PATIENT HISTORY QUESTIONNAIRE

Please complete the following questions by marking the appropriate answers.

Patient Registration and Information

Authorization and Consent for release of Information

If you do not wish to add anyone to this release, please select "No."

Acknowledgement of Notice of Privacy Practices

I acknowledge receipt and understanding of The Spine and Pain Center’s Privacy Practices. I understand that if I would like a copy of this notice, I am to request a copy from the office or may view it on www.spineandpaincenter.com.

Disclosure of Physician Ownership Notice to Patients

The Spine and Pain Center is committed to providing the best quality healthcare to every patient we treat. As a patient of The Spine and Pain Center, we are please to inform you of the following:

1. The physicians of The Spine and Pain Center have ownership interest in Tulsa Spine and Specialty Hospital.
2. You have the right to choose the provider of your healthcare services. Therefore, you have the option to use a healthcare facility other that Tulsa Spine and Specialty Hospital.
3. You will NOT be treated differently by your physician if you choose to obtain healthcare services at a facility other than Tulsa Spine and Specialty Hospital.

If you have any questions concerning this notice, please feel free to ask your physician or any representative of Tulsa Spine and Specialty Hospital. We welcome you as a patient and value our relationship with you.

Acknowledgement of Disclosure

By signing this Disclosure of Physician Ownership, you acknowledge that you have read and understand the foregoing notice and hereby understand that your physician has an ownership interest in Tulsa Spine and Specialty Hospital.

Financial Policy

Thank you for choosing The Spine and Pain Center for your healthcare needs. We are committed to your treatment being successful. Please understand that payment of your bill is considered a part of your treatment. The following statement is our Financial Policy which we require you to read and sign prior to any treatment.

FULL PAYMENT OF OFFICE COPAYS ARE DUE AT THE TIME OF SERVICE. You are responsible for deductibles and coinsurance as directed by your insurance policy. We accept cash, money orders, Visa/Mastercard, Discover and American Express.

Insurance

Your office copay is due at the time of your visit. For your convenience, we will file insurance claims with all insurance carriers. You will be responsible for any deductibles, coinsurance and any non-covered or excluded services as explained in your policy. Payment of any patient portion due after insurance is expected upon receipt of a statement. We can not bill your insurance company unless you provide us with all information, so please bring your insurance cards to your appointment. You are responsible for notifying us of any change in insurance coverage each visit. If no insurance is presented, you will be treated as a cash pay patient and will need to pay for services as they are rendered. Once the card is presented, we will gladly file a claim and refund any money due to you.

Private Pay

If you do not have insurance, payment is due at the time if service. We accept cash, money orders, Visa/Mastercard, Discover and American Express. Please be prepared to pay in full at the time of your visit unless prior payment arrangements have been made.

Workers Compensation

Only authorized referrals will be accepted. If notification is not received prior to the appointment the patient will be responsible for charges incurred. Patients must notify The Spine and Pain Center prior to scheduled appointments with the following information: attorney’s name and phone number, employer name, contact person and phone number, work comp carrier name, adjuster’s name and phone number, the date of injury and the claim number.

Personal Injuries and Motor Vehicle Accidents

Patients must notify The Spine and Pain Center prior to their scheduled appointments with the following information: Personal injury case number, company and contact information.

No-Show Policy

A $30.00 no-show fee will be charged in the event you fail to show for an appointment without contacting our office 24 hours in advance of the scheduled appointment time. Payment of the no-show fee will be required prior to rescheduling any future appointments or processing medication refill requests. In the case of repeated no-shows, you may be required to pre-pay a nonrefundable administrative fee of $100-$300 prior to rescheduling your next appointment. If the rescheduled appointment is not kept, the fee will be considered a no-show charge. You are also at risk for being discharged from the practice in the event of reoccurring tardiness/no-shows.

Form Completion Charges

Pre-payment is required before forms will be processed. Form completion is at the discretion of your physician. The fee is $25.00 for the first page and $10.00 for each additional page.