1434 Broadrick Drive
Dalton, Georgia 30722

Phone:706/278-5961 | Fax: 706/275-0280

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May leave a voicemail?
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Do you prefer:  Phone  Text

Which provider are you seeing today?:   Dr. Idom  Dr. Veys  Melodi PA-C

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Insurance Information: (Please present any and all insurance cards to the receptionist)

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Notice Regarding Insurance: If filing insurance for your visit, we must have complete information and any required referral at the time of visit. If you cannot provide the correct and most up to date information, we will be unable to file your insurance, and payment in full will be required.

Payment for your charges cannot be determined until the claim to your insurance company has been submitted. Payment will be based on your individual health plan and the amount applied to your plan deductable/coinsurance will be your responsibility. Procedures which are excluded from coverage, based on your plans determination for medical necessity will also be your responsibility. Your office copay is due at the time of visit. Any procedures performed will be considered surgery by your insurance company and deductible /coinsurance may apply. For all other patients, payment is required at the time of visit. We will provide you with the necessary documentation to file for your reimbursement upon your request.

I have read and understand the above information and am aware I am responsible for payment for service I receive.

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Acknowledge of Consent

Communication Consent:

HIPPA is an acronym for Health Insurance Portability & Accountability Act of 1996 a federal law.

The Administrative Simplification section of the act is of concern to our practice and requires us to comply with specific rules regarding:

• Unique Identifiers for health plans, providers, individuals and employers.
• Healthcare Transactions & Code Sets for transmitting electronic data.
• Privacy Regulations over disclosures and use of health information.
• Security Regulations over protections of electronic health information.

All of these rules have been developed by the Department of Health & Human Services and will become final in a staged manner. It will be the policy of North Ga. Urology Center to not release confidential and/or unauthorized information by phone, answering machine, work telephone, voicemail, postal mail, cell phone or fax. Whenever returning phone calls and an answering machine pick up, we will not leave messages if the name or telephone number is not on the recorded message to identify the residence. Information will not be left with an unauthorized person who answers the phone.

If you would like to have your medical information released to someone other than yourself, please complete the following: I authorize North Ga. Urology Center to release medical information to the following people including my listed emergency contact.

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Final Signature

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