PATIENT FINANCIAL RESPONSIBILITY FORM
As a courtesy, Nevada Pain & Spine Specialists will file all claims to your insurance carriers for services provided. In order to extend this courtesy, we need a picture ID and your current insurance card(s), and the information in the attached forms.
- Many procedures that we perform require pre-determination and pre-authorization from your insurance carrier and may take 2-4 weeks to obtain.
- If you have an HMO plan with which we are contracted, you need a referral authorization from your primary care physician.
- Insurance coverage varies widely; we strongly recommend that you become familiar with your policy and the benefits, restrictions and non-covered services that are specific to your plan.
- If any changes in your insurance coverage or benefits occur while being treated at Nevada Pain & Spine Specialists, you are responsible to notify us immediately.
- Co-pays are due at time of service
- Patients are responsible for co-pays, coinsurance, deductibles and all other costs not covered by insurance or Medicare.
- Parent/Legal guardian is responsible for co-pays, coinsurance, deductibles and all other costs not covered by insurance or Medicare, if patient is a minor or requires legal guardian.
If you are being seen for a work-related injury, you need to complete the information in the attached forms.
If you are being seen for an injury related to an auto accident, you need to complete the information required in the appropriate form.
If you are not covered by health insurance or Medicare, we expect payment in full at the time of service. We do offer a 20% discount for payment in full at time of service. If you are unable to pay in full, our staff is happy to discuss/arrange payment options prior to your visit.
PATIENT FINANCIAL RESPONSIBILITY:
I have read the foregoing and I understand that I am responsible for the charges not covered by insurance or Medicare, and that all charges are due and payable within 30 days. If I am a Medicare patient, I am only responsible for the deductible, coinsurance and non-covered services. If I am unable to pay in full within 30 days, I am to contact the Billing Department for financial arrangements at 775-451-1736 Ext: 111. My account will be considered delinquent after 90 days. I will be discharged as a patient from Nevada Pain and Spine Specialists.
Completion of any forms requested by patient by our physicians requires an office visit. We may not complete all forms as it may be more appropriate for your primary care provider and/or surgeon to complete. Please let us know what type of form you are requesting to be completed when you call to schedule an appointment. Our staff will determine if we can complete the form, if so they will
schedule the appropriate time with your physician. The charge for completing the form(s) ranges from $25.00 to $200.00. The amount is due at the time of your appointment.
Call your pharmacy for refills. They may fax refill requests to 775-786-4031