NEUROSPINE SOLUTIONS
New Patient Packet

Financial Agreement

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Morgan P. Lorio, M.D., F.A.C.S
John Testerman, M.D.

Payment for office services are due at the time services are rendered unless arrangements have been approved in advance by our office staff. We accept cash, personal checks, and credit cards. There will be a charge of $30.00 for each returned check.

ATTENTION AUTOMOBILE ACCIDENT PATIENTS: We do not hold for litigation. We do ask that payment be made prior to services.

PATIENTS WITH MEDICAL INSURANCE MUST REALIZE THAT:

  1. Your insurance is a contract between you, your employer and the insurance company. We are not party to that contract.
  2. Our fees are generally considered to fall within the acceptable range by most companies and therefore are recovered up to the maximum allowance covered by each carrier.
  3. Not all services are a covered benefit in all contracts. Insurance companies can select services that they will not cover.

We must emphasize that as medical care providers, our relationship is with you, not your insurance company. While the filing of insurance claims is a courtesy that we extend to our patients, all charges are your responsibility from the date of services rendered.

I hereby agree to pay any and all charges that exceed or that are not covered by insurance.

Signature: ________________________________________________________ Date: ________________________

I hereby authorize the above physician to release information concerning my case history and treatment, examination, or hospitalization which I recieve, including copies of hospital and medical records to include drug, alcohol, and psychiatric information if applicable. I hereby release you, your organization, or others from liability or damage that may result from furnishing information requested above. This authorization shall remain in effect until widthrawn by me in writing.

Signature: ________________________________________________________ Date: ________________________

I hereby assign and direct you to pay without further notice from me, to the above physician such amount as may be payable to me for medical and/or surgical treatment. I understand that I am responsible for all charges not covered by this authorization.

Signature: ________________________________________________________ Date: ________________________

MEDICARE PATIENTS: I authorize any holder or medical or other information about me to be released to the Social Security Administration or its intermediaries any information needed for this or a related medical claim. I permit a copy of this authorization to be used in place of the original and request payment of benefits to myself or to the party who accepts assignment. Regulations pertaining to Medicare assignments of benefits apply.

Signature: _________________________________________________________ Date: _______________________