First Name * Last Name * Date of Birth Social Security Number Street Address1 Street Address2 City State / Province Postcode / Zip Home Phone Number Cell Phone Number Email Employer Occupation Referred By Primary Care Physician Height Weight Preferred Language English Spanish Chinese German Other Decline Ethnicity Non-Hispanic or Latino Hispanic or Latino Unknown Decline Race American Indian/Alaska Native Asian Black or African American Decline Native Hawaiian of Pacific Islander Other Unknown White Marital Status Single Married Widowed Separated Divorced First Name Last Name Preferred Phone Number Relationship to Patient
An advanced directive is a document that you complete to be used in a situation when you can’t speak for yourself and make your own decisions regarding the healthcare you want. It can do two things: (1) name the person you want to make decisions on your behalf when you can’t and (2) provide that person and your health care team with information on the decision you would make if you could speak for yourself.
Do you have any type of Advanced Directive? If yes, which type of Advanced Directive do you have: Please bring your insurance cards with you to your appointment. Primary Insurance Carrier Name Policy Number or Medicare ID Number Effective Date Relationship to Subscriber Self Spouse Dependent Other Name of Subscriber (If Different from Patient) Subscriber Date of Birth (If Different from Patient) Secondary Insurance Carrier Name (If Applicable) Policy Number or Medicare ID Number Effective Date Relationship to Subscriber Self Spouse Dependent Other Name of Subscriber (If Different from Patient) Subscriber Date of Birth (If Different from Patient)
I hereby authorize Pacific Neurosurgery to furnish information to insurance carriers concerning this illness/accident, and hereby irrevocably assign to the doctors all payments for medical services rendered. I understand that I will be responsible for any legal costs and attorney’s fees incurred for collection of any past due account. I further understand that I am financially responsible for all charges whether or not covered by insurance.
Current Medication & Dosage (mg) Allergies (Drug and/or Medical) Previous Surgical Procedures & Approx. Dates Previous Significant Injuries & Approx. Dates Do You Experience Any of the Following?
Below, please indicate any symptoms you are currently experiencing (within the last month):
Is there anything else you would like to add?
Has any family member experienced the following?
If yes, please indicate who: Is or has been an alcoholic? If yes, please indicate who: Is or has been a drug addict? If yes, please indicate who: Had unusual bleeding tendencies? If yes, please indicate who: If you have any additional comments, please enter them here:
I agree that in return for services provided to me by Pacific Neurosurgery, I will pay any account balances at the time of service or will make financial arrangements with Pacific Neurosurgery. If co-payments, deductibles, out-of-network balances, non-covered services and/or past balances are designated by my health plan, I agree to pay those balances directly to Pacific Neurosurgery. I understand that if my account is delinquent and all efforts to collect any balances have been exhausted, it may be turned over to a collection agency.
Non-Participating Insurance Accounts A patient who is insured by an insurance carrier with which the practice does not participate, is considered a self-pay patient. It is the patient's responsibility to inform the practice of any insurance coverage changes, to confirm the practice's participation and to verify their eligibility before each visit. I understand and agree that I am obligated to pay the full charge(s) of all services rendered to me by Pacific Neurosurgery if I belong to a plan in which Pacific Neurosurgery does not participate.
Self-Pay Patients Self-pay patients are those who are covered by an insurance carrier with which the practice does not participate or patients without insurance at the time of service. I understand and agree that, as a self pay patient, I am individual responsible to pay the full charges at the time of service.
HMO Referrals and Authorizations If your insurance is an HMO (has a designated primary care physician), you are required to inform the office of this at the time of scheduling your appointment so an authorization may be obtained. If this information is not provided at the time of scheduling, you will be asked to reschedule your appointment.
Non-Covered Services I understand that my insurance plan may not pay for all of my medical services and costs. Some items and services are not considered “covered benefits” under your health insurance plan and as such, your insurance will not pay for these services. It is the patients responsibility to understand what your plan covers and does not cover. You will be responsible for all non-covered charges/services. Missed Appointments Failure to arrive for a scheduled appointment and/or failure to cancel an appointment within 24 hours will result in a missed appointment fee of $50 for each occurrence. The patient is fully responsible for this payment. I have read and understand the policies written above: *
Pacific Neurosurgery requires that all patients keep a credit card or debit card on file as a convenient way to pay for any outstanding patient balances. This is due to an increasing amount of deductibles and co-payments required by insurance companies, and to decrease the number of delinquent accounts.
We will bill your credit card
ONLY in the following situations:
1. Your balance is 90+ days old and/or we have sent you at least 3 statements
2. You instruct us to bill your credit card for any outstanding balance
3. If you set up a payment plan with us
Should you decline to provide a credit card or debit card number, you will be responsible for paying any outstanding balance upon receiving a billing statement. Should you not pay your balance due after three statements, your balance will be sent to collections without further notice and you will no longer be able to receive services by Pacific Neurosurgery until this balance is paid in full.
Your credit card information is kept confidential and secure, and payments to your card are processed only after the claim has been processed by your insurance company, and the insurance portion of your claim has been paid and posted to your account.
I authorize Pacific Neurosurgery to charge the portion of my bill that is my financial responsibility to the following credit card or debit card:
Credit Card Number Expiration Date (MMYY) CVV Cardholder Name (If different from patient) Billing Zip Code
I (we), the undersigned, authorize and request Pacific Neurosurgery to charge my credit card, indicated above, for balances due for services rendered that my insurance company identifies as my financial responsibility. The authorization relates to all payments not covered by my insurance company for services provided to my by Pacific Neurosurgery. This authorization will remain in effect until I (we) cancel this authorization. To cancel, I (we) must give a 60 day notification to Pacific Neurosurgery in writing and the account must be in good standing.
I decline to provide a credit card and understand the above policy I have read and understand the above policy *
If you have any additional documentation, please upload here: