unless a preapproved payment plan is in place. All balances due after 90 days will be charged interest and reviewed for collection activity from an outside collection agency. A fee of $40.00 will be added for any return checks. We gladly accept cash, VISA or Mastercard, and checks for your convenience.
• We do offer automatic payment check or credit card drafts for your convenience. Please ask our staff for more information.

Commercial Insurance: Copays and balances are due at the time of services. SEO will submit your claim to your carrier as a courtesy if all current and accurate information is provided. Payments on existing balances are also due the day of your appointment. If payment is not received from your insurance company within 30 days, the balance becomes your responsibility.

Self-pay: A predetermined prepayment is required at the time of service for each visit. This prepayment may not cover the entire charges for each visit depending on your treatment. The remaining balance is due on your next visit. A payment is expected every 30 days or at the time of your next visit. Remaining balances are due within 60 days of date of service. Any balances due after 90 days will be charged interest and reviewed for collections activity from an outside agency.

Workman’s comp: All work-comp accounts must be approved by an insurance company and employer before your visit. If we have verified the claim with your work-comp carrier no payment necessary. If your work-comp claim is denied the charges becomes your responsibility and self-pay policy applies on any balance.

Medicare: If you are currently enrolled in Medicare part B or any Medicare CMO, a copay, deductible and coinsurance may apply. Medicare will not cover your entire bill. All balances must be paid in full within 60 days from date of service.

Medicaid: We are currently participating with Medicaid, Peachstate, Wellcare, and Caresource. If for any reason the claim is denied the balance will be your responsibility and must be paid in full within 60 days of the date of service.