New Patient Form

Thank you for choosing Nevada Pain and Spine Specialists to assist you with your pain management. We appreciate your trust in us and look forward to the opportunity to work with you and your primary care provider and physician.

Please keep in mind this appointment is for an initial CONSULTATION/EVALUATION ONLY. Prescription medications MAY NOT be prescribed at this appointment. It is very important that you continue medication management with your primary care provider or physician.

** If for any reason, you have to cancel and/or reschedule your appointment; please notify us at least 24 hours in advance. If you “NO SHOW” twice as a new patient to the practice, we will not reschedule your consultation without payment in full in advance.

OFFICE HOURS:
Monday – Friday, 7:30 AM – 5:00 PM (Lunch 12:00 – 1:00)
Phone: 775-689-5410, Fax: 775-786-4031

Please bring the following to your appointment:

• All current medication bottles
• Completed Registration Form
• If relevant, X-Ray and/or MRI films
• Driver’s License or another Photo Identification.
• Current Health Insurance Card(s)
• Current Prescription Card
• Co-payment (if required by your insurance)

***Completed New Patient Packet, questionnaire and financial policy must be returned 48 hours PRIOR to your scheduled appointment*** Best option is to complete through our patient portal which can be found painspine.com If you have any questions, or need assistance of any kind, please call anyone of our schedulers:

• Dr. Steven Berman: 775-451-1718
• Dr. Kenneth Pitman: 775-451-1704
• Dr. Anwar Mack: 775-451-1705

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Call to schedule for the following:
Brian Douglas, PAC
Emma Buckius, PAC
Corinne Canavero, APRN
Jayme Yocom, APRN

PATIENT FINANCIAL RESPONSIBILITY FORM

INSURANCE:
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.

WORKER’S COMPENSATION:
If you are being seen for a work-related injury, you need to complete the information in the attached forms.

AUTO ACCIDENT:
If you are being seen for an injury related to an auto accident, you need to complete the information required in the appropriate form.

CASH/SELF PAY:
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.

FORMS:
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.

PHARMACY REFILLS:
Call your pharmacy for refills. They may fax refill requests to 775-786-4031

Work-Related Injury

**WE REQUIRE A COPY OF YOUR C4.**

MEDICARE PATIENTS

(These questions are required by Medicare)

Is Medicare Primary?
I request that payment if authorized Medicare/Other insurance company benefits be made either to me or on my behalf to Nevada Pain & Spine Specialists for any serviced furnished me by that part who accepts assignments/ physician. Regulations pertaining to Medicare assignment of benefits apply. I authorize any holder of medical or other information about me to the Social Security Administration and Health Care Financing Administration or its intermediaries or carrier or any other insurance company any information needed for this or a related Medicare/ Other Insurance Company claim.

I understand my signature requests that payment be made and authorized release of medical information necessary to pay the claim. If item 9 of HCDA-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.

Is Medicare Secondary?
If you checked yes, please check any boxes below that apply to you:

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ONLY COMPLETE THIS SECTION IF THIS IS A WORK-RELATED/WORK COMP INJURY

HIPAA

Please review the following document and fill out the form below:
HIPAA Document

ACKNOWLEDGEMENT OF PRIVACY PRACTICES
I have read the Notice of Privacy Practices and understand my rights contained in the notice.

Acknowledgement and Consent to Discuss Treatment

I have read The Notice of Privacy Practices and understand my rights contained in the notice.

By way of signature, I provide this practice with my authorization and consent to use and disclose my protected health care information for the purposes of treatment, payment and healthcare operations as described in the Privacy Notice.

I also authorize and give permission for representatives of NPSS to discuss information regarding appointments, medication treatment, information regarding medications, test/lab results, insurance and billing with:

Do we have permission to: