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Patient Forms

For your convenience you may fill out our Premier Surgical Cleveland Patient Form in advance using a Chrome, FireFOx or Safari browser. The information will be securely emailed to the Premier Cleveland office. Please allow at least 20 minutes to complete the form in one sitting. Your information will NOT be saved if you return to the form later.

Cleveland Patient Form
Payment Options / Billing Questions?

If you have questions about our financial policies or if you need to make special payment arrangements, please contact the Premier Surgical Central Billing Office at 865.306.5700.

Payments may be mailed to:
Premier Surgical
P.O. Box 52948
Knoxville, TN 37950-2948.

Pay by phone: 866-371-1918
Pay online:

Notice of Privacy Practices for Protected Health Information

This notice describes how information about you may be used and disclosed and how you can get access to this information. Please review it carefully. You have the right to obtain a copy of this notice upon request.

Affordable Care Act: Section 1775

Premier Cleveland Patient Forms

Insurance & Managed Care Plans

Premier Surgical Associates accepts most health insurance plans. Please call your health plan to verify our surgeon is a participating provider under your health coverage. The phone number for your health plan’s Customer Service should be listed on your insurance card.

Referrals & Authorizations

It is your responsibility to obtain all required referrals and authorization approvals from your insurance company. Failure to do so will result in reduced benefits and higher patient responsibility.


Please provide current copies of your insurance card(s) and immediately notify us of any changes. We also need your co-pay, deductible and co-insurance information. If you have no insurance, we will work with you to communicate the financial aspects of your care.

Financial Policy

Premier Surgical Associates will file your insurance for you and follow up with your insurance company(s) for sixty (60) days. After 60 days, you will be responsible for any remaining balance. You are responsible for payment regardless of your insurance coverage or legal representation in situations such as accidents or workers compensation.

Office Visits

All co-pays, deductibles or co-insurance are due at the time of service.


If surgery is required, you will be responsible for all or a portion of the fee. We will file your claim directly to your insurance company. Please remember that most insurance companies do not pay the full amount, and therefore, you are responsible for the balance. If there is a problem in paying the balance in full, please let us know and we will be happy to work with you.

Interest & Fees

Balances that remain unpaid for 30 days are subject to interest at 18% APR. Balances that are turned over to collection agencies are assessed a 30% collection fee.

Worker’s Compensation

You must contact your employer and your workers compensation insurance company and be assigned a case worker before we can treat you for a worker’s compensation injury.