All routine calls will be be returned within hours, in in the order in in which they were received.

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1 Office Policies We would like to to take the opportunity to to explain the policies of of our office. Please take notice of of include fever, changes with r surgical incision or or increased pain, NO medication refills will be be done under any circumstance through these answering service numbers. They may be be reached at All routine calls will be be returned within hours, in in the order in in which they were received. Please allow hours for prescription refills. To help facilitate these requests, please leave r name, the name of of the medication, r birth date and the pharmacy phone number in in r message. Under no no circumstance will medication refill requests be be taken after 5p.m. and If If we have ordered imaging studies for, (x-rays, CT scans, MRI s) it it is is r responsibility to to bring the written reports as as well as as the actual films to to r follow-up visit. Unfortunately, we will have to to reschedule r appointment if if we don t have all all of of the appropriate information. All tests will be be reviewed by by the physician on on r follow-up visit, and the results will not be be given over the phone prior to to that appointment. Please be be assured that we are committed to to the highest level of of care for. Please feel free to to contact our office at at for our Safety Harbor patients and for our Tampa patients if if should have any further questions. Thank for choosing Joseph Spine & Scoliosis to to participate in in r care. I Patient Signature, Guardian, or or Personal Representative W. W. W. Dr. Martin Luther King King Jr. Jr. Blvd., Suite Tampa, Florida Phone: Fax:

2 Notice Office of Privacy Private Policies Practices ** This We notice would describes like to take how the r opportunity health information to explain may the be policies used and of our disclosed, office. and Please how take notice can access of this the information. following: Please review carefully. ** At Please contact Joseph Spine our answering & Scoliosis, service we have after always hours kept for EMERGENCY r health information CALLS secure only. and This would confidential. include fever, The Health changes Insurance with r Portability surgical and incision Accountability or increased Act require pain, NO us medication to continue maintaining refills will r privacy to give this notice and to follow the terms of this notice. This law permits us to use or be done under any circumstance through these answering service numbers. They may be reached disclose r health information to those involved in r treatment. For example, reviews of r file by a specialist doctor whom we may involve in r care. We may use or disclose r health information for payment of r services. For example, we may send a report of r progress to r insurance company. We may use or disclose r health information for our normal healthcare operations. For example, one of our Please staff will allow enter 24 r hours information prescription into our refills. computer. To help We may facilitate use r these information requests, to please contact leave. r For example, name, we the want name to of call the and medication, remind r about birth r date appointment. and the pharmacy If are phone not home, number we may in r leave this information message. on Under r answering no circumstance machine will or with medication the person refill who requests answers be the taken telephone. after 5p.m. In an and emergency, we may over disclose the weekend r health hours. information to a family member or another person responsible for r care. We may release some or all of r health information when required by law. If we have ordered imaging studies for, (x-rays, CT scans, MRI s) it is r responsibility to Except bring as the described written above, reports this as practice well as will the actual not use films or disclose to r r follow-up health information visit. Unfortunately, without r we prior written will authorization. have to reschedule You may r request appointment writing if that we don t we not have use or all disclose of the appropriate r health information. as All described tests will above. be reviewed We will let by the know physician if we can on r fulfill follow-up r request. visit, and the results will not be given You have the right to transfer copies of r health to another practice. We will mail r files for. You Please have a be right assured to receive that we a copy are of committed r health to information, the highest level with a of few care exceptions. for. Please feel provide free us to with contact a written our request office regarding at the information for our Safety want Harbor to have patients copied, and however, we may charge for our a reasonable Tampa fee patients for the if copies. should have any further questions. You have the right to request and amend r health information. Please provide us with r request to make changes in writing. If wish to include a statement in r file, please provide it to us in writing. We may or may not make the changes that request, but will be happy to include r statement in r file. If we agree to an amendment or change, we will neither move nor alter earlier documents, but will add new information. Joseph Spine and Scoliosis You I have a read right and to receive understand a copy the of above-mentioned this notice. policies. You may file a complaint with the Department of Health and Human Services, 200 Independence Avenue SW, Patient Room 509F, Signature, Washington, Guardian, D.C. or Personal You Representative will not be retaliated against for filing a complaint. However, before filing a complaint, or for more information or assistance regarding r health information privacy, please contact our Privacy Officer at (727) Mease Drive Safety Harbor, Florida Phone: Fax:

