Accident or Auto Injury Patients: It is our goal to offer our services to a wide range of patients and understand that some patients may require our care due to injuries sustained, at least in part, by the negligence of third parties. We attempt to bill any insurance available to you including Personal Injury Protection through your automobile insurer where applicable, your health insurance carrier AND we will refrain from collecting any unpaid or non-covered services until you have concluded your claim. In return, it is your obligation to provide us with the name and contact information of any insurer you wish to have billed as well as your policy and/or claim number at the time of your initial visit. If you fail to provide us with that information, your insurance will not be billed and you will be responsible for the full payment of all charges incurred and to the extent allowed by law. You also understand that any services which are not paid or covered by any insurer will remain your personal responsibility regardless of the outcome of any claim you may have pending against other parties. At the conclusion of any such claim, it is your responsibility to contact our facility, or instruct your legal representative to contact our facility, to inform us that the claim has been concluded and to arrange final payment for the charges incurred. During the pendency of any claim for which you have retained legal counsel, we will refrain from collection efforts but strongly encourage you to make payment arrangements for any balance remaining after the payment of insurance benefits to the extent you are financially able. It is your responsibility to inform us of the name and contact information of your legal representative at the time of your initial visit. You are also responsible to notify us of any change in your legal representation with in ten (10) days of the change. In the event that you are no longer represented by legal counsel, we will initiate collections efforts within ten (10) days of notification. In the event you have any balance at the conclusion of your claim but do not recover enough to pay the balance, you remain personally liable for the balance and we will commence collection efforts sixty (60) days after the conclusion of your claim if other arrangements to pay the balance have not been made. Balances incurred for our services remain your responsibility regardless of whether the treatment rendered by our physicians or in our facilities are deemed unrelated to the incident giving rise to your claim by any first or third-party insurance carrier, judge, jury, arbitrator, or other finder off act. You understand and acknowledge that you are freely choosing to receive treatment by our physicians or in our facilities and that you have not been made any promises or received any inducements to incur the expenses of such treatment based upon the outcome of any pending claim you have.
Surgical Patients: We understand that you have spent a tremendous amount of time researching your choice for your spine care. We also understand the importance of choosing a highly experienced minimally invasive surgeon and how that will positively impact your recovery time and overall outcome. As part of our effort to be fully transparent...
Please be advised that if a surgical procedure is recommended by your physician, based on your benefits, your insurance may not pay all or a portion of the fees that are charged by us for services rendered in the Biospine Ambulatory Surgery Center. You should also be advised that these same procedures may be covered and paid for by your insurance in a hospital setting. Since all procedures performed by our physicians are medically classified as “elective” we reserve our physicians time for in-hospital procedures only for patients categorized as “high risk” or “emergent”. Since most patients do not meet this criteria, we can refer you to another provider that will perform the procedure in a hospital setting. If you elect to change providers, we will continue to provide care for any emergent spine related conditions that may arise for the next 30 days, or until you find a new provider, whichever comes first. Possible alternatives for orthopedic surgeons in the area can be provided upon request.
Medical Records Requests: When a patient, physician or other party is requesting medical records, the office may require 5-10 working days for completion of this request, due to the many other office responsibilities to other patients.
No Show Appointments: Patients who do not call to cancel appointments will be charged a $50.00 fee, and discharged from the practice after the third “no show.”
Delinquent Accounts: All delinquent accounts will be turned over to an outside collection agency or attorney if balances remain unpaid for a period of 120 days unless arrangements are made with our facility. You are responsible for all fees and charges incurred from the collection agency and/or legal process regarding the settlement of your account.
FINANCIAL POLICY ACKNOWLEDGEMENT
I ACKNOWLEDGE THAT I HAVE READ, UNDERSTAND, AND AGREE TO FINANCIAL POLICY.
NOTICE OF PRIVACY PRACTICES: I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. These rights include, but are not limited to: access to my medical records; restrictions on certain uses; receiving an accounting of disclosures as required by law; and requesting communication about my health information by alternative means or at alternative locations.
Patient Acknowledgment of Gulfcoast Spine Institute’s and BioSpine, LLC’s “Notice of Privacy Practices and Patient Right: I HEREBY, ACKNOWLEDGE THAT A COPY OF YOUR NOTICE OF PRIVACY PRACTICES CONTAINING A COMPLETE DESCRIPTION OF MY PRIVACY/CONFIDENTIALITY RIGHTS WILL BE GIVEN TO ME AT MY FIRST APPOINTMENT. I, understand that a copy of this notice is also posted in your office for additional reference. I, further, understand that you have the right to change your Notice of Privacy Practices at any time and that I may contact you at any time in writing to obtain a current copy.