New Patient Form

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

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

After three occurrences you will be terminated fromNeuSpine Institute. If we terminate our service withyou, we willbe happy to transfer a copy of your medical recordsto your new physician upon receipt of a signed authorizationto release records.

Late Policy:

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

LIST OF SURGERIES AND HOSPITALIZATIONS

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

Cancer/Oncology

Cardiovascular/Hematologic

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 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.

PATIENT AUTHORIZATION & CONSENT

I hereby voluntarily consent to medical treatment, including diagnostic procedures, surgical and othermedical 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 authorize 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.

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).
2. This medical information may be used by the personI 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.

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

For and consideration of NEUSPINE INSTITUTE LLC agreeing to pursue the responsible insurance carrier for payment of benefits due and not requiring prepayment for services, I hereby irrevocably assign all rights and benefits to NEUSPINE INSTITUTE LLC for Medical Payment Coverage, and other benefits which I may have accordance with Florida Statute §627.736. This includes any benefits from my insurance company and any other entity may be responsible for medical expenses incurred. I further authorize NEUSPINE INSTITUTE LLC to collect payments & prosecute any necessary actions to collect payments for services as they see fit and allowable by law and contract. 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. I agree to pay any applicable deductible or copayment not covered by any policy of insurance cited above. I understand that as a benefit and convenience to me, NEUSPINE INSTITUTE LLC will bill any pursuit collection against the insurance company or other responsible entity on my behalf. I hereby instruct and direct my insurance company to pay my benefits directly to NEUSPINE INSTITUTE LLC on the address provided on the bill. If my current policy prohibits direct payment to doctors, 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 INSTITUTELLC at the address on the bill. NEUSPINE INSTITUTE LLC medical care is being provided for a reasonable fee for treatment that I have sought out for under my above mentioned insurance carrier and is medically necessary. I instruct my insurance carrier or other responsible entity 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 tothe 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, includinga request by myself to reserve benefits for pending disability claims. I hereby give NEUSPINE INSTITUTE LLC limited power of attorney to endorse and sign my name on any draft for payment to either NEUSPINE INSTITUTE LLC or myself if said draft represents payment for charges related to services rendered by NEUSPINE INSTITUTE LLC.

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 a copay of any applicable insurance policy, declaration page, all applicable endorsements, transcripts and/or copies of any recorded statements, examinations under oath and request for same, independent medical evaluations and requests for same, and peer review reports, this request includes the name of other medical providers to whom payments have been under my policy of insurance in favor of NEUSPINE INSTITUTE LLC. If any language within this agreement has the effect of invalidating this agreement, that language shall be deemed void and the remainder of the assignment shall maintain full force and effect. A photocopy 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 if surgery is necessary.

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

Onset of Symptoms

Pain Description

Interventional Pain Treatment History

Please mark all of the following treatments you have had for pain relief.