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

• 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 scanned 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 insurance 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 provide approval from their employer, billing information, as well as notify the front office staff at time of visit that the injury is job-related. A call may be made to the employer to verify approval of services.
• JCMG does not become involved in third-party disputes; auto accidents and personal liability. Per your request, JCMG will file these charges with your medical insurance. Charges will need to be paid in full at the time of service.
• 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 parent/guardian written or verbal approval.