3 Please initial each space and sign below: Office Policies Treatment Agreement I promise full cooperation with my treating physician whether by surgical or non-surgical means. I understand that if I do not follow my doctor s instructions concerning my care and treatment, less than optimal results may occur. Release include fever, of Information changes with r surgical incision or increased pain, NO medication refills will be done For the under purpose any circumstance of payment, I through allow these answering Joseph Spine service & numbers. Scoliosis They to release may be my reached Private Health Information to any and all of my insurance carriers, their third party payors and claim reviewers until the claim is resolved. For the purpose of treatment, I also allow All routine calls Joseph will be Spine returned & Scoliosis within 24 to release hours, in my the information order which or contact they were any and received. all of my treating physicians. Please allow 24 hours for prescription refills. To help facilitate these requests, please leave r Acknowledgement name, the name of the of medication, Receipt r of Notice birth date of and Privacy the pharmacy Practices phone number in r message. I acknowledge Under circumstance that I was provided will medication a copy of the refill HIPPA requests Notice be taken of Privacy after 5p.m. Practices and and over that the weekend I have read hours. (or had the opportunity to read if I so chose) and understand the Notice. Patient If we have Financial ordered imaging Policy studies for, (x-rays, CT scans, MRI s) it is r responsibility to bring 1. the As written our patient, reports as are well responsible as the actual for films all authorizations/referrals to r follow-up visit. needed Unfortunately, to seek we will have treatment to reschedule in this office. r appointment You must inform if we don t the office have of all all of personal the appropriate (home address, information. phone All tests will numbers, be reviewed etc ) by and/or the physician insurance on changes r follow-up and authorization visit, and referral the results requirements. will not be In given the over the event phone the prior office to is that not appointment. informed, will be responsible for any charges denied. 2. Your payment for office services are due at the time of service. We will accept VISA, Please MasterCard, be assured that American we are committed Express, Discover to the highest and cash level or of check. care for. Please feel free to contact 3. Your our office insurance at policy is a contract for our between Safety Harbor and patients r insurance and company. for As our a Tampa courtesy, patients if we will should file r have insurance any further claim questions. for with an assignment of benefits if we participate with r carrier. You are agreeing to have r insurance company pay the Thank doctor for directly. choosing If r insurance Joseph company Spine & Scoliosis does not pay to participate the practice in within r care. 90 days, the patient or guardian seeking care for a minor, will be responsible for payment of services. You are encouraged to contact r designated patient account representative at our office Joseph with Spine any questions. and Scoliosis 4. Please honor our 24 reschedule notice. Repetitive broken or cancelled appointments I have and/or read and non-compliance understand the may above-mentioned result in transfer policies. of r care to an alternative practice. 5. We have made prior arrangements with insurers and other health plans to accept an assignment of benefits. We will bill those plans with which we have an agreement and Patient will Signature, require Guardian, to pay or the Personal co-pay/co-insurance/deductible Representative at the time of service. Your upfront portion will be calculated based on r insurance benefit/limits and our 1800 Mease Drive Safety Harbor, Florida Phone: Fax:

4 negotiated fee agreement with r carrier. If are seeing our doctors on an Out of Network basis, will be subject to those out of network rates. 6. Not all services are a covered benefit in all insurance policies, some plans even impose a waiting period before covering services (pre-existing). In the event r health plan determines a service to be "not covered/pre-existing," or do not have an authorization, will be responsible for the complete charge. We will attempt to verify benefits for some specialized services; however, remain responsible for charges to any service rendered. Patients are encouraged to contact their plans for clarification of benefits prior to services rendered. Office Policies Dear 7. Patient: Pre-scheduled Surgical procedures require pre-payment. Your deductible/coinsurance/co-pay like to take the for opportunity this procedure to explain is due the prior policies to the of pre-operative our office. Please appointment. take notice For of We would additional services provided in the hospital, we will bill r health plan. Any balance due is r responsibility. Please 8. contact We realize our that answering temporary service financial after hours problems for EMERGENCY may affect timely CALLS payment only. of r This account. would include If fever, such changes problems with do arise, r surgical we encourage incision or to increased contact us pain, promptly NO medication for assistance refills in will be done managing under any r circumstance account. Any through payment these exceptions answering will service be agreed numbers. upon They in writing. may be reached 9. PAST DUE accounts are subject to collection proceedings. All fees including, but not limited to collection fees, attorney fees and court fees shall become r responsibility in All routine addition calls to will the be balance returned due within this office. 24 hours, in the order in which they were received. 10. There is a service fee of $25.00 for all returned checks. Upon an NSF or CLOSED Please allow ACCOUNT 24 hours occurrence, for prescription all future refills. remittances To help will facilitate need these to be requests, in other forms please of leave payment. r name, the Restitution, name of the if applicable medication, will r be requested birth date from and the the pharmacy State s Attorney s phone number Office. in r message. 11. Our Under Medicaid no circumstance policy is as follows: will medication Medicaid refill is ONLY requests accepted be taken for after scoliosis 5p.m. children. and Authorization of Payment If we I hereby have ordered assign imaging all Medical studies benefits for, directly (x-rays, to CT scans, Joseph MRI s) Spine it is & r Scoliosis responsibility for the to bring payment the written of any reports services as well rendered. as the actual I also films authorized to r release follow-up of medical visit. Unfortunately, records necessary we to will have process to reschedule my health r claims. appointment I fully understand if we don t that have in the all event of the my appropriate insurance information. company does All tests will not pay be reviewed for the services by the I physician received, on I will r be follow-up financially visit, responsible and the results for payment. will not be given We are dedicated to providing the best possible care and service to and regard r complete understanding Please be assured of our that policies we are as committed an essential to the element highest of level r of care care and for treatment.. Please If feel have free any to questions, contact our please office discuss at them with for our our front Safety office Harbor staff or patients supervisor. and for our Tampa patients if should have any further questions. Patient s Name: Signature of Patient/Guardian: : 1800 Mease Drive Safety Harbor, Florida Phone: Fax:

