• SPECIALTYCARE CLINICS

  • DR. DAVID MASEL, MD, FAANS, FACS - NEUROSURGEON

    13988 Diplomat Drive, Suite 100 C Farmers Branch, Texas 75234 Phone: 469-833-2927, Fax: 214-888-4450

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  • MEDICARE SUPPLEMENT INSURANCE:

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    WORKER'S COMPENSATION: It is important that you make our office aware if this is a worker's comp injury prior to your visit. Please have all relevant information available in order to quickly complete your check-in process.

    EMPLOYER PAY: If your employer is paying for your visit instead of filing worker's comp, we must have payment up front or a signed contract in hand before your visit. We must be notified of any responsibility changes the employer makes within 80 days of first date of service.

    MISSED APPOINTMENT POLICY: In an effort to provide excellent patient care, we will be implementing a missed appointment fee without a cancellation of at least 24 hours in advance. Cancellations must be done over the phone with

    a staff member in the neurosurgery department. Our direct number is 469-833-2927. Cancellation fee of $25.00 will be

    applied to your account in the event you fail to notify us 24 hours prior to your appointment time with Dr. David Masel,

    MD. Illness will be excused with a physician's note explaining your absence.

    By signing this, you are acknowledging that all the above information is accurate and correct to the best of your knowledge and that you fully understand the above mentioned.

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  • SPECIALTY CARE CLINICS - CONSENT FOR TREATMENT AND FINANCIAL AGREEMENT

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  • Iauthorize the doctor, Dr. David Masel, MD, to examine me (or the patient I am legally responsible for) and to do any x-rays or

    other diagnostic tests that may be needed to make a diagnosis and to provide treatment. I consent to necessary office or other outpatient treatment after being properly informed of alternatives, benefits, and risks.

    AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION: I authorize Dr. David Masel, MD to release to any insurance company, health plan, or government agency such medical information that may be required to process my claim for payment of this medical bill. I also authorize Dr. David Masel, MD to release appropriate medical information to any doctor, hospital, or other health care facility that has or will participate in my (the patient's) care. I authorize a photocopy, facsimile, or other electronic transmission of the above Assignments, Authorizations, and Releases to be used in place of the original until/unless I send written notice to the contrary to the offices of Dr. David Masel, MD. I further authorize any other doctor, hospital, or health care facility to release to Dr. David Masel, MD office any medical information concerning my (the patient's) illness or injury.

    FINANCIAL AGREEMENT: I agree to pay all professional fees charged by Dr. David Masel, MD for my (the patient's) care, irrespective of any insurance benefits to which I may be entitled, except if Dr. David Masel, MD has agreed to accept insurance benefits as full payment for covered services in accordance with federal or state law (e.g. Medicare, Medicaid) or by contract with a prepaid health plan or managed-care plan, and provided such insurance benefits are paid within 60 days of claims submissions, and provided there is no recovery from a third-party negligence lawsuit (see Injuries and Third-Party Negligence, below Ultimately, it is your responsibility to understand the coverage that you pay for in a monthly premium to your carrier. If an employer or its carrier denies a claim for payment for a work-related injury, or if a prepaid health plan, managed-care health plan, or Medicare, considers certain services ineligible or uncovered services, then you (patient) agree to pay for those services. It is understood that claims for services remaining unpaid 60 days after claims submission shall be presumed ineligible for insurance reimbursement, and you (patient) shall pay for those services. If patient is a minor - the parent/guardian who requests treatment for a child will be responsible for all fees.

    INJURIES AND THIRD-PARTY NEGLIGENCE: I understand and agree that if Dr. David Masel, MD has granted discounts from its usual fees for any reason, including its participation in prepaid or managed-care health plans, and if I (the patient) recover(s) any monies as the result of any judgment, award, or settlement of any lawsuit arising from treated injuries or illness, then I shall give a lien to Dr. David Masel, MD against such monetary recovery in the full amount of such discounts.

    DELINQUENCY: If my (the patient's) account becomes delinquent, I understand that Dr. David Masel, MD, at its sole discretion, may refer to a collection agency or an attorney as allowed by law.

