1770 Skylyn Dr. Spartanburg, SC, 29307 P: 864-577-9107 F: 864-699-1999
Primary Insurance Carrier:
Secondary Insurance Carrier:
I hereby authorize BG Neurology to provide informaƟon to insurance carriers concerning my treatment and hereby assign to the doctor all payments for medical services rendered. I understand that I am responsible for any amount not covered by my insurance.
CONSENT TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION
Disclosure: Your protected health information will be used by BG Neurology or disclosed to others for the purpose of treatment, obtaining payment, or supporting the day-to-day health care operations of the practice.
Please list the persons authorized to receive or discuss your health informaƟon:
You may revoke or terminate this authorization by submitting a revocation to BG Neurology. I have reviewed this consent form and give my permission to BG Neurology to use and disclose my health information in accordance with this consent.
You may revoke or terminate this authorization by submitting a revocation to BG Neurology.
I have reviewed this consent form and give my permission to BG Neurology to use and disclose my health information in accordance with this consent.
TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s).
This consent provides us with permission to perform reasonable and necessary medical examinations, testing, and treatment. By signing below, you are indicating that:
This consent will remain fully effective until it is revoked in writing. You have the right to discontinue services at any time. You also have the right to discuss treatment plans with your physician, including the purpose, potential risks, and benefits of any tests ordered for you. If you have any concerns regarding any tests or treatments recommended by your healthcare provider, we encourage you to ask questions.
I voluntarily request that a physician and/or mid-level provider (nurse practitioner, physician’s assistant, or clinical nurse specialist), and other healthcare providers or their designees, as deemed necessary, perform reasonable and necessary medical examinations, testing, and treatment for the condition that has brought me to seek care at this practice. I understand that if additional testing, invasive, or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s).
I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.
By signing this form, I hereby give permission to BG Neurology to share and obtain relevant assessments, records, reports, and other information with appropriate medical professionals concerning my healthcare.
I understand that I have the right to withdraw my consent at any time.
PLEASE READ ALL THE INFORMATION AND ACKNOWLEDGE BY SIGNING BELOW
BG Neurology requests that you provide a physical copy of your insurance card(s) at each visit. It is your responsibility to provide us with accurate information for billing your insurance. If you have any changes to your address, phone number, insurance, or employer, please notify the receptionist.
DEDUCTIBLES, CO-PAYMENTS, CO-INSURANCE, OR CHARGES FOR NON-COVERED SERVICES ARE DUE AT THE TIME OF SERVICE.
We accept cash, checks, and major credit cards. A processing fee applies to all credit and debit card payments:
For amounts up to $50, the fee is $2.00
For amounts over $50, the fee is $4.00
This does not apply to HSA cards.
You are expected to provide payment for any previous balances sent to collections prior to your office visit. We reserve the right to refuse service.
SELF-PAY PATIENTS: Patients without insurance are expected to pay at the time of service. For a full list of self-pay pricing, please see our receptionist.
I HAVE READ AND HAVE A FULL UNDERSTANDING OF THE FINANCIAL POLICY OF BG NEUROLOGY
Thank you for trusting BG Neurology with your medical care. When you schedule an appointment with BG Neurology, we set aside enough time to provide you with the highest quality care. If you need to cancel or reschedule your appointment, please contact our office as soon as possible, and no later than 24 hours prior to your scheduled appointment.
Please note that failure to confirm your appointment may result in cancellation.
This allows us time to schedule other patients who may be waiting for an appointment.
Please review our appointment/no-show policy below:
A $100 fee will be charged for no-show appointments.
After three no-shows or cancellations, we will be unable to continue reserving time for you within our practice. This does not apply if we had to cancel the appointment.
If you need to cancel or reschedule your appointment, please call 864-577-9107.
Fax 864 699 1999 Phone 864 577 9107
You are entitled to receive a “Good Faith Estimate” explaining how much your medical care will cost.
Under this law, healthcare providers are required to provide patients who do not have insurance, or who are not using insurance, with an estimate of the expected charges for medical items and services.
You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services that are reasonably expected at the time of scheduling. This includes related costs such as medical tests, equipment, and hospital services.
Please keep in mind that some procedures are performed at local area hospitals. You may need to contact the hospital directly regarding the hospital portion of your bill.
For patients who do not have insurance or who are not using insurance, BG Neurology will provide a written Good Faith Estimate of scheduled services before the medical service or item is provided, upon request.
You may also request a Good Faith Estimate from BG Neurology, or from any other provider, before scheduling a service or item.
If you receive a bill that is at least $400 more than your Good Faith Estimate, you have the right to dispute the bill.
Be sure to save a copy or take a picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit: https://www.cms.gov/nosurprises/ or call 1-800-985-3059.
This notice is not intended to be a full summary of the No Surprises Act. It is provided as a general informational overview of technical legal standards. For complete and current information, please refer to the applicable statutes, regulations, and official guidance materials: https://www.cms.gov/regulations-and-guidance/legislation/paperworkreductionactof1995pra-listing/cms-10791
Your licensed prescribing practitioner may indicate that a controlled medication may assist you in providing symptomatic relief. Controlled medications can be dangerous and habit-forming. These medicines must be taken only as prescribed by your doctor. Please read this agreement thoroughly and ask any questions you may have. Signing this agreement does not automatically indicate that your prescriber will prescribe any controlled substances.
I have reviewed this Informed Consent and Treatment Agreement for Controlled Substances. I understand it and agree to honor this agreement. I understand that failure to do so will result in the discontinuation of prescribed controlled substances and may result in discharge from this clinic.
If you are in agreement and fully understand the benefits and risks of controlled medications, please sign and date below.
Communication Authorization: I authorize the practice to contact me for appointment reminders, billing notifications, and limited healthcare-related information using the contact information I provide.
I understand that communication methods may include:
☐ Phone call ☐ Voicemail message ☐ Text message (SMS) ☐ Email
I understand:
Revocation of Consent: I understand I may revoke this authorization at any time in writing.
Please list the medications you are currently taking or attach a list (including prescriptions and over-the-counter medications).
