CONDITIONS OF REGISTRATION AND AGREEMENT FOR PATIENTS OF SPINE AND BRAIN INSTITUTE OF SAN DIEGO, INC.
If the patient is a minor, the parent, legal guardian, or authorized person (in writing) must sign.
MEDICAL CONSENT
The undersigned consents to any and all services that do not require informed written consent.
RELEASE OF INFORMATION
The undersigned acknowledges receiving Spine and Brain Institute of San Diego's Notice of Privacy Practices. Additional copies are available upon request.
FINANCIAL AGREEMENT
The undersigned agrees whether he/she signs as an agent or as a patient that in consideration of the services to be rendered to the patient, he/she hereby individually obligates him/herself to pay all monies due in accordance with the regular rates and terms of Spine Institute of San Diego. In addition, the undersigned understands that any deposit made for services incurred is merely a deposit, and that he/she will be financially responsible for all charges incurred.
Co-payments, co-insurance, payments for non-covered services and/or deductibles are due at the time of visit. Monies not collected at the time of visit will be the patient's responsibility.
All patient accounts are due and payable upon receipt of a billing statement. If it is necessary to employ professional collection agency and/or attorney to enforce this Agreement or to collect a judgment based on this Agreement, the patient or the person responsible for payment of fees related to the account that is the subject of this Agreement promises to pay all applicable Interest, court costs and attorney fees.
The undersigned herby agrees to provide 24 hours advance notice for all canceled appointments. Should 24 hours advance notice not be provided, he/she understands that they may be charged a missed appointment fee.
The undersigned hereby authorizes Spine and Brain Institute of San Diego to check and/or verify all references and financial information about him/her that is pertinent to his/her acc,ount, including but not limited to credit reports.
ELIGIBILITY GUARANTEE
The undersigned agrees that he/she must be eligible with their health insurance plan at the time of visit. The undersigned understands and agrees that Spine and Brain Institute of San Diego will not take responsibility for the refusal of an insurance company to pay for testing or treatment due to lack of insurance benefits. If he/she is unable to provide insurance coverage at time of visit, he/she has 30 calendar days to provide this information. If he/she is unable to provide eligible coverage within 30 calendar days, he/she will assume full financial responsibility for all charges incurred. In addition. should eligibility status of the patient's insurance terminate retroactively. he/she will be financially responsible for any services provided.