Emergency Contact Information
Primary Care Physician
Mail Order Pharmacy
Financial and Consent Agreement
ALL PROFESSIONAL FEES ARE DUE AT THE TIME OF SERVICE, UNLESS PREVIOUS ARRANGEMENTS HAVE BEEN MADE
Patient Information Form - Financial Agreement
- Services are rendered to the patient, not the insurance company. Our office will file your insurance if proper information is received.
- You are responsible for Co-Pays, Deductibles, Non-Covered Services, Co-Insurance and items considered “not medically necessary” by insurance.
- For unpaid claims over 45 days, it is your responsibility to follow up with your insurance company and the balance may be considered due and payable.
- It is your responsibility to notify our front desk of any insurance or address changes.
- You will be responsible for any changes that occur if your current insurance is not communicated at the time of service.
- Expenses incurred to collect patient-responsible debt may be charged to the patient or guarantor.
LIST OF SURGERIES AND HOSPITALIZATIONS
Please list all medications you are taking or provide a list (Include all over the counter medications and medications taken within the last month)
If you are not currently taking any medications, please write N/A.
If you do not have any allergies, please write N/A.
Acknowledgement and Consent For Notice of Privacy
Acknowledge of Receipt
I have reviewed NeuSpine Institute LLC Notice of Privacy, which explained how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document at no cost to me.
Consent to Release Medical Information to Personal Representative
, hereby consent to have my information released to the following individuals. This consent will remain in effect until otherwise notified by me in writing.
Do NOT release my information, except to health care providers and…
Patient Authorization & Consent
I hereby voluntary consent to medical treatment, including diagnostic producers, surgical and other medical services, provided by NeuSpine Institute LLC or their authorized designees, as they may in their professional judgment be necessary to provide appropriate medical, surgical or emergency care. I agree to reimburse the fees of any collection agency, which may be based on a percentage at a maximum of 50% of the debt, all costs, and expenses, including but not limited to reasonable attorney’s fees that may incur in such collection efforts.
I authorize NeuSpine Institute LLC physicians to submit claims to my insurance for services rendered by my medical providers. I authorized the release of any medical information necessary to process this assignment on the claim. I authorize payment to be made to NeuSpine Institute LLC physicians for services provided by them.
To All Patients:
In order to provide you with good service, it is of great importance we have your current address and phone number on file. Please be sure to contact us if your phone number and/or address changes. This information will be utilized to remind you of your appointment date and time.
Cancellation/No Show Policy:
Any cancellation, broken appointments, or no shows in which a 24-hour notice is not provided, after three occurrences, will result in termination from NeuSpine Institute.
Late Arrival Policy:
The clinic has limited waiting time for your appointment. If you are more than 15 minutes late, your appointment will be rescheduled.
If we terminate our service with you, we will be happy to transfer a copy of your medical records to your new physician upon receipt of a signed authorization to release records.
I have been informed and understand the policies listed above. I also understand if I fail to provide a 24-hour notice of a broken appointment, I will incur a service charge of $50.00.
New Patient Information
Please make sure that a response is written in EVERY SPACE
Previous SPINAL Surgeries:
Previous Treatment (please answer yes/no and details as applicable)
Have you seen any other providers since your last visit?
Please circle any symptoms you have experienced in the last two weeks:
Add Symptoms for the parts mentioned below (Burning, Numbness, Stabbing Pain, Weakness, Aching)