(605) 341-2424                                         Neurosurgical & Spinal Surgery Associates, P.C.       800-253-5876

fax (605) 341-4547                                   4141 Fifth Street, Rapid City, SD 57701           www.spinecenteronline.com                                                                                                                                                 

Dear                                                                      :   Welcome to Neurosurgical & Spinal Surgery Associates, P.C. We look forward to seeing you at your appointment with:

When you come to your appointment – Please bring the items marked below:  

1. MRI - actual films and report
2. CAT Scan - actual films and report
3. X-rays - actual films and report
4. Any medical records that pertain to your present condition
5. Diagnostic reports pertaining to your present condition including lab reports or any recent EKG
6. SD Medicaid. Bring your Medicaid Card, Referral Card and $3.00 co-pay
7. Other State’s Medicaid. Bring your Medicaid Referral Letter

If you forget any of these items, we may have to reschedule your appointment.

IF YOU ARE TAKING MEDICATION, PLEASE BRING YOUR MEDICATION OR INFORMATION CONCERNING YOUR MEDICATION WITH YOU.

 YOUR APPOINTMENT

We make every attempt to schedule appointments for the convenience of our patients. Sometimes appointment schedules change because an emergency or a prolonged surgery requires the physician’s continued presence. Circumstances like these occasionally cause all or part of the day’s appointments to be rescheduled. If this should happen, we will reschedule your appointment at the earliest time available. Please help us serve you and our other patients better by keeping your scheduled appointment. We ask that you notify our office at least 24 hours in advance if you wish to reschedule your appointment. However, if weather conditions are difficult on the day of your appointment, we encourage you to call and reschedule your appointment rather than risk travel.

OUR FINANCIAL POLICY

Payment is due at the time of service. Please be prepared to pay for services provided to you at the time of your appointment. We accept cash, check or credit card. If you have insurance that has contracted with us to provide care and you have met your out-of-pocket expense requirement please bring verification with you. If, for any reason, you feel you will not be able to pay at the time of your appointment or if you need information about the cost of your care, please contact our patient accounts department prior to your appointment at (605) 341-2424 or 1 800-253-5876.

INSURANCE COVERAGE

You are directly responsible to us for the cost of your care and the timely payment of your account. We will not be responsible for disputes between you and your insurance company other than to provide information regarding your claim for services. You will be responsible for your deductible, co-payment, or co-insurance amounts. If we don’t participate with your insurance company you will also be responsible for any non-allowed or non-covered charges.

WORKERS COMPENSATION

IF YOUR VISIT WILL BE PAID FOR UNDER A WORKERS COMPENSATION CLAIM, YOU MUST HAVE YOUR WORKER’S COMPENSATION INSURER CONTACT US WITH AN AUTHORIZATION AND GUARANTEE OF PAYMENT

PRIOR TO YOUR APPOINTMENT. You will be required to complete the Workers Compensation section on the back of our Patient Registration form.

MOTOR VEHICLE ACCIDENTS/PERSONAL INJURY LAWSUITS

If your appointment is the result of a motor vehicle accident or personal injury or if you have current litigation in process, you will still be responsible for payment at the time of your visit. Please bring your insurance card(s), if you wish to submit your bill to your private health insurance carrier.

MEDICARE/MEDICAID/CHAMPUS-TRICARE/INDIAN HEALTH SERVICE

We participate with all of the government-sponsored programs listed above. You must bring verification of eligibility with you to your appointment. Medicare patients who have met their deductible and have secondary insurance will not be required to pay at their initial appointment. Medicaid patients MUST HAVE A PURPLE REFERRAL CARD from their primary care provider and must pay their $2.00 co-pay prior to their appointment. Patients covered by Indian Health Services must obtain prior authorization from the Contract Health Services department at their IHS facility.

DISCLOSURE OF PHYSICIAN OWNERSHIP

Neurosurgical & Spinal Surgery Associates, P.C., The Spine Center at Rapid City, Neurology Associates and/or it’s physician’s, Marius Maxwell, Stuart G. Rice, Edward L. Seljeskog, Larry L. Teuber and Tim J. Watt have either a partial or entire ownership interest in Promotion Rehabilitation Center (PRC), Electrodiagnostic Services (EDS), The Black Hills Surgery Center (BHSC) and the Black Hills Imaging Center (BHIC). You have the right to choose the provider or facility for your health care services. Therefore, you have the option to use a health care provider or facility other than PRC, EDS, BHSC, or BHIC for services prescribed by us. You will not be treated differently if you choose to obtain health care services at a facility or provider other than PRC, EDS, BHSC or BHIC.

COMPLIANCE DISCLOSURE

In compliance with Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, and the Age Discrimination Act of 1975, it is the Policy of Neurosurgical & Spinal Surgery Associates, P.C., to provide admission or access to, or treatment or employment in, its programs and activities without regard to race, color, national origin, disability, or age. No distinction is made among any persons in eligibility for the receipt of benefits and services provided by or through the auspices of Neurosurgical & Spinal Surgery Associates, P.C. If you have any concerns regarding the provision of services or employment on the basis of disability, you may contact our Section 504 coordinator, James B. Shea at (605) 341-2424.

AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

Our Notice of Privacy Practices outlines our obligations to you under federal privacy law. Your signature on our patient registration form will authorize our use of your personal health information (PHI) to carryout treatment, payment and health care operations activities under state laws. The phone number(s) and address you provide us will be used to contact you for appointment reminders, medical follow-up, questions regarding account information, billing and insurance claims questions, mailing account statements and other contacts unless you tell us otherwise. In addition, we ask you to let us know to whom you will allow access to your medical records, account and/or billing information. We may ask you to complete an authorization for release of medical information if there are any questions or concerns.

SUMMARY

If you have questions regarding your appointment, our financial policy or anything else set forth in this welcome letter, please call us at (605) 341-2424. Your understanding is important!  We ask that you contact us before your appointment if you have any questions or anticipate any problems.

I HAVE READ, UNDERSTAND AND AGREE TO THE CONTENTS OF THIS NOTICE.

Patient/Responsible Party Signature                                                                                                               Date _____________________

(©8/2007)

(© 8/24/07)