Consent To Treat: I consent to evaluation, testing and treatment as directed by my provider. 

 

Assignment Of Insurance Benefits: I hereby authorize direct payment of my insurance benefits to Dr. Avinash Chavda/Virtuoso Spine & Joint for services rendered to me or my dependents by the physician or those under his supervision. I understand that it is my responsibility to know my insurance benefits and whether or not the services I am to receive are a covered benefit. I understand and agree that I will be responsible for any co-pay, coinsurance or balance due that my provider is unable to collect from my insurance carrier.

 

Insurance Benefits: I certify that the information given by me under these programs is correct. I authorize the release of any of my, or my dependent's records that these programs may request. I hereby direct that payment of my, or my dependent's be made directly to Dr. Avinash Chavda/Virtuoso Spine & Joint on my behalf. Failure to provide the correct and accurate information regarding insurance in order to file claims accurately and timely could result in a claim denial therefore may result in patient responsibility. I authorize release of medical records to determine liability for payments or treatment, and to obtain reimbursement. ALL COPAYS, DEDUCTIBLES, AND/OR COINSURANCE FOR ALL COMMERCIAL INSURANCE, MEDICARE AND MEDICARE REPLACEMENT PLANS ARE DUE AT THE TIME SERVICES ARE RENDERED, ACCORDING TO INSURANCE CONTRACT PROVISIONS. ALL PAYMENTS ARE DUE IN FULL THE DAY OF YOUR APPOINTMENT. 

 

Scheduling: Appointments can be scheduled by calling our office during business hours (8:00 AM–5:00 PM). Voicemails or text messages received outside these hours will be returned during business hours in the order they were received. Please note that we do not accept walk-ins or same day appointments. Our schedule is typically booked a week in advance, but we will accommodate you as soon as possible if a cancellation arises. Please write down your appointment date & time on your personal schedule.

 

Injections: Please allow up to 2 weeks for your steroid injection to become fully effective. Please schedule and attend a follow-up appointment for 2 weeks after your procedure date. If you have any questions or concerns, please contact our office. 

 

Imaging: If an imaging study was ordered for you today (i.e. MRI, X-Ray, CT, Ultrasound), please allow up to 72 hours to be contacted. If you have not heard from them one week following your appointment, please give us a call. Your results will be discussed at your next clinic visit. 

 

Physical Therapy/Chiropractic: If physical therapy and/or chiropractic care was ordered for you today, please allow up to 72 hours to be contacted. If you have not heard from them one week after your appointment, please give us a call. We use multiple physical therapy/chiropractic offices, so if they do not take your insurance or the location is inconvenient, please do not hesitate to call us. We would be happy to send an order to the office of your choice. 

 

Specialist Referrals: If you have been referred to a specialist (i.e. neurologist, neurosurgeon, orthopedic surgeon), please allow up to one week to be contacted by their office. If you have not heard from the office by that time, please contact us. 

 

Prior Authorizations: For office and certain hospital procedures, insurance prior authorizations can take up to 14 days and, in some cases, up to 30 days. Please allow adequate time for these approvals to avoid unnecessary out-of-pocket costs. We kindly ask for your patience, as the process depends entirely on your insurance provider, and we have no control over whether they approve, deny, or respond to our request. If you have any questions regarding your plan's prior authorization decision-making process, please contact the customer support number listed on the back of your insurance card. In the event that a prior authorization is denied or pended by your insurance, our office will contact you as soon as possible with further information.

 

Medication Prior Authorizations: New CDC guidelines and DEA regulations have made this increasingly difficult. If your prescription is high cost or the pharmacist states it needs a prior authorization, PLEASE CALL US. We do not know your prescription needs a prior authorization until either you or your pharmacist notifies us. Once we receive the prior authorization request, we will work with your insurance company to get this approved. This requires us submitting paperwork/medical records on your behalf. The insurance company has up to 15 days to respond (varies per insurance plan). Once the medication is approved, the pharmacist must resubmit the prescription to insurance again. In the interim, please take your medications as you were previously prescribed.

 

 Medication Refills (Opioid): Patients are responsible for tracking their medication refills and monthly refill appointments. Long-term opioid prescriptions require an opioid contract, monthly visits, and quarterly urine drug screening. If the physician prescribed a new long acting pain medication (i.e. hydrocodone, buprenorphine, oxycodone) and it was delayed due to prior authorization, your new regimen will start the date you pick the new medication up. Please remember to reduce the amount of pain medication (Norco, Percocet, Oxycodone) you are taking while taking a long acting pain medication. YOU WILL NOT BE REFILLED EARLY. If you need clarification on your new regimen, please do not hesitate to call.

 

Medication Refills (Non Opioid): If your follow up is scheduled more than 4 weeks out, you will need to CONTACT THE OFFICE for a prescription refill. Having your pharmacy fax a request is an unreliable way of notifying us. Please text your requests to 214-774-4878. If you don't have access to texting, then please feel free to call our office for your refill. Again, we ask that you call 2-3 days prior to your refill date.

 

Form Completion: Our office completes certain work and disability-related forms, including FMLA, ADA accommodations, handicap placards, and court/jury duty requests. There is $50 fee per form due at the time of request. Processing requires 3-5 business days, so please submit forms with sufficient time before their due date. Our office will contact you once your form is completed and ready for pick-up.
Please note: As a specialist office, we are unable to complete certain long-term or physical-evaluation forms, which should be handled by your primary care provider.

 Late Cancellation/No Show Fee: I understand that I must call to cancel or reschedule an appointment at least 24 hours (1 business day) before the time of the appointment. If I do not cancel or reschedule 24 hours prior and do not come to my appointment, I will be charged the following fees:

Consultation & Follow-up Appointments: $50 fee

Procedural Appointments: $100 fee

Please note: Insurance companies CANNOT be billed for missed appointment fees assessed. If you are late, there is a possibility your appointment will have to be rescheduled out of consideration for those patients that are scheduled after you.

 

Payment Policy: I understand and acknowledge the following:

*Verification of benefits given to us by your insurance company is NOT a guarantee of payment. 

*We cannot guarantee payment of your claim. Reduction or rejection of your claim by your insurance company does not relieve your financial obligation you have incurred. 

*There is a $40.00 fee assessed for ALL returned checks.

*Late fees will apply to all accounts over 90 days past due.

*If your policy is an HMO, you are responsible for contacting your primary care physician and obtaining a REFERRAL AUTHORIZATION, if needed. Failure to do so may result in your claim denial and you will be responsible for the balance due on your account.

*If any patient is owed a refund, all claims on the account must be processed and paid in full before overpayment is refunded.

*By signing this form, I state that I have read and understand and agree to the information in this document and the information I have provided is true and correct. If there are any changes or updates, I will notify my provider immediately.

I acknowledge and agree that I am financially responsible for all charges incurred for services provided by Virtuoso Spine and Joint, regardless of my insurance status. I understand and agree to the following terms: 

 

Insurance and Coverage Responsibility: It is my responsibility to verify whether Virtuoso Spine and Joint is in-network or out-of-network with my insurance provider. If my insurance is out-of-network or denies coverage for any reason, I remain responsible for full payment of all services rendered. If I do not have insurance and am a self-pay patient, I agree to pay all fees according to Virtuoso Spine and Joint’s self-pay rates. I am responsible for all deductibles, co-pays, co-insurance, and any denied claims, even if I have insurance.

Payment Obligations: I agree to pay all balances in full upon receipt of a statement unless other arrangements have been made in writing with Virtuoso Spine and Joint. If I fail to make timely payments, I may be subject to late fees, collections actions, and legal proceedings.

Collections and Legal Recourse: In the event of non-payment, I understand that my account may be referred to a collection agency or legal action may be taken. I agree to be responsible for any collection fees, attorney’s fees, and court costs incurred in the collection process.

 

By signing below, I confirm that I have read, understand, and accept the terms outlined in this agreement.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

 

Introduction: At Virtuoso Spine and Joint, we are committed to protecting the privacy of your medical information. This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment, and healthcare operations and for other purposes that are permitted or required by law. It also describes your rights regarding your PHI.

Uses and Disclosures of PHI: We may use and disclose your PHI for the following purposes:

 

Treatment: We may use and disclose your PHI to provide, coordinate, or manage your healthcare and any related services. This includes sharing information with other healthcare providers involved in your treatment.

