Neurosurgical & Spinal Surgery A

We require payment for the completion of forms you ask us to complete on your behalf. We receive many requests for completion of these forms. This requires extra work, time and financial resources in excess of what is normally needed to complete the medical record.

We will make every effort to complete these forms within 5 business days; however, we cannot make any assurance of completion within your time frame(s).

A charge of $10.00 applies to completion of the following forms:

Ø Personal disability insurance forms;

Ø Loan payment forms;

Ø Credit insurance forms;

Ø Other insurance policy forms that make loan payments in the event of disability;

Ø Unemployment Insurance forms;

Ø Disability, workers compensation and Family Medical Leave Act forms after you have been

discharged from our physicians care.

A charge of $20.00 applies to the completion of the above forms if completion is required in 24 hours or less.

The following forms will be completed at no charge to the patient:

Ø Application for public assistance forms;

Ø Family Medical Leave Act forms;

Ø Workers Compensation forms;

Ø Department of Social Services forms;

Ø Social Security Administration

· We are not obligated to complete these forms, but do so as a courtesy to you. We reserve the right to refuse to complete any forms you present to us for completion

· Please submit your request for completion of forms well in advance of when they are needed. We will attempt to complete the forms as quickly as possible however, in order to properly address them we need adequate time to review your records.

· Please make sure that all of your information is completed on the form before you give it to us.

· Do not complete the section(s) of the form that are required to be completed by our office.

· Please provide a stamped, addressed envelope to expedite mailing of completed forms.

· Forms which require comprehensive review of patient records, analysis and a detailed response may be charged a higher fee. We will inform you of these charges at the time the services are requested.