IMPORTANT DISCLOSURE, AUTHORIZATION,
ASSIGNMENT OF BENEFITS NOTICE AND BILL OF RIGHTS
By signing below, I acknowledge that I understand the following:
1. I hereby consent for treatment, consultation, or testing. I allow the provider, to release any
information as required, in accordance with HIPPA guidelines.
2. I hereby assign to Global Neuro and Spine Institute any benefits under any policy of insurance,
indemnity agreement or any other collateral source as defined by Florida statues, for any services
and /or charges provided by Global Neuro and Spine Institute It is the intent of the undersigned that
this assignment be deemed irrevocable unless both the patient and an unauthorized representative
for Global Neuro and Spine Institute execute a revocation of this Assignment of benefits prior to the
filing of any suit for insurance benefits. The Assignment of Benefits shall apply to any and all
causes of actions, suits, claims, counter-claims and demands.
3. I hereby authorize all parties involved to release any and all documentation related to my care to
Global Neuro and Spine Institute.
4. I hereby authorize my attorney to release my settlement disbursement to Global Neuro and Spine
Institute.
5. Under Florida Law, physicians are generally required to carry malpractice insurance. Otherwise,
they must demonstrate financial responsibility to cover potential claims for medical malpractice.
Your doctor may have decided not to carry medical malpractice insurance. This is permitted under
Florida law subject to certain conditions. Florida law imposes penalties against non-insured
physicians who fail to satisfy adverse judgments arising from claims of medical malpractice. This
notice is provided pursuant to Florida law.
6. I agree and hereby authorize Global Neuro and Spine Institute to retain legal counsel of its choice in
order to collect any and all outstanding balances as a result of treatment, services, or products
provided, and to proceed against any insurance company for refusal to pay benefits due and owning
under Florida law.
1. If you need a referral from your insurance company or your primary care physician to be seen in
our facility, the referral must be presented at the time of your visit. If it is not available, it will be
your responsibility to obtain one. Consequently, you will need to reschedule your visit should the
referral not be available. We encourage you to call your primary care physician and have your
referral faxed to us. Our fax numbers can be obtained from the front desk.
2. Many insurance companies require authorization or pre-authorization in order to have supplies
and/or services dispensed by a doctor’s office or facility. Due to the many changes in insurance
policies, it is no longer an easy task to interpret each individual policy. Although Global Neuro and
Spine Institute tries to stay aware of these changes, it is not always possible; therefore, we urge you,
the patient, to please check with your insurance company regarding your coverage. It is your
responsibility to know your individual coverage and is limitations.
Global Neuro and Spine Institute
3. By rendering services and/or leaving the office with supplies that are not authorized, you will be
financially responsible if your insurance company denies payment. In instances when your
insurance company gives approval for care or services and later reverses its position, for whatever
reason, you agree to be fully responsible for services rendered.
4. If you have a co-payment or any out-of-pocket expense, deductible, etc.., it must be paid at the time
services are rendered.
5. I understand that I am responsible for any deductible or copayments under my insurance and that I
am responsible for any charges should my insurance benefits become exhausted. I agree that in the
event that it becomes necessary to collect monies owed by me, I will be responsible for all cost
including, but not limited to, collection agency commissions, attorney fees and court costs. In
addition, I agree to pay an interest charge of one and one half percent (11/2 %) per month on any
balance after 45 days of service. Being carefully informed of these facts, I have decided to remain
in the care of my physician and his associates.
6. If for any reason you cannot keep your appointment, 24-hour notice must be given, otherwise
a $50.00 fee will be charged.
7. I HEREBY AUTHORIZE THE ASSIGNEE TO REQUEST ALL DOCUMENTS AND
INFORMATION PERMITTED BY FLORIDA STATUTE SECTION 627.4137, INCLUDING
BUT NOT LIMITED TO A COPY OF THE APPLICABLE INSURANCE POLICY,
DECLARATION PAGE REFLECTING COVERAGE ON THE DATE OF LOSS, AND THE
APPLICABLE PIP/LOG/LEDGER, ALL OF WHICH TO BE PROVIDED TO THE ASSIGNEE
UPON REQUEST. This request is authorized pursuant to the terms of my policy as well as Florida
Statutes 627.4137. I hereby authorize this assignee to request and receive a copy of my PIP
Log/Ledger periodically.
8. Be further advised that I AM HEREBY PLACING YOU ON NOTICE PERSUANT TO FLORIDA
CASE LAW THAT SHOULD YOU (THE INSURANCE COMPANY/CARRIER) DENY,
REDUCE, OR FAIL TO PAY ANY PART OF, OR AN ENTIRE BILL WHICH WAS
SUBMITTED ON MY BEHALF FROM THIS PROVIDER, I (THE ASSIGNOR) AS WELL AS
THE ASSIGNEE ARE REQUESTING IN ADVANCE THAT YOU RESERVE, OR “SETASIDE”, THE AMOUNT YOU
RECEIVED OR DENIED UNTIL THE DISPUTE IS
RESOLVED. Should you submit a check to assignee which is loss that the correct contractual
amount, and contains any language referring to “Full and Final Payment” I have instructed
Assignee to return the check to you (the carrier) and consider the bill still due and owing (i.e. A
late payment as defined in F.S.S 627.736). Additionally, SHOULD THE REMAING AMOUNT
OF MY BENEFITS APPROACH THE AMOUNT WHERE THERE WOULD BE
INSUFFICIENT FUNDS TO PAY THE AMOUNT YOU REDUCED, DENIED, OR FAILED
TO PAY, PLEASE NOTIFY ME (THE ASSIGNOR) AND THE ASSIGNEE OF THIS FACT.
Should my benefits exhaust; please notify me (the assignor) and assignee promptly.
