(770) 834-0873 Patient Information

Billing & Insurance

Medical Records Requests

Complete an online Medical Record request form.

Disability and FMLA Forms

If you need FMLA or Disability Forms completed, please submit this authorization form to ensure  your paperwork is completed in a timely manner.  This completed form can be faxed to our office at (770) 834-6118 or dropped off at our front desk.     


Billing Policies & Co-pays

We participate with many local and national insurance plans.  To determine if we participate in your insurance plan, please call your insurance company or look in your participating network guide prior to your visit. If you provide complete and accurate information about your insurance, we will submit claims to your insurance carrier and receive payments for services. However, depending on your insurance coverage, you may be responsible for co-payments, co-insurance, or deductible amounts. You are responsible for paying those charges.  

If your insurance requires a co-payment, we expect to collect that at the time of service. Your insurance will not cover this fee.

Prior Authorization

If your insurance requires pre-approval or referrals to our practice, it is your responsibility to make sure that referral has been made.


If you do not have health insurance, you will be asked to pay for services prior to your appointment with our doctors, or to arrange a payment plan with our billing staff prior to your visit. We accept cash, checks, credit and debit cards.

If your insurance coverage has terminated, or you have provided incorrect information, you are responsible for paying for services we provided to you. If we are unable to collect these bills from you, we may use a collection agency to recover payments. If this occurs, you will be responsible for all collection charges and fees associated with your account.


No Surprises Act

Effective January 1, 2022, the No Surprises Act, which Congress passed as part of the Consolidated Appropriations Act of 2021, is designed to protect patients from surprise bills for emergency services at out-of-network facilities or for out-of-network providers at in-network facilities, holding them liable only for in-network cost-sharing amounts. The No Surprises Act also enables uninsured patients to receive a good faith estimate of the cost of care.


Billing Disclosures – Your Rights and Protections Against Surprise Medical Bills

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.


What is “Balance Billing”, Sometimes Called “Surprise Billing”?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a healthcare facility that isn’t in your health plan’s network.


“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.


“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care–like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.


You are Protected from Balance Billing for:

Emergency services

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.


Additionally, Georgia protects patients from balance billing when patients receive (i) covered non-emergency services from an out-of-network provider when patients did not receive notice that the provider was out-of-network; (ii) covered medically necessary services from an out-of-network provider when such services are not available in-network,; (iii) covered medically necessary services from an out of network provider at an in-network facility, if patients did not have a reasonable opportunity to choose an in-network provider. These protections apply to patients with coverage through insurers licensed to transact accident or health insurance, a nonprofit hospital service corporation, a nonprofit medical service corporation, a health maintenance organization (“HMO”), and preferred provider organization (“PPO”). These protections only require patients to pay the amount required for in-network services.


Certain Services at an In-Network Hospital or Ambulatory Surgical Center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.


If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.


You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.


Georgia State Protections

Many of the protections are the same within the Georgia state regulation, but there are few key differences. The Georgia regulation only applies to self-insured manufacturer strength plans and management plans and is limited to aids supported in Georgia. In addition to hospitals and changing position surgery centers, the Georgia regulation again applies to imaging centers and birth centers. Also, Georgia law has a different process to address grievances as well as for disclosure requirements than the federal standard. 

When Balance Billing isn’t Allowed, You also Have the Following Protections:

You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.


Your health plan generally must:

  • Cover emergency services without requiring you to get approval for services in advance (prior authorization).
  • Cover emergency services by out-of-network providers.
  • Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
  • Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.


If you believe you’ve been wrongly billed, you may contact:

The U.S. Centers for Medicare & Medicaid Services (CMS) at 1-800-MEDICARE (1-800-633-4227) or visit https://www.cms.gov/nosurprises for more information about your rights under federal law.

The Georgia Office of the Commissioner of Insurance and Fire Safety office (https://oci.georgia.gov) at 404-656-2070. 


Good Faith Estimate

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost. 

Under the law, healthcare providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment and hospital fees.

Make sure your healthcare provider gives you a Good Faith Estimate in writing at least one business day before your medical service or item. You can also ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

Make sure to save a copy or picture of your Good Faith Estimate.


Have Additional Questions?

For questions or more information about your right to a Good Faith Estimate, visit cms.gov/nosurprises or call 1-800-MEDICARE (1-800-633-4227). To schedule an appointment, contact our orthopaedic clinic in Carrollton, GA at today!

For Questions

Please call (770) 834-0873, to speak with our staff, if you have any questions about your services. We want to work with you to avoid any financial problems, and to assure that your account remains in good standing.