Form

I hereby give authorization for payment of insurance benefits to be made directly to Tien Le, M.D. and any other healthcare provider including other Physicians or Physician Assistants at Total Spine and Brain Institute, PLLC (TSBI) for services rendered. I am financially responsible for all charges whether they are covered or rejected by my insurance and/or Workman’s Compensation. In the event of default, I agree to pay all costs of collection and reasonable attorney fees. I authorize TSBI to release all information necessary to secure the payment of benefits. I hereby authorize TSBI to provide medical record information pertaining to the care rendered to any other healthcare provider, hospital, insurance carrier, workman's compensation carrier, or law firm as appropriate for the purpose of evaluation and treatment and/or reimbursement of medical services. I agree that a photocopy of this agreement shall be as valid as the original. This agreement will remain until revoked by me in writing.

Insurance

In most cases we will accept your insurance benefits. Your portion of the bill (also known as copayments, coinsurance, or deductible) is to be paid at the time of service. We cannot waive or discount this fee due to our contract with insurance companies. We reserve the right to charge a monthly interest rate of 5% to any unpaid balance. In the event of surgery, this will take effect 90 days after the date of surgery. ​The balance is your responsibility whether your insurance company pays or not.

We cannot file a claim to your insurance company unless you give us your insurance information. Please present your insurance card at the time of check-in. It is necessary for us to keep a copy of the insurance card in your medical records chart.

Your insurance policy is a contract between you and your insurance company. ​We are not a party to that contract​. Please be aware that some, and sometimes all, of the services provided may not be covered by your insurance company.

In the event that a charge is not covered by your plan, you will be billed the balance after we obtain an Explanation of Benefits from your insurance carrier. Outstanding charges are due upon receipt. Accounts with unpaid charges 120 days from the original date a claim has been filed, are placed with a collection agency. You will be responsible for any collection costs.

Self-Insured

If you are a non-insured patient, you will be required to pay the full amount before being seen by the physician. Your appointment will be rescheduled if you are unable to pay for your visit at the time of service.

Missed Appointments

We understand that schedules sometimes change with short notice, but we would appreciate the courtesy of a 24-hour notice if you need to cancel an appointment. If the appointment is not canceled 24 hours in advance or you do not show up for your scheduled appointment, you will receive an invoice with the missed appointment fee. We reserve the right to charge $50 for missed appointments and $250 for missed in-office procedures. Please help us serve you better by keeping your scheduled appointment. We try to confirm all appointments between 3 to 5 days before; however, this is a courtesy. Not receiving a reminder from our office does not release a patient from the responsibility of remembering an appointment.

Disability Forms

There will be a charge of $50.00 to complete any and all medical leave (FMLA) papers.

Returned Checks

There will be a $25 service charge for all returned checks.

Medical Records Request

Copies of medical records will be released within written patient authorization in a timely manner. Please allow us one week to complete the request. Outside request service fee is $1.00 per page for the first 25 pages, then 25 cents per page thereafter.

Patient Confidentiality

I have read this office's PRIVACY POLICY PRACTICES and have received a copy if I so desire.