Financial Obligation / Assignment of Benefits
It is your responsibility to inform the front desk of any and all updates to your insurance plan as well as your personal information. Failure to do so could result in charges becoming patient responsibility. I assign and authorize payments to Total Spine and Rehab, also known as TSR.
It is your responsibility to understand your insurance plan. Please make sure to contact your insurance provider to determine if TSR is in network and covered under your insurance plan. It is your responsibility to know what your deductible, copay, percentages, and other related expenses for treatment are. Be aware that our office has different types of providers. It is your responsibility to know if services related to treatment for Chiropractic, Physical Therapy, and Physical Therapy Assistant are covered under your insurance policy.
Our fees are considered usual, customary, and reasonable by most companies.
You are responsible for the payment of charges for the health care we provide. Unless your health insurance company, HMO, or Medicare agreement with Total Spine and Rehab prohibits it, payment is due at the time of visit. Our office accepts cash, credit card, and check payments. Patients that do not have benefits through a third party may speak with the front desk attendant regarding our fees.
By signing this document, I acknowledge that I am responsible for the financial obligation arising from the provision of care to myself, or the person for whom I am acting as a personal representative (such as an unemancipated minor). I am assigning and authorizing payments to Total Spine and Rehab. If your carrier has not paid a claim within sixty (60) days of submission, you agree to take an active part in the recovery of your claim. There could/will be a rebilling fee of 30% of the total charges added to all accounts not paid in full within 90 days of service. I acknowledge I will incur the reasonable costs of collections including attorney's fees should I fail to satisfy my financial obligation.
HIPAA Privacy Notice / Communication
Total Spine and Rehab requires a signed consent before sharing medical information with a third party. For exclusions to this policy, please ask a front desk staff member for a copy of our Notice of Privacy Practices. Details regarding the protection of patient privacy are detailed on that document.
There are times when TSR will need to contact you in order to provide you with appointment details and X-ray results. If you would like to opt out of receiving calls from us please let us know. Otherwise, we will use the number provided to contact you. By signing below you agree that in order to service your account or collect monies owed, TSR and/or agents may contact you by telephone at any number associated with your account, including wireless numbers, which could result in charges to you. You may also be contacted through text messages or emails, if you provide them. You have the right to revoke this consent in writing, except to the extent we already have used or disclosed your protected health information in reliance on your consent.
Testing / Consent to Treatment
Your physician will determine what treatment is most appropriate to address your symptoms and condition. I voluntarily consent to the rendering of care, including treatment and performances of diagnostic procedures performed by the doctor or staff as appropriate. I understand TSR may refer me for diagnostic test (such as MRI) outside the office. I give consent for TSR to use my information to arrange such test, and I give consent that the results be released back to TSR for review. I understand the potential risk and consent to treatment. I understand I am free to ask questions about my treatment at any time. It is always your right to refuse any recommended test or treatment.
Additional Medicare Consent
I certify that the information given by me in applying for payment under Title XVIII and/or Title Xl of the Social Security Act is correct. I authorize and holder of medical or other information about me, to release to the Social Security Administration or its intermediary carriers, and information needed for this or related Medicare claim.
Female Waiver
By my signature below on this form, I do hereby state that to the best of my knowledge, I am not pregnant, nor is pregnancy suspected or confirmed at this particular time. OR if I am pregnant, I will notify any and all technicians who will be performing X-rays or any other procedures.
I understand by signing this for, I am authorizing TSR to treat me as long as I seek treatment or until I withdraw my consent in writing.