Patient Agreement

Please follow the link to download and complete our Patient Agreement form in advance of your visit:
Patient Agreement Form

Limitation of Practice:
Patient understands that Drs. Jenkins and Morrow’s practice is limited to Oral and Maxillofacial Surgery.

Patient Consent:
Patient hereby gives consent, if needed, for drawing blood samples for diagnosis or in case of accidental puncture or exposure of medical personnel, during my course of treatment either in the offices or in the hospital.  These tests may include AIDS testing.

Insurance Claims Filing:
In all cases, the patient is responsible for payment of their account.  As a courtesy, Drs. Jenkins & Morrow will file a claim to the patient’s insurance carrier.

Assignment and Release:
Patient hereby authorizes and assigns applicable insurance benefits to be paid directly to the physician.  Patient is financially responsible for non-covered services. Patient authorizes release of information necessary to process insurance claims. Patient authorizes disclosure of medical record information to JCAHO surveyor in connection with the performance of his/her duties as a surveyor.

Deductibles/Co-payment:
Payment of your deductible, as a well as, an estimated share of the fee is due at time services are rendered.  Payments can be made in the form of cash, check, Visa/MasterCard.  If the insurance pays more or less than the estimated amount, you will be billed or reimbursed accordingly.  Patient balances are due 30 days after insurance coverage payment has been made.

Unpaid Balances:
If, for any reason, the patient cannon make scheduled payments, the patient must immediately contact the office of Drs. Jenkins and Morrow to make acceptable arrangements.  Drs. Jenkins and Morrow reserve the right to refer all unpaid accounts to collection agencies.  Any fees associated with collection, including collection agency contingency fees and/or court, will be added to the patients account balance.  After an account has been placed with a collection agency; all patient visits and procedures will be conducted on a cash only basis.

Service Charges:
Drs. Jenkins and Morrow reserve the right to assess a service charge, not to exceed $20.00/month, for any unpaid balance over 30 days after the insurance coverage has been paid.