Patient Paperwork

Patient Portal

Financial Agreement


We recognize the need for a clear understanding between our patients and this office regarding financial arrangements for medical care. Our financial policy is a necessary part of assuring the resources required to maintain health care services for our patients and for the community.

Office visits are to be paid at the time of service. We accept cash, checks/money orders, Visa, MasterCard and Discover. Exclusions to this policy are those patients whose primary health insurance carrier is Medicare, Medicaid, Workman's Compensation or a Preferred Provider Organization with which we participate. Patients enrolled in a managed care plan must pay at the time of service if the required authorization has not been received. Co-payments and deductibles are due and payable at the time of service.

If you have insurance, we will bill your insurance company for health care services rendered. It is extremely important that we obtain complete information about your primary and supplemental insurance companies, including phone numbers and addresses. It should be understood that your insurance policy is an agreement between you and your insurance company to pay you certain amounts for medical care. Your doctor's bill, on the other hand, is an agreement between you and your doctor. You are responsible for the payment of your doctor's bill regardless of the status of your insurance claim. If your insurance company pays only a portion of the bill or rejects your claim, they will send an explanation to you. Reduction or rejection of a claim by your insurance company does not relieve you of the financial obligation you have incurred. If you are involved in a legal dispute, payment is due when services are rendered, regardless of any pending legal decisions.

A detailed statement of charges for hospital visits and surgical services will be sent to you at the end of each month. Payment in full is due within 30 days. If unusual circumstances should make it impossible for you to meet our credit terms, we invite you to call or personally discuss the matter with our billing department. This will avoid misunderstandings and enable you to keep your account in good standing. Except when hardship or previous credit arrangements warrant otherwise, accounts 90 days past due are referred to a collection agency. Your' account with us is then considered terminated. Any collection costs incurred may be added to your account balance. Our fee for a returned check is twenty-five dollars.

Patients who require Surgery or Testing:

Preauthorizations and second surgical opinions have become requirements for most insurance companies. We insist that when a surgery or testing procedure (MRI scan, CT scan, myelogram, discography, outpatient surgery, etc.) is scheduled, that you contact your insurance company immediately to determine what, if any, preauthorization requirements the insurance company deems necessary before the surgery or procedure is performed. During your surgery or testing procedure, services may be rendered by physicians independent of our practice such as: radiology, anesthesiology, physical therapy, etc. Please let our scheduling clerk know if you have a preference on where your procedure is performed because of insurance coverage or provider plan participation.

We cannot stress enough how important it is for you to be aware of your insurance company's requirements on hospitalization and surgery. Your insurance company can deny payment or drastically reduce payment to you for services that are provided if their requirements are not met.

Many orthopedic, neurosurgical and spine procedures require an assistant at surgery to ensure quality care to our patients. Either an assisting surgeon or physicians' assistant, aid with surgical procedures where it’s deemed medically necessary. Our practice employs Physician Assistants for this reason. We will bill your insurance for the Surgeon's fee, as well as the assistant's fee. Please ask a scheduling clerk whether an assistant is required for your surgery. We suggest that you contact your insurance company as soon as possible to determine whether they cover an assistant's fee. You agree that you are responsible for these charges whether or not covered by insurance.

Should you have any questions or need clarification of any of these policies, please do not hesitate to contact our office. Our goal is to work with our patients to ensure that their medical care is the finest available and that this care does not become a financial burden.

Assignment of Benefits

I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled, including Medicare, private insurance, and any other health plan to Neurological Associates, Inc.dba West Virginia OrthoNeuro. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I hereby agree to pay any and all charges that exceed or that are not covered by insurance. I hereby authorize said assignee to release all information to secure the payment. To ensure continuity of care, I hereby authorize the release of all medical records to my primary and referring physicians. I hereby release copies of this information sheet to any hospital I may be admitted to. I also authorize Medicare, private insurance, and any other health plan to furnish said assignee any information regarding payment of my claim.

By signing this form, I acknowledge that I have been offered a copy of the West Virginia OrthoNeuro Notice of Privacy Practices.


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