Dear Patient:
The Physicians at Fort Worth Brain & Spine Institute, LLP are independent, private practice physicians. This means our Physicians
are not employed by any corporate or outside health care entity. And this means we work for YOU, not for a hospital, an
administrator, or any other corporate or outside health care entity.
In order to assure the highest quality and efficient delivery of your health care, the Physicians of Fort Worth Brain & Spine Institute,
LLP may maintain financial interests in other health care facilities and providers. Our commitment to providing the highest quality
care for our patients is paramount. Having financial interests in certain health care facilities and/or providers enables your Physician
to have additional control on the quality of care provided to you as opposed to having little control or input with corporate health care
entities. A simple example would be having an imaging study done in a specific fashion tailored to the patient’s individual condition,
rather than having to accept a “cookie-cutter” study that is done the same way for every patient, regardless of the condition being
investigated.
Decisions regarding your care are always based on your best individual medical treatment plan developed by you and your Physician.
Patients of Fort Worth Brain & Spine Institute, LLP always have the option of utilizing alternate health care facilities or providers, and
at times, this may actually be dictated by their individual health insurance plan. Regardless, your Physician and you will develop the
best treatment regimen available for your specific condition, using evidence-based “best practices.” Please feel free to discuss your
options or any questions you may have with your Physician or our staff during your visit. We welcome any questions regarding this
aspect of your patient care.
The following list includes the facilities and providers for which our Physicians maintain any form of ownership interest. As a Patient
of Fort Worth Brain & Spine Institute, LLP, you may receive care or services from any of these facilities or providers. Your Physician
may receive some form of financial benefit related to the care or services rendered by these facilities and providers, depending on the
legal ownership structure of each individual facility or entity.
• Methodist Southlake Hospital, Southlake, TX 76092
• Baylor Surgical Hospital, Fort Worth, TX 76110
• Parkway Surgical Hospital, Fort Worth, TX 76177
• Page Medical, Grapevine, TX 76051
• Vaquero Medical, Grapevine, TX 76051
• Polestar Medical Solutions, Southlake, TX 76092
• Trinity IOM, Fort Worth, TX 76104
• 117 Surgical Assistants, Fort Worth, TX 76104
• Squire Surgical Services, Southlake, TX 76092
• Fort Worth Ranch Assist, Fort Worth, TX 76109
• Myeuverse IOM, Fort Worth, TX 76102
• FW CSN Monitoring, Fort Worth, TX 76102
• Lone Star Monitoring, Irving, TX 75063
• Lone Star Neurosurgical Assistants, Westlake, TX 76262
• Select Pain Procedure Center, Fort Worth, TX 76102
• Brain Assist, Keller, TX 76248
• IONM, Keller, TX 76248
Patient Acknowledgement
I acknowledge that my attending Physician(s) has disclosed to me, at the time of initial contact and at the time of referral (A) his/her
affiliation if any, with the facilities or providers for whom, I, the patient am being referred, and (B) that he/she may receive financial
benefit related the care rendered by the facility or provider based on the individual legal ownership structure of the facility or provider.
I understand that I, the Patient, have the right to choose the providers of my health care services.
Please sign below to acknowledge the receipt of this disclosure and to indicate that you do not have any objections to using the
facilities or providers listed above.