New Patient Forms

Financial Policy

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We are committed to providing our patients with the best possible care and are anxious to help you receive your maximum allowable benefits. In order to achieve this goal, we need your assistance and your understanding of our payment policy.

As a courtesy to our patients, we will gladly file your insurance for you. The total charge for your care is your responsibility, whether or not your insurance company pays. We cannot file to your insurance company unless you give us correct information and allow us to copy your insurance card. We accept assignment of benefits, which will enable your insurance company to pay our doctor directly.

We must emphasize that as dental/medical providers, our relationship is with you, our patient, and not your insurance company. We will verify your eligibility and benefits as a complimentary service. While the filing of claims is a courtesy that we extend to our patients, all charges are your responsibility from the date the service is rendered.

WE DO NOT PARTICIPATE IN ALL DENTAL PLANS/ANY MEDICAL PLANS.

INSURANCE CONTRACTS ARE BETWEEN YOU, YOUR EMPLOYER,AND THE INSURANCE COMPANY. WE ARE NOT PARTY TO THAT CONTRACT. THEREFORE, IT ISYOUR RESPONSIBILITY TO OBTAIN ANY AND ALL AUTHORIZATIONS AND/OR REFERRALS FROM YOUR PRIMARY CARE PHYSICIAN AND INSURANCE COMPANY PRIOR TO BEING SEEN OR TREATED BY OUR DOCTORS. SHOULD YOU FAIL TO DO THIS AND SHOULD YOUR INSURANCE COMPANY DENY OUR CHARGES, YOU ARE RESPONSIBLE FOR ANY AND ALL BALANCES.

NOT ALL SERVICES ARE COVERED BENEFITS IN ALL CONTRACTS. SOME INSURANCE COMPANIES SELECT CERTAIN SERVICES THEY WILL NOT COVER.

There is no dental/medical insurance that pays every charge for dental/medical care at 100%.

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If your insurance company has not paid any outstanding portion of your bill within 30 days, the balance is expected to be paid in full by you at this time. We reserve the right to bill you additionally for late fees up to $25.00 per month past due. At 90 days from the date of service all balances have to be paid in full by you or your insurance company. At that point, if your account is not resolved it will be turned over to a collection agency and collection fees up to an additional 50% of your balance will be added to your account.

We accept CASH, CHECKS, VISA/MASTERCARD/DISCOVER/AMERICAN EXPRESS.

Any/all debit/credit card payments will be increased by a 3% processing fee.

Thank you for choosing us as your oral and maxillofacial surgery provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered part of your treatment. We reserve the right to require some procedures to be paid in full prior to scheduling/rescheduling.

I have read the Financial Policy of Shelbourne and Associates. I understand and agree to this Policy.

HIPAA Privacy Policy

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Notice to patient: We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose your health information. Please check the box below to acknowledge receipt of the Notice. You may refuse to sign this acknowledgement.

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

Our Legal Duty

We are required by applicable federal and state law to maintain the privacy of your protected health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your protected health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect immediately and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and provide the new Notice at our practice location, and we will distribute it upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this notice.

Your Authorization: In addition to our use of your health information for the following purposes, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

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Uses and Disclosures of Health Information

We use and disclose health information about you without authorization for the following purposes:

Treatment: We may use or disclose your health information for your treatment. For example, we may disclose your health information to a physician or other healthcare provider providing treatment to you.

Payment: We may use and disclose your health information to obtain payment for services we provide to you. For example, we may send claims to your dental health plan containing certain health information.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. For example, healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

To You or Your Personal Representative: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to your personal representative, but only if you agree that we may do so.

Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your absence or incapacity or in emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

Disaster Relief: We may use or disclose your health information to assist in disaster relief efforts.

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

Required by Law: We may use or disclose your health information when we are required to do so by law.

