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.

Please bring your insurance cards with you to your appointment.

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.

Below, please indicate any symptoms you are currently experiencing (within the last month):

Has any family member experienced the following?

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.

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:

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 have read and agree to the Patient's Rights and Privacy Policy