This document explains the financial policies of our practice so that you, as a patient receiving health care services from Nevada Pain and Spine Specialists (NPSS), understand your financial responsibilities and obligations to our practice.
I request that payment of benefits under my Medicare or private insurance plan for services rendered by providers of Nevada Pain and Spine Specialists, be paid on my behalf to Nevada Pain & Spine Specialists. I authorize any holder of medical or other information needed to process my medical claims to release said records to the Social Security Administration and Health Care Financing Administration or its intermediaries or carriers or any other insurance company, needed for this or a related Medicare/ Other Insurance Company claim.
I understand that my signature below authorizes payment and release of medical information necessary to pay the claim. If item 9 of HCFA-1500 claim form is completed, my signature authorizes releasing of the information to the insurer or agency shown.
In Medicare/ Other insurance assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare/ Other insurance company as the full charge, and the patient is responsible only for the deductible, coinsurance, and non-covered services. Coinsurance and the deductible are based upon the charge determination of the Medicare/ Other insurance company.