New Patient Form

I, the Patient, recognize and agree that neither NeuSpine Institute nor its healthcare providers must bill any insurance available to me (except as required by Florida PIP laws) when the cause, in whole or part, of my condition(s) for which I seek any service(s) from NeuSpine Institute is a tort (the negligence of another), be it a motor vehicle collision, slip or trip and fall, or any other tort event, and in a tort setting NeuSpine Institute is hereby authorized not to bill any health insurance source available to me, including but not limited to Medicare, Medicaid, or other governmental insurance source. Regardless of whether there is any other possible payer (other than me) that may be available to NeuSpine Institute as a source for payment of my medical bills in whole or part, no matter what the cause of my condition(s) for which I seek any services from NeuSpine Institute, I, the Patient, hereby agree that I shall remain liable to NeuSpine Institute for payment of the full amounts charged to me by NeuSpine Institute for the services rendered by NeuSpine Institute, I have no right to seek or compel NeuSpine Institute to reduce any bill to me, and in any event, I hereby waive any alleged right I may have to seek or compel NeuSpine Institute to reduce any bill to me.

Any Follow-up appointment cancellation or no-show in which a 24-hour notice is not provided, will result in a $50 charge. Any Injection appointment cancellation or no show in which a 24-hour notice is not provided, will result in a $75 charge.

After three occurrences, you will be terminated from NeuSpine Institute. 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, the Patient, recognize and agree that even if NeuSpine Institute terminates its relationship with me, I shall remain liable for payment of the full amount of all charges billed to me by NeuSpine Institute.

Late Policy:

The clinic has limited waiting time for your appointment. If you are more than 15 minutes late, your appointment will be rescheduled.

LIST OF SURGERIES AND HOSPITALIZATIONS

**Mark the following conditions/diseases that you have been treated for in the past**

Cancer/Oncology

Please list all medications you are CURRENTLY taking. Include all over the counter medications.

Local Pharmacy

Mail Order Pharmacy

Acknowledge of Receipt

I have reviewed the 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.

NEUSPINE INSTITUTE HIPAA Privacy Authorization Form Authorization for Use of Disclosure of Protected Health Information

(Required by the Health Insurance Portability andAccountability Act, 45 C.F.R. Parts 160 and 164)

I Authorize NEUSPINE INSTITUTE LLC. to use and disclose the protected health information described below

By signing,
1. I authorize the release of my complete health record (including records related to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse) to any attorney or law firm that is representing me in any matter, and to any healthcare provider that has provided or may come to provide any healthcare service to me, and to any billing or collections service.
2. This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct.
3. This authorization shall be in force and effect during my entire care at NeuSpine Institute LLC.
4. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on the authorization or if the authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.
5. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.
6. I may inspect and receive a copy of the information being used and disclosed pursuant to this Authorization form.
7. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.
8. I authorize that a copy of this authorization shall be as binding and effective as an original.

Assignment of benefits, liens, direct payment authorization, authorization to release insurance information, and authorization to escrow unpaid medical & PIP benefits

NeuSpine Institute LLC

For and consideration of NEUSPINE INSTITUTE LLC agreeing to provide me with medical care and related services and not requiring prepayment for rendition of services, I hereby irrevocably assign all rights and benefits I have to NEUSPINE INSTITUTE LLC for Personal Injury Protection and Medical Payment Coverage, and other benefits which I may have according to Florida Statute § 627.736. This includes any benefits from my insurance company and any other entity that may be responsible for medical bills I incur. I further authorize NEUSPINE INSTITUTE LLC to collect payments & prosecute any necessary actions to collect payments for services as it sees fitin accord with law. THIS DOCUMENT CONSTITUTES AN ASSIGNMENT OF RIGHTS AND BENEFITS.

