Medical Consent for Methods of Communication

SOUTH TEXAS BRAIN & SPINE CENTER

Purpose of this Consent

This form outlines your consent for South Texas Brain & Spine Center to communicate with you regarding your healthcare, specifically concerning appointments and financial matters related to delinquent accounts. By signing this form, you authorize the clinic and its agents to use various methods of communication as described below.

Preferred Communication Method

Please indicate your preferred method(s) of communication for general clinic messages, appointment reminders, and financial communications by checking the appropriate box(es) below:

Authorized Communication Methods

I, authorize South Texas Brain & Spine Center and its agents, attorneys (including collection agencies) to contact me using the following methods for the specified purposes:

1. Appointment Reminders and Scheduling:
   • Phone Calls: Automated telephone dialing equipment or personal calls to my current or any future phone number(s) (home, cell, work).
   • Text Messages (SMS): Automated or personal text messages to my current or any future wireless device number(s).
   • Emails: Electronic mail to my current or any future email address(es).
   • Purpose: To provide reminders for upcoming appointments, confirm appointments, reschedule appointments, or communicate any changes related to my scheduled visits.
2. Delinquent Account Communications:
   • Phone Calls: Automated telephone dialing equipment, artificial or prerecorded voice messages, or personal calls to my current or any future phone number(s) (home, cell, work).
   • Text Messages (SMS): Automated or personal text messages to my current or any future wireless device number(s).
   • Emails: Electronic mail to my current or any future email address(es).
   • Purpose: To contact me regarding any delinquent account(s) I owe South Texas Brain & Spine Center, including efforts to collect any portion of my account which is past due.

Patient Acknowledgment and Consent

I understand that standard text messaging and email rates may apply, depending on my mobile phone or internet service plan. I also understand that while South Texas Brain & Spine Center takes reasonable precautions to protect my privacy, electronic communications (such as unencrypted emails or text messages) may not be entirely secure.

I have read and understand this disclosure and agree to the terms described above. I confirm that the phone numbers and email addresses provided to South Texas Brain & Spine Center are accurate and that I am the subscriber or customary user of these numbers and addresses.

Consent for Treatment

I, the undersigned patient, or the patient's legal guardian, hereby consent to the rendering of medical care, including diagnostic procedures, medical and surgical treatment, and other services as deemed necessary or advisable by the physicians and staff of South Texas Brain and Spine Center.

I understand that the practice of medicine is not an exact science and that no guarantees have been made to me as to the result of treatments or examinations.

I understand that I have the right to be informed of the diagnosis, the nature and purpose of any proposed treatment, the risks and benefits of the proposed treatment, the alternatives to the proposed treatment (including no treatment), and the risks and benefits of the alternatives. I also understand that I have the right to ask questions and to refuse any proposed treatment.

I acknowledge that I have been given the opportunity to discuss any concerns or questions I may have with my healthcare provider.

By signing below, I affirm that I have read and understand this Consent for Treatment.

Payment terms and conditions

Insurance: Insurance is a contract between you and your insurance company. We are NOT a party to this contract. However, we will bill your insurance company as a courtesy to you. Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility. You agree to pay any portion of the charges not covered by insurance. Any remaining balance after your insurance pays is due upon receipt of your statement. If your insurance company requires a referral and/or pre-authorization, you are responsible for making sure they have been obtained. Failure to obtain the referral and/or pre-authorization may result in a lower payment from the insurance company and more liability for you. If there are any changes to your insurance information, please notify our office immediately.

Deductibles/Coinsurance/Copayments: We will contact you prior to your procedure to discuss prepayment of your deductible, coinsurance or copayment. Deductibles, copayments, and coinsurance amounts will be collected prior to your surgery. These are required by your insurance company and agreed upon by you when you accept their insurance. We will estimate your costs to the best of our ability, but additional charges may be incurred based on the actual procedures that were performed. It is your responsibility to know and understand what your insurance will cover, which procedures are non-covered by your insurance policy (review your benefit summary), and procedures that are denied or not authorized by your insurance.

Medicare: You are responsible for your coinsurance amount and non-covered services.

For Medicare Advantage Plans, copayments will be collected at the time you check in for your procedure/surgery.

Workers Compensation and Accident or Liability: We will bill your claim for you, to the applicable insurance. If the claim is denied or benefits are exhausted, we will bill your private insurance company. For this reason, your private insurance information is required to be on file with CSC. You will be responsible for any unpaid balance.

Self-Pay or No Insurance: We will estimate your costs to the best of our ability, but additional charges may be incurred depending on the actual procedures that were performed. The minimum amount required to be paid prior to the date of service is 50% of the estimated cost of the surgery. Payment arrangements for your remaining balance must be made before the date of service and are subject to approval by the Manager.

 General Information: Payments can be made by cash, or credit card. Accounts 90 days past due are subject to collection proceedings, and you will be responsible for all collection costs and interest fees. If it’s deemed that you are due a refund, we will refund on overpayments greater than $5.00

You may also receive bills from the anesthesiologist, pathologist, laboratory, and for durable medical equipment (i.e. crutches, braces,)

Financial Policy Agreement

Welcome to South Texas Brain and Spine Center. We are committed to providing you with the best possible medical care. To help us achieve this, we ask that you read and understand our financial policy.

1. Payment Due at Time of Service: All co-pays, deductibles, and co-insurance amounts are due at the time of service. For your convenience, we accept cash, check, and major credit cards.
2. Insurance Filing: As a courtesy, we will file your insurance claim(s) for you. However, please remember that your insurance policy is a contract between you and your insurance company. You are ultimately responsible for all charges incurred.
3. Patient Responsibility: You are responsible for any charges not covered by your insurance, including but not limited to:
   • Services deemed "not medically necessary" by your insurance company.
   • Services provided outside of your insurance network (if applicable).
   • Charges for missed appointments or late cancellations (see below).
4. Missed Appointments/Late Cancellations: We require at least [e.g., 24-hour] notice for cancellation or rescheduling of appointments. Appointments canceled with less than [e.g., 24-hour] notice or missed appointments (no-shows) will be subject to a fee of $50.00. This fee is not covered by insurance and will be your direct responsibility.
5. Billing Inquiries: If you have any questions regarding your bill, please contact our billing department at (361) 883-4323 x 114
6. Payment Plans: If you anticipate difficulty paying your balance, please discuss payment arrangements with our billing department prior to your appointment.

By signing below, I acknowledge that I have read, understand, and agree to the financial policy of South Texas Brain and Spine Center.

HIPAA Notice of Privacy Practices Acknowledgement

I acknowledge that I have received and had the opportunity to review the Notice of Privacy Practices South Texas Brain and Spine Center This notice describes how my protected health information (PHI) may be used and disclosed, and how I can access this information.

If I have any questions regarding the Notice of Privacy Practices, I understand that I can contact the Privacy Officer at (361) 883-4323.