Kindly note the following about the insurance:

Direct settlement for outpatient treatment may be restricted to certain groups. Prior authorization may be required for some tests or procedures.

I hereby certify that all of the above is correct.

I accept the final bill as my responsibility. In the event of a refusal of payment by my insurer or sponsor, in whole or in part of the medical bill, for any reason, then I undertake to settle the total account or the part rejected as my responsibility.

General Consent

Thank you for choosing American Spine Center as your health care provider. Please read carefully the following document regarding Medical Records, Financial Agreement, Medical Insurance, Personal Valuables, Missed and Broken Appointments, Patient Rights and Responsibilities, and Consent to Examination and Treatment.

Medical Records
I understand my healthcare information will be stored, viewed, and shared by my healthcare providers in one secure electronic medical record system. Once all my providers document my treatments and services in this shared record, I understand it cannot be separated.
I also authorize American Spine Center to obtain from other healthcare providers, insurance companies, government agencies, and other sources on an as-needed basis, pertinent information about my health including HIV/AIDS status, any alcohol or drug abuse data, occupational and mental health-related information, for the purpose of diagnosis, evaluation, treatment and prognosis of my condition.
I agree that my medical records may be shared with my insurance carrier or its agents to obtain pre-authorization for care and to support the payment of my claims or bills. In all cases where my medical records are released, I understand that the facility will only share what is necessary.

Financial Agreement
Patients are responsible for full payment at the time of services if not covered by some other third party or private insurance.
By signing below, I do agree that in consideration of the services rendered to me, I hereby obligate myself to pay all amounts due for services presented in accordance with the rates and terms of American Spine Center. Should the account be referred to an attorney for collection, the undersigned shall pay all reasonable attorney fees and collection expenses.

Medical Insurance
American Spine Center accepts the assignment of medical insurance benefits. That means your insurance will pay us directly the amount due based upon your benefits coverage. Your insurance policy is a contract between you and your insurance company, as per this contract, you may be responsible for a portion of the bill.

By signing this form, I authorize the assignment of my benefits to American Spine Center for treatment and related services. I understand that, as my insurance benefits may require, the payment of co-pays, co-insurance, and deductibles are due at the time of services and are my responsibility.

Patient's Valuables
American Spine Center has no provision for the safekeeping of money or other valuables and these should either be kept at home or kept in the safekeeping of family or friends. American Spine Center cannot accept any responsibility for the loss or damage of articles that the patient or legal representative considers valuable.

I release the American Spine Center from any and all liability for the loss or damage to any “valuables” which I may choose to retain in any storage area therein, despite the warning and advice on this document.

Missed and Broken Appointments

Please help us serve you better by keeping the scheduled appointments. We recognize there are times when it is not possible to keep the appointment.

• If you are not able to keep an appointment, please call our outpatient clinic at least 24 hours prior to the appointment time.
• If you are late for an appointment then you shall not expect to be seen immediately, which will cause a delay in service to our other patients who are on time. We will try to accommodate you on the same day if there is any cancellation, if not we will give you the very next available appointment. Please bear with us, every patient's care is important to us.

By submitting this online registration, I agree with American Spine Center Missed and Broken appointment policy.

Patient's Rights and Responsibilities

• I have been offered and/or received a written copy of my patient rights and responsibilities
• I understand that the American Spine Center will provide interpretation services at no cost to me in my preferred language of communication.

Consent to Examination and Treatment

By submitting this form, I attest that I am capable of reading and comprehending this without assistance, and have signed the form of my own free will. I agree that I have been made aware of the availability of assistance, and /or an interpreter to help me in completing this form, and declined any aid.

• I, (the undersigned, or the undersigned responsible party) do hereby agree and give my consent for my (or the indicated patient) admission/examination and treatment to American Spine Center.
• I understand that my agreement to accept this service is called general consent and that it includes any routine procedure(s) or treatment(s) such as blood drawing, physical examination, administration of medication(s), taking X-rays, use of local anesthesia, or other non-invasive procedures.

I acknowledge the fact that American Spine Center has the authority to dispose of specimens taken for laboratory or pathology examination. In addition, I hereby authorize any and all persons caring for me to review and /or release my personal health information to other healthcare providers treating me.

I certify that I have read and understand this form and that no guarantees have been made to me as to the results of treatments or examinations done at the American Spine Center.