American Spine Center

American Spine Center

Patient Registration Form

إستمارة تسجيل المريض

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.

: لطفا انتبه لهذه الملاحظات فيما يتعلق بشركات التأمين

.قبول المرضى تحت منصة التأمين قد يقتصر على مجموعات محددة وذلك حسب الأتفاق مع شركة التأمين. كما أن بعض الفحوصات والتحاليل قد تحتاج الى موافقة مسبقة من شركة التأمين

.أتعهد أنا الموقع أدناه بأن كل ما ذكر أعلاه صحيح

كما أقبل الفاتورة النهائية على مسئوليتى الشخصية وفى حال رفضت شركة التأمين أو الجهة المسئولة التى تتحمل مصاريف علاجى تغطية العلاج كليا أو جزئيا لأى سبب من الأسباب سأخذ على عاتقى سداد كل المصاريف أو الجزء المتبقى منها دون تغطية وعلى ذلك أوقع


You could skip this section if there are no companions.
(يمكنك تجاوز هذه الصفحة إذا لم يكن معك مرافقين)

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.

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.

الموافقة على الشروط العامة

شكراً لإختيارك المركز الأميريكي للعمد الفقري كمقدم للرعاية الصحية. يرجى قراءة المستند التالي بعناية فيما يتعلق بالسجلات الطبية , والإتفاقات المالية , والتأمين الطبي , والأشياء الشخصية الثمينة , والمواعيد الفائتة , وحقوق المريض ومسؤولياته , والموافقة على الفحص والعلاج.


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