Please note:  If you are unable to complete and submit the forms prior to your scheduled appointment, please arrive 30 minutes early to do so or we may need to reschedule. Thank you.

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Authorization To Pay Benefits To Physician: I authorize the release of medical or other information necessary to process health insurance claims. I also request payment of benefits to my provider when they accept assignment.

Authorization To Release Medical Information: I hereby authorize my Provider to release any information necessary for my course of treatment.

I certify that the above information is correct as of the date signed.

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I, the undersigned, hereby consent to the following Treatment:

• Administration and performance of all treatments
• Administration of any needed anesthetics
• Performance of such procedures as may be deemed necessary or advisable in the treatment of this patient
• Use of prescribed medication
• Performance of diagnostic procedures/tests and cultures
• Performance of other medically necessary or advisable based on the judgment of the attending physician or their assigned designees.

I fully understand that this is given in advance of any specific diagnosis or treatment.

I intend this consent to be continuing in nature even after a specific diagnosis has been made and treatment recommended. The consent will remain in full force until revoked in writing.

I understand that Southwest Spine and Pain Center may include consent at satellite offices under common ownership.

I, the undersigned, acknowledge that Southwest Spine and Pain Center will use and disclose my information for the purposes of treatment, payment, and healthcare operations as described in the Notice Privacy Practices.

A photocopy of this consent shall be considered as valid as the original.

I acknowledge that I am able to have access to a complete copy of the Southwest Spine and Pain Center “Notice of Privacy Practices”. I understand that if I have questions or complaints that I should contact the Privacy Official.

Medicare Patients: I authorize to release medical information about me to the Social Security Administration or its intermediaries for my Medicare claims. I assign the benefits payable services to Southwest Spine and Pain Center.

I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.

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I herby authorize the release or use of my individually identifiable health information (protected health information or PHI) and medical information by ­­Southwest Spine and Pain in order to carry out treatment, payment, or health care options. You should review the Practice's Notice of Privacy Practices for a more complete description of the potential release and use of such information, and you have the right to review such Notice prior to signing the Consent form. We reserve the right to change the terms of its Notice of Privacy Practices at any time. If we do make changes to the terms of its Notice of Privacy Practices, you may obtain a copy of the revised notice by writing our practice or requesting a copy from our front desk staff. You retain the right to request that we further restrict how your protected health information is released or used to carry out treatment, payment, or health care operations. Our practice is not required to agree to such requested restrictions; however, if we do agree to your requested restriction(s), such restrictions are then binding on the Practice.

By signing below, I attest that the information provided above is true and accurate.

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Thank you for choosing us as your medical clinic.  Our team of skilled providers are committed to providing you with quality and affordable health care.  For us to continue providing excellent care, we offer this agreement to all patients.  A copy will be provided upon request. If you do not agree to the terms listed below, we will be unable to proceed with your appointment(s). The parties may not alter this Agreement.

1. Registration: To ensure accurate billing and the proper delivery of care, all patients must complete our patient information form.  We also need a copy of your valid driver’s license and current valid insurance card. Most insurance companies have time limits for filing claims, so it’s important to provide us with accurate and up-to-date information.  If your insurance information is incorrect or if you fail to notify us of any changes in a timely manner, you may be responsible for the balance of your claim. 

2. Insurance: We accept assignment and participate with many insurance plans.  If your insurance plan is not a plan we participate with, please reach out to your insurer for options or payment in full will be due at each visit.  We encourage you to familiarize yourself with your insurance benefits and advise you to reach out to your insurer with any questions to ensure you receive the maximum coverage available.

3. Claims: We will submit claims to your Primary, Secondary, and Government Issued Tertiary insurance, and we will support you in any way we can to help get your claims processed correctly.  However, it is your responsibility to ensure any additional information requested by your insurance company is provided in a timely manner.  Please remember that your insurance benefits are a contract between you and your insurance company.  Please also be aware that any amounts left as your responsibility is determined by your insurance company.

4. Patient copayment: All copayments are due at the time of service. This is part of your agreement with your insurance provider.

5. Uninsured patients: We understand that some patients may not have insurance, to accommodate this we offer a discount for those who pay at the time of service. If the charges are not paid at the time of service, the discount will no longer apply and the full charged rate will be expected before the next visit.  If a balance remains, you will receive a monthly statement that is due upon receipt.  Any account balance over 90 days will be subject to review for collection action.

6. Outstanding Balance:  If your balance remains unpaid for more than 90 days, we may need to temporarily suspend services until the balance is settled.  Please understand that if your account remains unpaid and is sent to a collection agency, each referral to collections or report to a credit bureau may negatively impact the responsible party’s credit score. You will also be responsible for any additional collection fees (such as interest, court costs, reasonable attorney’s fees, etc.), as outlined by law. We want to work with you to avoid this, partial payments or payment plans may be accepted with prior arrangement.

7. Missed appointments: If an appointment is missed, a fee may apply. If you need to cancel an appointment, please let us know at least 24 hours in advance so we can allow someone else the opportunity to receive care.

8. Credit Card: A credit card will not be kept on file unless opted into. I understand by not having a card on file, I will receive a statement, and payment will be due upon receipt. Failure to pay to upon receipt, may result in additional fees.

Thank you for taking the time to review and agree to our Health Care Financial Agreement. If you have any questions or need further clarification, please don’t hesitate to reach out to our team. We’re here to help patient’s live life again!

By signing below, you acknowledge and bind the terms of the agreement.

Only click "save" if you wish to save and continue later, otherwise click "Next" to continue completing the paperwork. Leaving the window up and returning without clicking save, may result in a loss of any information entered.

Only click "save" if you wish to save and continue later, otherwise click "Next" to continue completing the paperwork. Leaving the window up and returning without clicking save, may result in a loss of any information entered.

Only click "save" if you wish to save and continue later, otherwise click "Next" to continue completing the paperwork. Leaving the window up and returning without clicking save, may result in a loss of any information entered.

Only click "save" if you wish to save and continue later, otherwise click "Next" to continue completing the paperwork. Leaving the window up and returning without clicking save, may result in a loss of any information entered.

Only click "save" if you wish to save and continue later, otherwise click "Next" to continue completing the paperwork. Leaving the window up and returning without clicking save, may result in a loss of any information entered.

Only click "save" if you wish to save and continue later, otherwise click "Next" to continue completing the paperwork. Leaving the window up and returning without clicking save, may result in a loss of any information entered.

Only click "save" if you wish to save and continue later, otherwise click "Next" to continue completing the paperwork. Leaving the window up and returning without clicking save, may result in a loss of any information entered.

PLEASE CLICK SUBMIT

(DO NOT CLICK "SAVE" if you have completed your paperwork. Please select "SUBMIT" to send us your finalized paperwork. PLEASE WATCH FOR YOUR CONFIRMATION EMAIL (also check spam.)