ASSIGNMENT AND RELEASE

I certify that I, and/or my dependent(s) have insurance coverage and assign directly to EBENEZER HEALTHCARE SERVICES all insurance benefits, if any, otherwise payable to me for services rendered. I understand the above named doctor may use my health information any may disclose such information to the above named insurance company/companies and their agents for the purpose of obtaining payment of services and determining insurance benefits or benefits for related services. This consent will end when my current treatment plan is completed or one year from the signed date.

Office Policies and Procedures 

Our Goal is to make the provider/patient relationship as beneficial as possible. We will seek an active part in your healthcare needs. We want our patients to be informed of the office policies; therefore, we ask that you read and take home this copy of our office policies. A signed copy was filled out by you during registration and kept for our records. 

Office Hours: (Any hours outside of our normal business hours are considered after hours.) Monday: 8am-6pm 

Tuesday: 8am-6pm 

Wednesday: 8am-6pm 

Thursday: CLOSED Friday: 8am-2pm 

After Hours Emergency: In the event of an emergency please call 911. For after hours non emergencies please call 405-378-2119 and you will be attended to or called back as soon as possible. THIS SERVICE IS NOT INTENDED FOR REFILLS OR CANCELLING APPOINTMENTS. 

Appointments When calling for appointments, please inform us of the reason for the appointment so enough time may be allotted for your visit. Same day appointments are not guaranteed so please call in advance for your appointment. All calls and reasons for appointments are kept confidential. Patients who are over 15 minutes late may be asked to reschedule their appointment. If you must cancel or reschedule your appointment please give a 24 hour notice. 

Patients who do not show up for scheduled appointments may be dismissed from the clinic care after three such incidents.

Please contact your pharmacy for refill requests. They will fax your request to us at 405-759-7022. Medication refills will be completed within 24 hours of the request, if possible. PLEASE CALL YOUR PHARMACY FOR REFILLS BEFORE YOU ARE OUT OF YOUR MEDICATION. No refill requests for pain medicine (narcotics) will be authorized without patient first being seen for follow up appointment. No exceptions will be made. 

Referrals If your insurance company requires a referral to a specialist, please notify our office at least one week before your scheduled appointment. It may be necessary for you to be seen by your primary care provider before we can issue a referral. Many times, self referrals can be made, so please check your insurance provider manual. Once the referral is made you need to pick-up a copy from the office. 

Payment and Insurance All payments, including co-payments, deductibles, co-insurance, and private pay, are due at the time of service. We reserve the right to refuse an appointment if prior arrangements have not been made and you are not prepared to pay your bill. Please bring your insurance card to each visit. We will file insurance claims for all charges incurred in our office except for automobile accidents, work-related injuries, or third-party injuries. Charges from an automobile accident will be the patient's responsibility and are due at the time of service. We will provide you with the necessary paperwork to submit the claim to the auto insurance. We do not treat or file any Workers Compensation claims and injuries. 

Medical Records and Miscellaneous We will be happy to provide you with a copy of your records as long as a proper request form is filled out. 

There will be a charge of $1.00 for the first page and $0.50 for each additional page to be copied plus any postage amounts. These fees have been set by the Oklahoma State Legislature. 

I HAVE READ THIS OFFICE POLICY AND AGREE TO ABIDE BY THE TERMS LISTED ABOVE Signature 

I understand that my healthcare information is protected. I understand that, in order for us to leave detailed messages containing specific dental information on my voice mail or answering machine, I need to give permission for us to do so.

Treatment Consent for Shared Information with Family & Friends Under the HIPAA Privacy Law we are permitted and we may make a professional judgment that certain disclosures are in your best interests even without this signature. I understand that information is limited to verbal discussions and that no paper copies of my protected healthcare information will be provided without my signature on a Release of Information Form.

The name(s) listed below are family members or friends to whom I grant permission for the providers at Ebenezer Healthcare Services and their representatives at our clinic to verbally discuss my care using their best judgment and grant them permission to disclose medical information that is relevant to my care or relevant for payment.

Regarding the following: Appointment Reminders/Changes Account Payments/Balances Cost Estimates Needed Treatment/Completed Treatment It will be my responsibility to keep this information up to date, as I recognize that relationships and friendships may change over time. This consent will be considered valid until such time that I revoke it in writing. I reserve the right to revoke it at any time.