Neurosurgical Care Agreement and Informed Consent

This agreement is made between _______________________ ("Patient") and _______________________ ("Provider/Practice").

1. SCOPE OF SERVICES

1.1 Medical Services

• Neurosurgical evaluation and diagnosis
• Surgical intervention as deemed medically necessary
• Post-operative care and follow-up
• Emergency care coordination when applicable

1.2 Excluded Services

• Primary care services
• Non-neurosurgical specialty care
• Routine health maintenance

2. PATIENT RESPONSIBILITIES

2.1 Medical Information

• Provide accurate and complete medical history
• Disclose all current medications and supplements
• Report any changes in condition promptly
• Inform of any other treating physicians

2.2 Compliance

• Follow prescribed treatment plans
• Attend scheduled appointments
• Complete recommended diagnostic tests
• Participate in physical therapy when prescribed

3. FINANCIAL AGREEMENTS

3.1 Insurance and Payment

• Verify insurance coverage
• Pay applicable co-pays and deductibles
• Understand insurance pre-authorization requirements

4. SURGICAL CONSENT

4.1 Informed Consent

• Separate surgical consent forms required for each procedure
• Discussion of risks, benefits, and alternatives
• Right to refuse treatment

5. TERMINATION

Either party may terminate this agreement with written notice, ensuring appropriate transition of care.

SIGNATURES

Patient: _________________ Date: _________________

Provider: ________________ Date: _________________

Witness: _________________ Date: _________________