Public Health and Public Benefit: We may use or disclose your health information to report abuse, neglect, or domestic violence; to report disease, injury, and vital statistics; to report certain information to the Food and Drug Administration (FDA); to alert someone who may be at risk of contracting or spreading a disease; for health oversight activities; for certain judicial and administrative proceedings; for certain law enforcement purposes; to avert a serious threat to health or safety; and to comply with workers’ compensation or similar programs.

Decedents: We may disclose health information about a decedent as authorized or required by law.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody the protected health information of an inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).

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Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. You may also request access by sending us a letter to the address at the end of this Notice. We will charge you a reasonable cost-based fee for the cost of supplies and labor of copying. If you request copies, we will charge you for each page, and per hour for staff time to copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes other than treatment, payment, healthcare operations, and certain other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. In most cases we are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in certain circumstances where disclosure is required or permitted, such as an emergency, for public health activities, or when disclosure is required by law). We must comply with a request to restrict the disclosure of protected health information to a health plan for purposes of carrying out payment or health care operations (as defined by HIPAA) if the protected health information pertains solely to a health care item or service for which we have been paid out of pocket in full.

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or at alternative locations. (You must make your request in writing.) Your request must specify the alternative means or location, and provide satisfactory explanation of how payments will be handled under the alternative means or location you request.

Amendment: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances.

Electronic Notice: You may receive a paper copy of this notice upon request, even if you have agreed to receive this notice electronically on our Web site or by electronic mail (e-mail).

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Questions and Complaints

If you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

I acknowledge receipt of the HIPAA privacy practices above.

Medicare Opt-Out

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If you do not have medicare: To complete the registration process, please enter all 0's for the "Beneficiary Medicare Number" and sign.

Private Contract – Provider Opt-Out of Medicare

Provider Name: Shelbourne & Associates Oral & Facial Surgery:Courtney Shelbourne, DMD, Miles Ware, DMD, Colleen Holewa, DMD

Provider Address: 1081 Johnnie Dodds Blvd, Mount Pleasant, SC 29464

Beneficiary Name: *

Legal Representative (if applicable)

Beneficiary Medicare Number *

This private contract is between the physician and beneficiary noted above. The beneficiary is a Medicare Part B beneficiary and is seeking services covered under Medicare Part B. The physician above has informed the beneficiary or his/her legal representative they have opted-out of the Medicare Program. The current Medicare opt-out period is from 10/26/2024 to 10/26/2025. The Physician noted above is not excluded from participating in Medicare Part B under SS1128, 1156, or 1892 of the Act.

The beneficiary or his/her legal representative has read and agreed to the following terms of the private contract by placing their initials by the items below:

I, or my legal representative, accept full responsibility for payment of the physician’s or practitioner’s charge for all services furnished by this physician/practitioner;

I, or my legal representative, understands that Medicare limits do not apply to what the physician/practitioner may charge for items or services furnished by the physician/practitioner;

I, or my legal representative, agree not to submit a claim to Medicare or to ask the physician/practitioner to submit a claim to Medicare;

I, or my legal representative, have been informed of the expected or known expiration date of the opt-out period; which is 10/26/2024 to 10/26/2025;

I, or my legal representative, understand that Medicare payment will not be made for any items or services furnished by thephysician/practitioner that would have otherwise been covered by Medicare if there was no private contract and a properMedicare claim had been submitted;

I, or my legal representative, enter into the contract with the knowledge that the beneficiary has the right to obtain Medicare covered items and services from physicians and practitioners who have not opted out of Medicare, and that the beneficiary is not compelled to enter into private contracts that apply to other Medicare covered services furnished by other physicians or practitioners who have not opted out;

I, or my legal representative, understand that Medigap plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare

I, or my legal representative, agree this contract was not entered into during a time when the beneficiary required emergency care services or urgent care services.

Signature

Please draw your signature in the box below to sign this form.

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Contact Information

Insurance Information

Primary Dental Insurance

Secondary Dental Insurance

Medical Insurance

Guarantor

Medical History

Financial Policy

HIPAA Privacy Policy

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Release Authorization

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Medicare Opt-Out

Private Contract – Provider Opt-Out of Medicare

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