Payment: We may use and disclose your PHI to bill and collect payment for the services we provide to you. This may include disclosures to insurance companies, Medicare, Medicaid, or other third-party payers.

Healthcare Operations: We may use and disclose your PHI for our healthcare operations, which include activities such as quality assessment, training of healthcare professionals, and conducting audits or compliance programs.

Legal Requirements: We may disclose your PHI when required by law, such as in response to a court order, subpoena, or other legal process.

Public Health Activities: We may disclose your PHI for public health activities, such as reporting diseases to public health authorities as required by law.

Research: We may disclose PHI for research purposes, but only if certain conditions are met and with appropriate safeguards in place to protect your privacy.

Your Rights Regarding PHI: You have the following rights regarding your PHI:

 

Right to Inspect and Copy: You have the right to inspect and obtain a copy of your PHI maintained by us, with limited exceptions.

Right to Amend: If you believe that your PHI is incorrect or incomplete, you have the right to request an amendment of your record.

Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of your PHI, although we are not required to agree to all requested restrictions.

Right to Request Confidential Communications: You have the right to request that we communicate with you about your PHI in a certain way or at a certain location.

Right to Receive an Accounting of Disclosures: You have the right to request an accounting of certain disclosures of your PHI made by us.

Right to Obtain a Paper Copy: You have the right to obtain a paper copy of this Notice upon request, even if you have agreed to receive this Notice electronically.

Changes to this Notice: We reserve the right to change the terms of this Notice at any time. We will post a revised Notice in our facility and on our website. The revised Notice will apply to all PHI we maintain.

 

Complaints: If you believe your privacy rights have been violated, you have the right to file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, contact our Privacy Officer at 214-774-4878.

 

Contact Information: If you have any questions about this Notice or about how we use or disclose your PHI, please contact our Privacy Officer at 214-774-4878.

 

Acknowledgement: I acknowledge that I have received a copy of this Notice of Privacy Practices.

  

By signing below, I confirm that I have read, understand, and accept the terms outlined in this agreement.

I hereby authorize Virtuoso Spine & Joint and its healthcare providers to use and disclose my protected health information (PHI) for the purposes of treatment, payment, healthcare operations, and as required by law, including for legal purposes as described below:

 

Purpose of Disclosure: This authorization permits the clinic to use and disclose my PHI for the purpose of providing treatment, obtaining payment for services rendered, conducting healthcare operations, and as required by law, including responses to subpoenas or other legal demands.

Specific Information to be Disclosed: This includes, but is not limited to, medical history, diagnosis, treatment plans, and any other information related to my health.

 

Recipients of Information: This authorization extends to healthcare providers and personnel involved in my care, as well as to third-party payers (insurance companies, Medicare, Medicaid) for the purpose of obtaining payment. It also includes disclosure to legal authorities or in response to subpoenas or other legal demands as required by law.

Expiration: This authorization shall expire when revoked in writing by the patient. 

Right to Revoke: I understand that I have the right to revoke this authorization at any time, except to the extent that action has already been taken in reliance on this authorization. Revocation must be in writing and submitted to Virtuoso Spine & Joint.

Effect of Refusal: I understand that I am not required to sign this authorization to receive treatment at Virtuoso Spine & Joint. However, refusal to sign may affect the clinic’s ability to provide treatment or obtain payment.

HIPAA Privacy: I acknowledge that I have received a copy of the clinic’s Notice of Privacy Practices, which provides a more complete description of the uses and disclosures of my PHI.

 

Notice of Privacy Practices AcknowledgmentI acknowledge that I have been offered and/or received a copy of The Med Spa of Kingwood’s Notice of Privacy Practices, which describes how my health information may be used and disclosed. I understand that I may request a copy at any time.

 

By signing below, I confirm that I have read, understand, and accept the terms outlined in this agreement.

I allow Virtuoso Spine & Joint to release any patient information, including accounting information to the family or friend listed below as an authorized person. I understand that I may revoke this agreement at any time.

By signing below, I confirm that I have read, understand, and accept the terms outlined in this agreement.

By signing and dating below, I acknowledge and agree that my written signature applies to the sections and terms outlined in this form, all of which I have read, understand, and fully agree to, and I hereby certify that this signature serves as my formal consent: