I understand that under the Health Insurance Portability and Accountability Act (“HIPAA”), I have certain rights to privacy regarding my protected health information. I acknowledge that I have received or been given the opportunity to receive a copy of the Notice of Privacy Practices of Axis Spine PLLC (the“Practice”). These practices are acceptable to me. I also understand that the Practice has the right to change its Notice of Privacy Practices and that this updated information is on the company website (www.axisspinecenter.com) and that I may contact the Practice at any time to obtain a current copy ofits Notice of Privacy Practices.
I hereby authorize Axis Spine (“the practice”) and its employees to use and disclose my medical and financial information (PHI) to the person(s) or organizations(s) identified below. It is at my request, that the specificinformation that may be used and disclosed includes any and all of my personal health and financial information in the records of the practice that pertain to me. In addition, I understand that by signing this document, I agree that as part of my physical and emotional health care, my PHI may be disclosed to other clinical providers upon request, as well as to any Health Insurance or other insurance or benefit company or employer (including their agents) from whom I or my family may seek benefits or leave of absence;further, my employer may receive Work Status reports which may contain PHI. I agree to notify Axis Spine PLLC in writing if I wish to exclude any such company or employer from receiving PHI.
This Authorization shall expire upon the earlier of 1) a written revocation of this Authorization; 2) upon my termination ofall services with the Practice; or 3) until the date indicted below.
I understand that:*It is my responsibility to inform the Practice of any desired change in this Authorization.*I have the right to revoke this Authorization at any time by alerting the Privacy Officer, in writing, at7600 Mineral Drive Ste 700, Coeur d'Alene, ID 83814, ph: 208-457-4208, except to the extent the Practice has taken actionin reliance of th this authorization prior to receipt of my revocation.* I have the right to refuse to sign this Authorization. The Practice will not condition treatment, payment,enrollment in a health plan, or eligibility for benefits on my authorization.* The person(s) I authorize may not be governed by privacy laws, therefore, information disclosedpursuant to this authorization may be subject to re-disclosure by the recipient and no longer be protected by federalprivacy law.
Thank you for choosing Axis Spine PLLC as your health care provider. We are committed to the successful treatment of your condition. Your clear understanding of our Financial Policy is important to our relationship. Please call our billing department if you have any questions.
o All patients must complete our Patient Registration Formso For cases which we bill insurance directly, we must have a copy of your Insurance ID card(s). If you do not present your insurance card at the time of service the visit will be treated as self-pay and you must pay upfront or your appointment will be rescheduled.o For cases where we bill a third party (WC/Auto), we require a copy of your private Insurance ID card(s) for our records.o Insurance Co-Payment is due at time of service.o We accept cash, check, or credit card (Visa or MasterCard)
INSURANCE (PPO/POS/Commercial/Medicare Advantage Plans)All co-payments are due at the time of service. We are members of most, but not all, plans. You are responsible for verifying that we are providers for your plan. If we are not contracted providers for your plan, you agree to pay patient responsibility charges for claims processed as “Out of Network”. You are responsible for co-payments, deductibles and co-insurances on your plan. We maintain the right to collect payment towards patient responsibility prior to any high cost treatment (Surgery, MRI, other). If applicable, you will be directed to speak to a patient representative. You are responsible for any service denied by your insurance as a non-covered service.HMO INSURANCEAll co-payments are due at time of service. You are responsible for providing the referral for your visit. We will assist with referrals for surgery and other services as directed by your plan. If you are an HMO member, you will not be billed additionally as long as we have the necessary referrals.
MEDICAREWe do accept Medicare assignment. As a Medicare patient, you are responsible only for the difference between the approved amount and the amount that Medicare pays, and of course, your deductible. If you have supplemental insurance, please provide a copy of the card and we will bill it for you. You will receive a bill after your insurance has paid if there is any remaining balance.SELF PAYPayment is due in full at the time of service. If you are unable to pay your balance in full, you must see a patient representative to make other arrangements.WORKERS’ COMPENSATIONIf you are being seen here as a result of work related injury, you must notify our staff prior to your appointment. We will require information regarding both your Workers’ Compensation insurance and your private health insurance. We must obtain treatment authorization prior to your visit. If authorization for treatment under Workers’ Compensation is denied, as a courtesy we will bill your health insurance carrier. If payment is not received from these parties, we have a right to bill you directly. If you have obtained an attorney, we will need the name, address and phone number for our records. AUTO ACCIDENT CLAIMSIf you are being seen as a result of an auto accident, you must notify our staff prior to your appointment. We require both your Auto Insurance information and your private health insurance. If payment is not received from these parties, we have a right to bill you directly. If you have obtained an attorney, we will need the name, address and phone number for our records.TREATMENT FOR A MINOR CHILDA parent or legal guardian must accompany patients who are minors (under 18 years of age). This accompanying adult is responsible for payment of the account, according to policy outlined above.RETURNED CHECKA $35.00 charge will be added to your account for any check returned by your bank for any reason.DISABILITY or INSURANCE FORMSThere will be a charge of $30.00-$50.00, depending on the complexity, for the completion of medical/disability/FMLA forms. Payment is due before paperwork is processed. Please allow 7-10 days for completion of these forms.NO SHOW POLICYYou will be charged $50.00, if you were scheduled for an appointment in our office, but you did not attend the appointment and did not provide advanced notice of cancellation to our clinic.
I understand that if the office agrees to bill insurance as a courtesy, I must submit information as needed to ensure payment for services rendered to me. I understand that I am ultimately responsible for payment of all services.