    INSURANCE ASSIGNMENT: I authorize my insurance company or third-party payer to whom a claim for payment has been submitted to pay any eligible benefits directly to Dr. David Masel, MD. I hereby authorize payment to go directly to Specialty (and/or Medicare) and understand Care Clinics for medical benefits payable by insurance company that I am responsible for any charge not covered by the terms of my insurance policy. I hereby assign Dr. David Masel, MD full rights to represent my (the patient's) interests in any complaints of appeals for denial of benefits or reimbursement to the Texas Department of Insurance (State Insurance Commissioner I hereby authorize said assignee Dr. David Masel, MD to furnish these agencies such information as may be necessary to support such complaints or appeals.

    I agree I cannot revoke the FINANCIAL AGREEMENT or the INSURANCE ASSIGNMENT at any time while any portion of the medical bill remains unpaid. I have read, understand, and do hereby agree to the terms of the forgoing Assignments, Authorizations, and Releases. I also certify that the PATIENT INFORMATION I have provided is true and accurate to the best of my knowledge.

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  • SPECIALTY CARE CLINICS - HIPAA COMPLIANCE PATIENT CONSENT FORM

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  • Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

    The notice contains a patient's rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

    The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

    You have the right to restrict how your protect health information is used and disclosed for treatment, payment, or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allow for the use of the information for treatment, payment, or healthcare operations.

    By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a

    revocation will not be retroactive.

    BY SIGNING THIS FORM, I UNDERSTAND THAT:

    May we phone, email, or send a text to you to confirm appointments?

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  • SPECIALTY CARE CLINICS - PRESCRIPTION REFILLS AND PHONE MESSAGES

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  • It is your responsibility to know your insurance and bring your card with you to all appointments Is Dr. David Masel, MD a CONTRACTED PROVIDER of your insurance? Do you need PRIOR AUTHORIZATION for procedures? Are x-rays and supplies included in your COPAY? How much is your COPAY for a specialist? Do you have a YEARLY DEDUCTIBLE? If so, has it been met?

    PLEASE HELP US HELP YOU. There are hundreds of insurance companies thereby making it almost impossible for our staff to know the specific requirements for each policy. Please call your insurance company prior to your appointment to obtain

    PROTOCOL FOR PRESCRIPTION REFILLS:

    Please reach out to your pharmacy first for refill requests Please allow 48-72 hours on refill requests

    In order to be as efficient as possible, these are the policies in effect regarding all prescriptions.

  • I have read and understand the above information regarding MY INSURANACE POLICY, PRESCRIPTION REFILLS, and the HIPAA EXCEPTIONS AUTHORIZATION for leaving messages.

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  • SPECIALTY CARE CLINICS - MEDICAL RELEASE FORM

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  • SPECIFIC INFORMATION TO BE DISCLOSED:

  • I understand that I may revoke this authorization at any time except to the extent that action has been taken in reliance on it; and that in any event, this authorization automatically expires 90 days from the date of my signature or as otherwise specified by date, event, or condition as follows. I agree that a photocopy of this authorization may be

  • THIS INFORMATION IS PRIVILEGED AND CONFIDENTIAL. IT IS INTENDED FOR THE INDIVIDUAL ENTITY DESIGNATED. YOU

  • ARE HEREBY NOTIFIED THAT DISSEMINATION DISTRIBUTION, COPY OR OTHER USE OF THIS INFORMATION BY ANYONE

  • OTHER THAN THE RECIPIENT DESIGNATED ABOVE IS AUTHORIZED AND STRICTLY PROHIBITED.

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  • SPECIALTY CARE CLINICS - INTAKE

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  • Please rate the severity of your pain (10 is the greatest pain):

  • N/A 1 2 3 4 5 6 7 8 9 10

  • N/A 1 2 3 4 5 6 7 8 9 10

  • N/A 1 2 3 4 5 6 7 8 9 10

  • N/A 1 2 3 4 5 6 7 8 9 10

  • PLEASE INDICATE THE DISTRIBUTION OF YOUR

  • PAIN/SYMPTOMS ON THE DIAGRAM TO THE RIGHT:

  • 0000000 Numbness, Tingling, Pins, Needles

  • What makes the pain better or worse (check all that apply)?

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  • Neck / Back Surgery (include dates):

  • Medications: Please list all medications you currently take along with its dosing and schedule

  • Past Surgical / Hospitalization History:

  • Health Status / Cause of Death

  • PATIENT OR GUARDIAN SIGNATURE

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  • Should be Empty:
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