This assignment concerns only the bills for NEUSPINE INSTITUTE LLC and those costs including, but not limited to, attorney’s fees, other costs, and interest necessary in procuring payment from the above-names insurance company and/or other entities. This assignment is not intended to assign any other causes of action that may belong to the undersigned patient, nor does it delegate any duties of mine. I agree to pay any applicable deductible or copayment not covered by any policy of insurance. I understand that as a benefit and convenience to me, NEUSPINE INSTITUTE LLC may pursue collection against the insurance company or other responsible entity for itself or on my behalf, at its election. I hereby instruct and direct my insurance company/companies to pay my benefits directly to NEUSPINE INSTITUTE LLC at the address provided on the bill(s). If my current policy prohibits direct payment to doctors or healthcare providers, then I hereby instruct and direct my insurance company or other responsible entity to make the check payable to me and mail it to NEUSPINE INSTITUTE LLC at the address on the bill, and I hereby authorize NeuSpine Institute to endorse any such instrument of payment with my name and negotiate or deposit it to NeuSpine Institute’s account, at NeuSpine Institute’s election. I agree that NEUSPINE INSTITUTE LLC is providing me healthcare services that I have sought out for my benefit, at charges I hereby determine to be reasonable to me, and that the care / services I seek from NeuSpine Institute are reasonable and medically necessary from my perspective.

I instruct my insurance carrier(s) to pay these bills to the full extent of my available benefits under the insurance policy and Florida law. If any portion of the charge for these services is either reduced or denied in whole or in part, my insurance company or other entity is to place funds equal to the amount of the reduced or denied charges into escrow and hold the escrowed funds until agreement or resolution of legal action by NEUSPINE INSTITUTE LLC. I further instruct my insurance company to make payment for charges submitted by NEUSPINE INSTITUTE LLC in priority to any other request to escrow benefits, including a request by myself to reserve benefits for pending disability claims. I hereby give NEUSPINE INSTITUTE LLC a limited power of attorney to endorse and sign my name on any draft or other instrument for payment to either NEUSPINE INSTITUTE LLC or myself if said draft represents payment for charges related to services rendered by NEUSPINE INSTITUTE LLC, and in any event, to negotiate any and all such payments for the account and benefit of NeuSpine Institute.

I further direct my insurance carrier as the responsible entity to provide information to NEUSPINE INSTITUTE LLC which is otherwise available to me including but not limited to information relating to any copay under any applicable insurance policy, declaration page, all applicable endorsements, transcripts and/or copies of any recorded statements and examinations under oath and requests for same, independent medical evaluations and requests for same, and peer review reports. This request includes the name and address of other medical providers to whom payments have been made under my policy/policies of insurance. If any language within this agreement has the effect of invalidating this agreement, that language shall be deemed revised to the extent necessary to render such binding and effective under Florida Law, and the remainder of the assignment shall maintain full force and effect. A photocopy or electronic copy or transmittal of this assignment shall be considered as effective and valid as the original.

I am responsible for copays, co-insurances, and deductibles prior to my office visits and surgery date(s) if surgery is necessary.

Direction of Payment

I hereby authorize and instruct any insurance company or attorney to pay directly to Assignee the amount of all bills for services rendered. Without limitation of any other terms of this assignment or any other agreement with the Assignee, I also agree to pay in a current manner any difference between the total charges and the amount paid by the insurance company directly to Assignee. This assignment also allows Assignee to endorse any check or draft provided to Assignee in my name for purposes of payment for services rendered to me by Assignee or its employees, contractors, or agents.

PIP Log & Declaration Sheet Request

I hereby authorize Assignee to release requested information, which is pertinent to my case or condition(s), to my insurance company or any/all of my attorneys now or hereafter involved in this case, pursuant to 627.4137 Florida Statutes. I hereby request that a copy of the pip log and declaration sheet, which reflects the policy limits available at the time of this accident, be provided to this Assignee. I hereby authorize this Assignee to request and receive a copy of my pip log periodically as Assignee deems necessary. If any term or provision of this Assignment, Lien, and Authorization or the application thereof to any person or circumstance shall, to any extent, be determined to be invalid or unenforceable, the remainder of this Assignment, Lien, and Authorization, or the application of such term or provision to persons or circumstances other than those as to which it is held invalid or unenforceable, shall not be affected thereby, and each term and provision of this Assignment, Lien, and Authorization shall be valid and enforced to the fullest extent of the law.

