I am the biological parent/legal guardian of the above listed child and give the following people of legal age (18+) listed below authorization to bring my child to Hamilton Mill Pediatrics for medical care, including any neccessary treatments and consent for vaccinations. This statement will remain in effect until I give written notice of any changes. 

Thank you, 

Insurance: We bill participating insurances. You are expected to keep us up to date with your current and active insurance policy. You are expected to pay your deductible/copayment at time of service. If we have not received payment from your insurance company within 90 days from the date of service, you will be expected to pay the balance in full. If you do not provide us with up to date insurance prior to/or at time of service, you will be held responsible for any outstanding debt not paid for by the insurance company. 

 

Copayments/deductibles: Depending on your insurance policy, a copay/deductible or coinsurance may be required at time of service. Payment can be made in cash, check, or credit card. We also accept Health Savings Account cards (HSA) for payment. Please note that the copayment is a contractual requirement by the insurance company and cannot be written off by the clinic. Coinsurance may apply even after meeting your deductible.  Please note that there is a $25.00 service charge for any returned checks. 

 

Patients without insurance coverage: We are happy to work with patients who do not have insurance. All self-pay payments are due at time of service. Please contact the office for information on self pay pricing. 

 

Balances: Patients with an outstanding balance over 60 days must make at least a partial payment or payment arrangement prior to scheduling any further appointments. There will be a hold on your account until arrangements are made. Accounts with large outstanding balances are subject to dismissal from practice and risk the account being sent to collections. 

 

Missed appointments/Late cancellations: Missed appointments cause a delay in care to other patients. Any cancellation or late show without at least a 2 hour notice will be subject to a $30.00 fee for each appointment. We respectfully ask all patients to arrive 15 minutes early. We understand people run late due to circumstances beyond their control. If you are running late we ask that you call and notify the office. Excessive abuse of this policy is subject to dismissal from practice. We reserve the right to dismiss any new patients who no-show/no-call for their initial visit.

 

 

 

Medical Record Requests: There is a $15.00 charge for the copying/printing and mailing of medical records for all patients. 

 

Consent to Use and Disclosure of Protected Health Information: 

I hereby give consent for Samantha Ball, DO, LLC doing business as Hamilton Mill Pediatrics, to use and disclose protected health information (PHI) about me/the patient to carry out treatment, payment, and healthcare operations (TPO). 

With this consent, Samantha Ball, DO, LLC doing business as Hamilton Mill Pediatrics may mail to my home or alternative location as well as email or text any items that assist the practice in carrying out TPO, such as appointment reminders, lab results, and patient statements marked personal/confidential. 

I have the right to request that Samantha Ball DO, LLC restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does it is bound by this agreement. 

 

Assignment and Release:  I authorize payment to be made directly to Hamilton Mill Pediatrics by my insurance company, and I accept financial responsibility for all services not covered by my insurance. I authorize release of any medical care information requested by my insurance company. 

I have read, understand, and agree to the above policies. I also agree that if it becomes necessary to forward my account to a collection agency, in addition to the amount owed, I also will be responsible for the fee charged by the collection agency for costs of collections. 

If I do not consent, or later revoke it, Samantha Ball DO LLC doing business as Hamilton Mill Pediatrics may decline to provide treatment or services. 

I have the right to review the Notice of Privacy Practices prior to signing this consent. Samantha Ball DO LLC doing business as Hamilton Mill Pediatrics has the right to revise the Notice of Privacy Practices at any time. 

I have been made aware of the office copy of the Notice of Privacy Practices for Samantha Ball DO LLC, doing business as Hamilton Mill Pediatrics. I have also been given the opportunity to receive my own copy of the Notice of Privacy Practices. I understand that a copy is made available on the website (hamiltonmillpediatrics.com).

I understand that the Notice of Privacy Practices details how my health information may be used and disclosed as permitted under federal and state law, outlining my rights regarding my health information. 

Note: our full vaccine policy is available online on our website or you may request a copy from our front desk staff. 

We firmly believe in the effectiveness and safety of vaccines. We fully support and follow the American Academy of Pediatrics vaccine schedule. We require that all our patients be up to date and get all the current recommended vaccines for children and adolescents in a timely manner.

If you do not wish to vaccinate your children or are looking for alternative schedules, this is not the best practice for you, and you will be asked to find another office.

By signing below you agree to the above statement. 

My signature below verifies that Hamilton Mill Pediatrics has my full consent to administer any vaccine that is recommended for my child by the State of Georgia. My signature also gives permission for the office and the data exchange export to take place through the Electronic Health Record system to GRITS (Georgia Registry of Immunization Transaction and Services).