Patient Information

Patients will be required to complete and acknowledge the following forms:

• JCMG Notice of Privacy Practices—HIPAA
• Consent for Treatment, Release of Information and Financial Obligation
• Patient Registration
• Patient Health Information

• It is the patient’s responsibility to provide JCMG with their insurance billing information at the time of service. Insurance and pharmacy cards will be copied as needed, but verified at each visit.
• If a patient’s insurance company requires a referral, it is the patient’s responsibility to request the referral from their primary care physician. Patients unable to secure the referral prior to the visit will be asked to sign a form acknowledging that they may be financially responsible.
• The patient’s insurance plan may require a prior authorization for certain radiological or surgical procedures. Approval is required by most participating plans. Patients that request a procedure, which has not been authorized,will be asked to sign a statement of patient responsibility.
• Patients presenting with job-related injuries need to inform the front office staff at time of visit that the injury is job-related. A call will be made to the employer to verify approval of services and obtain appropriate billing information.
• JCMG does not become involved in third-party disputes. Per your request, JCMG will file these charges with your medical insurance.
• Financial responsibility for minors (children) will be based on the individual who signs the form at the initial patient registration. In the state of Missouri, both parents ultimately are responsible for paying a child’s health-care expense.
• Minors should be accompanied by a parent/guardian. When this is not possible, the accompanying adult or older child who comes alone needs to have a signed, date-specific authorization from the parent/guardian allowing treatment. If a signed authorization is not available, a call will be made to receive verbal approval from the parent/guardian and verified by two witnesses. The minor will not be treated without parental/guardian written or verbal approval.

Advance Directives

At the patient’s request, a copy of the advance directive will be placed in the medical record. For a copy of the advance directive packet, please click here.

Cancelling Appointments

Our policy requires that you provide 24 hours notice when you are not able to keep a scheduled appointment. You will be notified if you have two or more missed appointments. If you have missed two consecutive appointments JCMG will bill you $30 for the missed appointments.

Comments or Suggestions

JCMG welcomes your thoughts for continued quality improvement. Please use any of the following for issues or concerns:
1. Billing issues contact the Billing Office
2. Clinic related issues contact the Department Coordinator or Quality Coordinator
3. Suggestion box in the Lobby of the JCMG Medical Building.
4. Contact us on the web at contact@jcmg.org

Patient Billing

• JCMG participates with Medicare. Insurance claims will be filed and payments will come directly to JCMG. If applicable, secondary insurance will be filed. Any remaining, co-insurance, deductible, and non-covered services, will be billed to the patient by JCMG.
• JCMG participates with Medicaid. Co-payments will be collected at the time of service. Insurance claims will be filed and payments will come directly to JCMG. Any remaining spend down and non-covered services will be billed to the patient by JCMG. Medicaid patient failing to present a current Medicaid card will be responsible for their charges at the time of service.
• JCMG participates with many insurance plans. If a patient’s insurance is one of JCMG’s participating plans, the patient is responsible for the co-payment, deductible or co-insurance at the time of service. JCMG will file the claim, and payments will come directly to JCMG. Any remaining balances and non-covered services, will be billed to the patient by JCMG.
• If JCMG does not participate with an insurance plan, patients are responsible for 100% of the billed charges to be paid at the time of service. JCMG will provide the patient with an itemized statement/claim to file with the insurance company.
• Self-pay patients are expected to pay when services are rendered. JCMG offers a 25% discount if paid in full at the time of service. Exceptions include: Weight Treatment Center, Pharmacy, Sports physicals, DOT physicals, 3D ultrasound, CT Angiogram, Hearing Aids and cosmetic products and services.
• Patients will receive a separate bill for services rendered in the Outpatient Surgery Center.
• A separate bill may be sent for laboratory services that are processed by an outside laboratory.
• JCMG’s Radiology services function as an independent diagnostic facility with equipment in multiple departments. Therefore, patients may be responsible for additional co-payment for radiology services, whether in the physician office or in a separate facility depending on your insurance plan.
• The JCMG Billing Office is open 8 a.m.–5 p.m., Monday–Friday. Patients may call 573-556-5791, with billing questions. For your convenience, JCMG accepts Visa, MasterCard or Discover, cash, check or money order for payment.