Reservation of Benefits

Be further advised, I am hereby placing you on notice pursuant to Florida case law that should you (the insurance company/carrier) deny, reduce, delay, or fail to pay any part of or the entire bill which was submitted on my behalf from this health care provider, I (the assignor) as well as the assignee (health care provider) are requesting, in advance, that you reserve, or “set-aside,” the amount reduced or denied or delayed until the dispute is resolved. Should you submit a check to this health care provider which is less than the correct contractual amount, and it contains any language referring to or purporting to declare payments as “Full and Final Payment,” or the like, then I have instructed this health care provider to return the check to you (the insurer) and consider the bill still due and owing (i.e. a late payment as defined in F.S. 627.736). Additionally, should the remaining amount of my benefits approach an amount where there would be insufficient funds to pay the amount you reduced, delayed, or failed to pay, please notify me (the assignor) and this health care provider (the assignee) immediately.

Health Care Provider: NeuSpine Institute, LLC ("NeuSpine Institute")

If patient is incapacitated or under the age of 18, please indicate the patient's name, guardian name and relation to patient and obtain guardian signature.

FINANCIAL RESPONSIBILITY: NO HEALTH INSURANCE BILLING

By my signature below, I hereby acknowledge, agree, and understand that due to the time and nature of treatment to be rendered by NeuSpine Institute, LLC (hereinafter ''the Practice''), in addition to the risks to the Practice in undertaking my medical treatment of either underpayment or nonpayment by my health insurance carrier, I want the medical services prescribed by the Practice but do not want my health insurance (if I have any) to be billed. I understand that I have the right not to use health insurance, and I hereby elect not to use it. In this situation, which derives from another person having caused me injury and which is the reason I am seeking medical attention from the Practice, I also understand that the person(s) who caused my injuries is/are primarily responsible for paying for the medical care I undertake in an effort to have my injuries addressed by the Practice. I do not want to pay up front out-of-pocket for my co-pays, deductibles, co-insurance, or other patient responsibility costs related to these medical services, as might be the case if I used health insurance. I understand that by agreeing to this approach, I will remain personally liable for the payment of all medical services rendered but I am being offered the ability to pay for those medical services at a later time under a separate Lien Agreement with the Practice and with no additional interest on the amount owed. I understand that the term "health insurance carrier" includes health insurance, Medicare, Medicaid and/or managed healthcare of any kind.

By signing below, I hereby acknowledge that I have read and understand this agreement and have freely made my own decision in agreeing to this approach. Any questions I have about this document have been answered to my satisfaction by the Practice and I have had an opportunity to consult my attorney if needed.

THE FLORIDA PATIENT'S BILL OF RIGHTS AND RESPONSIBILITIES

Florida law requires that your healthcare provider or health care facility recognize your rights while you are receiving medical care, and that you respect the health care provider's or health care facility's right to expect certain behavior on the part of the patients.

1. A patient has the right to be treated with courtesy and respect with appreciation of his/her individual dignity, and with protection of his or her need for privacy.
2. A patient has the right to prompt and reasonable response to questions and requests.
3. A patient has the right to know who is providing medical services and who is responsible for his or her care.
4. A patient has the right to know what patient support services are available, including whether an interpreter is available if he or she does not speak English.
5. A patient has the right to know what rules and regulations apply to his or her conduct.
6. A patient has the right to be given by the health care provider information concerning diagnosis, planned course of treatment, alternatives, risks, and prognosis.
7. A patient has the right to refuse any treatment, except as otherwise provided by law.
8. A patient has the right to be given , upon request, full information and necessary counseling on the availability of known financial resources for his or her care.
9. A patient who is eligible for Medicare has the right to know, upon request and in advance of treatment, whether the health care provider or health care facility accepts the Medicare assignment rate.
10. A patient has the right to receive, upon request, prior to treatment, a reasonable estimate of the charge for medical care.
11. A patient has the right to receive a copy of a reasonably clear and understandable itemized bill and, upon request, to have the charges explained.
12. A patient has the right to impartial access to medical treatment or accommodations, regardless of race, national origin, religion, physical handicap, or resource of payment.
13. A patient has the right to treatment for any emergency medical condition that will deteriorate from failure to provide treatment.
14. A patient has the right to know if medical treatment is for purposes of experimental research and to give his or her consent or refusal to participate in such experimental research.
15. A patient has the right to express grievances regarding any violation of his or her right, as stated in Florida Law, through the grievance procedure of the health care provider or health care facility which served him or her and to the appropriate state licensing agency.
16. A patient is responsible to give the health care provider, to the best of his or her knowledge, accurate and complete information about present complaints, past illnesses, hospitalization, medications, and other matters related to his or her health.
17. A patient is responsible for reporting unexpected changes in his or her condition to the health care provider.
18. A patient is responsible for reporting to the health care provider whether he or she comprehends a contemplated course of action and what is expected of him or her.
19. A patient is responsible for following the treatment plan recommended by the health care provider.
20. A patient is responsible for keeping appointments and, when he or she is unable to do so for any reason, for notifying the health care provider or health care facility.
21. A patient is responsible for assuring that the financial obligations of his or her health care are fulfilled as promptly as possible.
22. A patient is responsible for following the health care provider’s or facility’s rules and regulations affecting patient care and conduct.

