Neurosurgical Practice Financial Policy Agreement

Patient Information

Name: _________________________ Date of Birth: _________________ Account Number: _______________

Financial Agreement Terms

1. Insurance and Payment Responsibility

• I understand that I am financially responsible for all charges, whether covered by insurance or not
• I agree to provide current and accurate insurance information
• I authorize the release of medical information necessary to process insurance claims

2. Payment Terms

• Co-payments are due at the time of service
• Self-pay patients must pay in full at the time of service
• Outstanding balances must be paid within 30 days of statement date

3. Surgical Procedures

• A deposit may be required prior to scheduled surgical procedures
• Pre-authorization requirements must be met before surgery
• I understand that separate bills will be generated for:
  • Surgeon's fees
  • Hospital charges
  • Anesthesia services
  • Neuromonitoring
  • Pathology services (if applicable)

4. Cancellation Policy

• 48-hour notice is required for appointment cancellations
• $75 fee for missed appointments without proper notice
• $250 fee for surgical cancellations without 7-day notice

5. Financial Assistance

• Payment plans are available upon request and approval
• Financial assistance programs may be available for qualifying patients
• Applications for assistance must be completed prior to service

Acknowledgment

I have read and understand the financial policy above. I agree to comply with these terms and accept financial responsibility for services rendered.

Signature: _________________________ Date: _____________

Print Name: ________________________

Relationship to Patient (if not self): ________________________