5 Patient Information Today s : Patient s Name: of Birth / / Address: Office Policies Daytime Phone Number: ( ) - Evening Phone Number: ( ) - Social Security Number: Primary include Insurance: fever, changes MEDICAL with / r AUTO surgical / WORK incision COMP or increased pain, NO medication refills will be done under any circumstance through these answering service numbers. They may be reached Accident Related? Auto / Work Comp of Accident: Please allow 24 hours for prescription refills. To help facilitate these requests, please leave r name, the name of the medication, r birth date and the pharmacy phone number in r message. Under no circumstance will medication refill requests be taken after 5p.m. and If we have ordered imaging studies for, (x-rays, CT scans, MRI s) it is r responsibility to Secondary bring the Insurance: written reports as well as the actual films to r follow-up visit. Unfortunately, we will have to reschedule r appointment if we don t have all of the appropriate information. All Subscriber Name; Subscriber of Birth: / / tests will be reviewed by the physician on r follow-up visit, and the results will not be given Please be assured that we are committed to the highest level of care for. Please feel free to contact our office at for our Safety Harbor patients and for our Tampa patients if should have any further questions. ( ) Male ( ) Female Subscriber Name: Subscriber of Birth: / / Contract Number/ID #: Group Number: Insurance Address: Insurance Phone Number: ( ) - Adjuster Information: Contract Number: Group Number/ID #: Insurance Address: Insurance Phone Number: ( ) - Primary Care Physician or Family Physician: Referring Physician: Address: Phone Number: ( ) - Please have r insurance card(s) and photo ID ready. Payment is expected at the time of r visit Mease Drive Safety Harbor, Florida Phone: Fax:

6 Patient Financial Responsibility Office Policies Disclosure Form Assignment of Benefits I authorize direct remittance of payment of all insurance benefits, including include fever, changes with r surgical incision or increased pain, NO medication refills will Medicare, be done under if I any am circumstance a Medicare through beneficiary, these answering to service Joseph numbers. Spine They & Scoliosis may be reached for all at covered medical services and supplies provided to me during all courses of treatment and care provided by Joseph Spine & Scoliosis. I understand and agree All routine this Assignment calls will be returned of Benefits within will 24 hours, have continuing the order in effect which for they as were long received. as I am being treated or cared for by Joseph Spine & Scoliosis, and will constitute a Please continuing allow 24 authorization, hours for prescription maintained refills. on To file help with facilitate these Joseph requests, Spine please & leave r name, the name of the medication, r birth date and the pharmacy phone number in r Scoliosis, which will authorize and allow for direct payment to Joseph message. Under no circumstance will medication refill requests be taken after 5p.m. and Spine over the & weekend Scoliosis hours. of all applicable and eligible insurance benefits for all subsequent and continuing treatment, services, supplies and/or care provided to me by If we have ordered Joseph imaging Spine & studies Scoliosis. for, (x-rays, CT scans, MRI s) it is r responsibility to bring the written reports as well as the actual films to r follow-up visit. Unfortunately, we Patient will have Name to reschedule (Please r Print) appointment if we don t have all of the appropriate information. All tests will be reviewed by the physician on r follow-up visit, and the results will not be given Patient Signature Please be assured that we are committed to the highest level of care for. Please feel free to Responsible contact our office Party at Name (Please for Print) our Safety Harbor patients and for our Tampa patients if should have any further questions. Responsible Party Signature W. W. Dr. Martin 1800 Mease Luther Drive King Jr. Safety Blvd., Harbor, Suite 250 Florida Tampa, Florida Phone: Phone: Fax: Fax:

7 Family Physician Office Policies Information Please list the name(s) and address(es) of r family physician or referring physician so we may keep Please them contact informed our answering of r progress service while after hours under for our EMERGENCY care. CALLS only. This would include fever, changes with r surgical incision or increased pain, NO medication refills will be done under any circumstance through these answering service numbers. They may be reached Family Physician: Name: Address: Please allow 24 hours for prescription refills. To help facilitate these requests, please leave r name, the name of the medication, r birth date and the pharmacy phone number in r Phone: message. Under no circumstance will medication Fax: refill requests be taken after 5p.m. and If we have ordered imaging studies for, (x-rays, CT scans, MRI s) it is r responsibility to Referring bring the written Physician: reports as well as the actual films to r follow-up visit. Unfortunately, we will have to reschedule r appointment if we don t have all of the appropriate information. All Name: tests will be reviewed by the physician on r follow-up visit, and the results will not be given Address: Please be assured that we are committed to the highest level of care for. Please feel free to Phone: contact our office at for our Safety Fax: Harbor patients and for our Tampa patients if should have any further questions. Patient Signature: : W. W. Dr. Martin Luther King Jr. Blvd., Suite 250 Tampa, Florida Phone: W. Martin Luther King Jr. Blvd., Suite 250 Tampa, Florida Phone: Fax: Fax: Mease Mease Drive Drive Safety Safety Harbor, Harbor, Florida Florida Phone: Phone: Fax: Fax:

8 Disclosure Office Policies Document I, We would like to take the opportunity to explain the hereby policies authorize of our office. Please Joseph take Spine notice & of Scoliosis to use or disclose the following protected information: (specifically describe the information to be used or disclosed, including, but not limited to, meaningful descriptors such as date Please of service, contact type our answering of service service provided, after level hours of detail for EMERGENCY to be released, origin CALLS of only. information, This would etc.). include fever, changes with r surgical incision or increased pain, NO medication refills will be done under any circumstance Family through Physician these answering Information service numbers. They may be reached Please list the name(s) and address(es) of r family physician or referring physician so we may keep Please them allow informed 24 hours of for r prescription progress while refills. under To help our facilitate care. these requests, please leave r The name, protected the name health of the information medication, may r be disclosed: birth date and (Insert the name(s) pharmacy of phone person number or entity in that r may have message. or receive Under the no information). circumstance will medication refill requests be taken after 5p.m. and Family over the Physician: weekend hours. Name: If we have ordered imaging studies for, (x-rays, CT scans, MRI s) it is r responsibility to bring the written reports as well as the actual films to r follow-up visit. Unfortunately, we Address: will have to reschedule r appointment if we don t have all of the appropriate information. All tests will be reviewed by the physician on r follow-up visit, and the results will not be given This Phone: over protected the phone health prior information to that appointment. is being used Fax: or disclosed for the following purposes: (List specific purposes here. The patient may indicate that the information to be released is at the patient s Please be request assured if that the we patient are committed does not choose to the to highest provide level an explanation of care for. of the Please purpose feel of free the to request). contact our office at for our Safety Harbor patients and for our Referring Tampa patients Physician: if should have any further questions. Name: Address: Phone: Fax: This authorization shall be in force and effective until: : Patient Signature: : W. W. W. Dr. Martin Martin Luther Luther King King Jr. Jr. Blvd., Blvd., Suite Suite Tampa, Tampa, Florida Florida Phone: Phone: Fax: Fax: Mease Drive Safety Harbor, Florida Phone: Fax: Fax:

9 AUTHORIZATION Authorization Office Policies For FORRelease RELEASE OF MEDICAL of Medical INFORMATION Information (Please Print) Patient include Name: fever, changes with r surgical incision or increased Today s pain, NO : medication refills will be done under any circumstance through these answering service numbers. They may be reached Social Security Number: of Birth: Please I hereby allow authorize 24 hours for prescription Joseph Spine refills. and To Scoliosis help facilitate to release these any requests, information please in my leave chart r to any name, medical the name practitioner, of the medication, doctor, hospital, r birth or medical date and institution/facility the pharmacy phone to which number I may in r be referred message. to Under assist with no circumstance my care. will medication refill requests be taken after 5p.m. and Additionally, I authorize to obtain any medical information from If we any have medical ordered practitioner, imaging studies doctor, for hospital,, (x-rays, or medical CT scans, institution/facility MRI s) it is r to assist responsibility in my care. to bring the written reports as well as the actual films to r follow-up visit. Unfortunately, we will have to reschedule r appointment if we don t have all of the appropriate information. All _ tests will be reviewed by the physician on r follow-up visit, and the results will not be given Signature over the of phone Patient, prior Guardian, to that appointment. or Personal Representative Please be assured that we are committed to the highest level of care for. Please feel free to contact our office at for our Safety Harbor patients and for our Tampa patients if should have any further questions. Thank Thank for for choosing choosing Joseph Joseph Spine Spine & Scoliosis Scoliosis to to participate provide r in r surgical care. care.

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