ADVANCE DIRECTIVE

An advance directive is a written or oral statement about how you want medical decisions made should you not be able to make them yourself. Additional information and/or forms are available at your request.

Upon admission to a surgery center, advance directives are waived for the duration of the surgery and recovery period.

PHYSICIAN OWNERSHIP

Your physician is an owner of a financial interest in Comprehensive Outpatient Joint and Spine Institute surgery center.

*THIS FORM IS FOR MEDICARE PATIENTS ONLY*

AGREEMENT THAT MEDICARE SHALL NOT BE BILLED

I hereby acknowledge and agree that neither NeuSpine Institute, LLC nor any physician employed by or contracting with it to provide any services to me (whether or not a Medicare participating provider), shall bill or receive payment from Medicare for any services and treatment provided to me if the cause, in whole or part, of the conditions for which I seek services from NeuSpine Institute, LLC is a tort. Rather, in accord with: (a) the Medicare Secondary Payer Rules (See 42 USC §1395y, et. seq.); (b) the Medicare Secondary Payer Manual, Chapter 2 (which expressly instructs that a physician, whether or not participating in Medicare, may pursue his lien agreement with the patient for his full charges in liability matters, and may collect his full charges from the primary payer (liability insurance or the tortfeasor), but cannot attempt to collect from the patient until the liability proceeds are available to him/her); and (c) the Florida Supreme Court’s holdings in Joerg v. State Farm, 176 So.3d 1247 (Fla. 2015) (including that Court’s determination that Medicare makes the tortfeasor the primary payer), payment for the full charges shall be first sought by enforcement of the lien I have given to NeuSpine Institute, LLC from the tortfeasor who caused my injuries necessitating the services and treatment I receive from NeuSpine Institute, LLC and its employed or contracted physicians (and the tortfeasor’s liability insurance carrier, and any other non-health insurance carrier (e.g., no-fault, PIP, or Med Pay) that may have any legal responsibility for paying medical bills I incur). This means that any settlement or other recovery I may obtain from the tortfeasor or his liability carrier, other non-health insurance carrier (e.g., no-fault, PIP, or Med-Pay), or all thereof, shall be subject to my lien agreement with this provider, and therefore, I understand that NeuSpine Institute, LLC shall fully enforce its lien rights pursuant to its express Lien Agreement with me, in accord with Florida law and the above-stated legal authorities, which I acknowledge and agree do not require healthcare providers to opt out of Medicare before being able to charge and collect their full charges for services rendered pursuant to the Medicare Secondary Payer Manual, Chapter 2, Alternative Billing (see, for example, pages 16-19 thereof).

ACKNOWLEDGEMENT OF THE FOREGOING AND RECEIPT OF NOTICE OF PRIVACY

I acknowledge and represent to NeuSpine Institute, LLC that I have read and understood the foregoing, and that I was provided a copy of the Notice of Privacy and that I have read and understood the same.

Mark the following symptoms that you currently suffer from within the last 2 weeks

Pain Description

Interventional Pain Treatment History