New Patient Questionnaire- Orthospine Advance Health Inc.

Please answer the following questions with the most accurate response possible. If some of the questions are unclear or do not apply, skip ahead to the next question. Your doctor will be going over this questionnaire with you during your visit and you can clarify your answers at this time. 

END OF NECK OR ARM PAIN QUESTIONS, PLEASE GO TO "C" IF YOU DON'T HAVE BACK PAIN

This questionnaire will give your Doctor information of how your pain has affected your ability to manage your everyday life activities. Please answer every question by marking only ONE box that better describes your current condition. In some cases probably two statements describe your condition, however PLEASE ONLY MARK ONE, that closest describes your condition. 

Payment for Services: Co-payments, deductibles, co-insurance, and self-pay balances are due at the time services are rendered unless payment arrangements have been approved in advance. Payment of your co-payments, deductibles, and co-insurance is part of your contract agreement with your insurance plan. Due to this, our failure to collect payment may be in violation of billing compliance and may be considered as an act of fraud by your insurance plan. 

Non-Covered Services: Please be aware that some or perhaps all of the services you receive may not be covered or considered reasonable or necessary by your insurance plan. If you elect to have these services, you will be asked to sign a waiver and payment in full will be expected at the time of service. 

Claim Submissions: We will submit your claims and assist you in any way you can to help get your claims paid. Your insurance plan may request information directly from you. Your failure to timely comply with your insurance plan's request may result in your claim being denied. If so, we will seek full reinbursement from you for services rendered; even if we are a participating provider with your plan. Your insurance benefit is a contract between you and your insurance plan.

Self-Pay: If you do not have valid health care coverage, you will be considered as self-pay. Payment in full is due at the time of service unless you make prior arrangements. Please be aware that if your injury is related to an accident, WE DO NOT accept auto insurances or liens.

Non-Payment: It is our office policy that payments for the payment plans be made every 30 days. If a payment is missed, it will considered past due. A payment will need to be made on any past due account PRIOR to scheduling any follow up appointments. If no resolution can be made, non-paymetn may result in dismissal from the practice. Please be aware that if a balance remains unpaid, your account could be turned over to a collection agency, and any fees associated with that agecy will be your responsibility. 

Payment Messages: We accept cash, personal checks, money orders, cashier's checks, Visa, and MasterCard for payment of services rendered. 

Returned Checks: A return check fee of $30.00 will be added to your account for any check returned by your bank. After the first occurrence, no personal checks will be accepted for payment services. 

I understand and agree with OrthoSpine Advance Health Inc./ Sablan Orthopedics Inc. Medical Services Financial Agreement.

Medicare lifetime- Signature on File

I request that payment of authorized Medicare benefits be made on my behalf to OrthoSpine Advance Health Inc./Sablan Orthopedics Inc. for any services furnished me by the physician. I authorize any holder of medical inforamtion about me to release to the Health Care Financing Administration and its agents any inforation to determine these benefits payable for related services

Private Insurance Authorization for Assignment of Benefits/Information Release

I, the undersigned authorize payment of medical benefits to OrthoSpine Advance Health Inc./ Sablan Orthopedics Inc. for any services furnished to the physician. I understand that I am financially responsible for any amount not voverage by my contract. I also authorize you to release to my insurance company of their agent information concerning health care, advice, treatment or supplies provided to me. This information will be use for the purpose of evaluating and administering claims of benefits. 

Disclosure Agreement, Bill of Rights and Responsibility

• I have the right to be seen in a timely manner. I will be informed of any delay, and I have the right to reschedule if a delay is too lenghty. 
• I will be informed of non-urgent test results in a timely fashion. It is my responsibility to contact the physician office for routine test result follow up appointments.
• My records will be holf in strict confidence and will only be released upon written notification from me. 
• I will make every effort to understand the benefits of my insurance plan, even to the extent of calling the carrier or benefits coordinator at my place of employment. I am responsible for obtaining all necessary referrals/ authorization from my primay care physician. Per your insurance plan, authorization doesn;t necessarily obligate payment. I am ultimate responsible for payment of services I recieve, including services not covered by my insurancesue to ineligibility of coverage. 
• I recieved a copy of the Medical Services Financial Agreement for OrthoSpine Advance Health/ Sablan Orthopedics Inc. and agree with policies established. 
• I agree to pay a $30.00 charge check that is returned by my bank. 
• I understand and Agree that if I No Show to a scheduled appointment 3 times within a 12 month period, I will be discharge from OrthoSpine/ Sablan Orthopedics Inc. practice and refer back to my PCP and he/ she will refer me to another specialist. 
• I agree to follow the prescription protocol.
• I understand that any disrespectful, language or behavior by the phone or during the office environment to any of the OrthoSpine/ Sablan Orthopedics Inc. staff, I will be consider to BE discharge from the practice.

I agree with Disclosure Aggreement, Bill of Rights and Responsibility

THIS IS TO VERIFY THAT I HAVE RECEVIED A COPY OF ORTHOSPINE ADVANCE HEALTH/ Sablan Orthopedics Inc. PRESCRIPTION REFILL PROTOCOL 

Authorization to Release Medical Information to Family/ Individuals Members

In accordance with federal government privacy rules implemented through the Healthcare Portability Act of 1996 (HIPPA), in order for your physician or staff of OrthoSpine Advance Health to discuss your condition with members of your family or other individual that you designate, we must obtain your authorization prior to do so. In the event of critical episode, or if you are unable to give your authorization due to severity of your medical conditons, the law stipulates that these rules may be waived. 

Consent to Use and Disclose of Protected Health Information

Your protected health information will be use by OrthoSpine Advance Health/ Sablan Orthopedics Inc. or disclosed to other for the sole purpose of treatment, obtaining a payment you should review the Notice of Privacy Practices for a more comprehensive description of how your protected information may be used or disclosed. You may review the notice proor to signing the consent. You may request a restriction on the use or disclosure of your protected health inforamtion. OrthoSpine Advance Health may or may not agree to restrict the use of disclosure of your violation of any agreed upon restriction will be a violation of the federal privacy standard.

You may revoke this consent to the use and disclosure of your protected helath information. You must revoke this sonsent in writing. Any use of disclosure that has already occurred prior to the date on which your revocation is received. OrthoSpine Advance Health reserves the right to modify the privacy practices outline in this notice, and you are entitled to have a copy upon request. 

I have been informed and understand above consents/ disclosures