ROCKY MOUNTAIN SPINE CLINIC, P.C. Eric R. Jamrich, M.D. John R. Barker, M.D. Chad J. Prusmack, M.D. Name_________________________________________________________________________ Birthdate ___________________ Last First Middle Initial SSN_______________________ Address ___________________________________Apt. # ______City____________________State________Zip_____________ Home Phone ( )__________________Work Phone ( )_________________ Cell Phone ( )____________________ E-mail Address_________________________________________ Preferred method of contact: □ Phone □ E-mail □ Text Gender ❑ Male ❑ Female Marital Status ❑ Single ❑ Married ❑ Widowed ❑ Divorced Employer _________________________________________ Occupation_______________________________________________ Employer’s Address______________________________________City_______________________State________Zip___________ Employment Status ❑ Full-Time ❑ Part-Time ❑ Retired ❑ On Leave ❑ Other In case of emergency contact _____________________________________________ Relationship _________________________ Home Phone ( ) _________________ Work Phone ( ) ___________________ Cell Phone ( ) _____________________ REFERRING PHYSICIAN /COMPLETE NAME AND ADDRESS: ___________________________________________________________________________________________________________ PCP (if different from Referring Physician) COMPLETE NAME AND ADDRESS ___________________________________________________________________________________________________________ Pharmacy__________________________________________________ Phone ________________________________________ INSURANCE INFORMATION ~ We will need a copy of your insurance card(s). Primary Insurance Address (Street/City/State) Employer ___________________________ __________________________________________ ____________________________________ Group #____________________ ID #________________________ Policy Holder ❑ Self ❑ Spouse ❑ Parent/Guardian Secondary Insurance Address (Street/City/State) Employer ___________________________ __________________________________________ ____________________________________ Group #____________________ ID #________________________ Policy Holder ❑ Self ❑ Spouse ❑ Parent/Guardian INSURED RESPONSIBLE PARTY INFORMATION – If other than self Name________________________________Relationship_________________Birthdate____________ SSN___________________ Address (if different from patient)_______________________________________________________________________________ Home Phone ( )___________________ Work Phone ( )________________ Employer________________________________ ACCIDENT INFORMATION Is this a ❑ Work Comp or ❑ Motor Vehicle Accident? ❑ Yes ❑ No If YES, on what date did the injury occur? ______________ Work Comp / Motor Vehicle Claim Number _____________________________________ Adjuster’s Name _________________________________________________________ Phone Number ( ) ________________________ Fax Number ( ) _______________________________ I authorize that payment of any insurance benefits for health care services be made directly to Rocky Mountain Spine Clinic, P.C. NOTE: If patient is a minor under the age of 18 years, these forms must be signed by parent or legal guardian. They cannot be signed by a minor. ___________________________________________________________ __________________________ Signature of Patient, Parent or Legal Guardian Date
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ROCKY MOUNTAIN SPINE CLINIC, P.C. Eric R. Jamrich, M.D. John R. Barker, M.D. Chad J. Prusmack, M.D.
E-mail Address_________________________________________ Preferred method of contact: □ Phone □ E-mail □ Text
Gender ❑ Male ❑ Female Marital Status ❑ Single ❑ Married ❑ Widowed ❑ Divorced Employer _________________________________________ Occupation_______________________________________________ Employer’s Address______________________________________City_______________________State________Zip___________ Employment Status ❑ Full-Time ❑ Part-Time ❑ Retired ❑ On Leave ❑ Other In case of emergency contact _____________________________________________ Relationship _________________________ Home Phone ( ) _________________ Work Phone ( ) ___________________ Cell Phone ( ) _____________________
PCP (if different from Referring Physician) COMPLETE NAME AND ADDRESS ___________________________________________________________________________________________________________
___________________________ __________________________________________ ____________________________________ Group #____________________ ID #________________________ Policy Holder ❑ Self ❑ Spouse ❑ Parent/Guardian Secondary Insurance Address (Street/City/State) Employer ___________________________ __________________________________________ ____________________________________ Group #____________________ ID #________________________ Policy Holder ❑ Self ❑ Spouse ❑ Parent/Guardian
INSURED RESPONSIBLE PARTY INFORMATION – If other than self Name________________________________Relationship_________________Birthdate____________ SSN___________________ Address (if different from patient)_______________________________________________________________________________ Home Phone ( )___________________ Work Phone ( )________________ Employer________________________________
ACCIDENT INFORMATION Is this a ❑ Work Comp or ❑ Motor Vehicle Accident? ❑ Yes ❑ No If YES, on what date did the injury occur? ______________ Work Comp / Motor Vehicle Claim Number _____________________________________ Adjuster’s Name _________________________________________________________ Phone Number ( ) ________________________ Fax Number ( ) _______________________________ I authorize that payment of any insurance benefits for health care services be made directly to Rocky Mountain Spine Clinic, P.C. NOTE: If patient is a minor under the age of 18 years, these forms must be signed by parent or legal guardian. They cannot be signed by a minor. ___________________________________________________________ __________________________ Signature of Patient, Parent or Legal Guardian Date
SURGICAL ASSIST SERVICES AUTHORIZATION OF DIRECT PAYMENT, DESIGNATION OF AUTHORIZED REPRESENTATIVE, AND/OR ASSIGNMENT AGREEMENT
I,_________________________(Patient/Guardian) the undersigned, hereby request that Surgical Assist services ("SA Services") be provided to me during my surgery scheduled on______________by______________________________and/or its affiliate (collectively, "Provider").
I hereby transfer all of my rights to payment, rights to appeal, rights to request and to participate in mediation and/or in arbitration, and rights to bring suit against my health insurance carrier or other third party payor ("Payor") in relation to the provision of Surgical Assist Services and all payment disputes related to Surgical Assist Services to Provider and to Acquisition Billing Services, LLC ("Claim Processor").
Acknowledgment of patient financial liability
I understand and agree that I am financially responsible to Provider for any charges not covered and not directly paid to Provider by my Payor or by my workers' compensation claim. By signing this form, I am accepting full financial responsibility for all fees and costs related to Surgical Assist Services performed during my surgery if my Payor denies payment of such fees and/or costs to Provider. I understand and acknowledge that Provider is an OUT‐OF‐NETWORK healthcare provider and is not contracted with my health insurer, Payor. I further acknowledge that I had a choice to select any healthcare provider to perform Surgical Assist Services and, after due consideration, I have voluntarily chosen to seek the care of an out‐of‐network provider. I understand that Provider may bill me for my ordinary out‐of‐network coinsurance and deductible amounts. I acknowledge that if specifically required by state law, Provider is obligated to also send me a balance bill statement setting forth any amount remaining after all payments made by Payor are deducted. I understand that Provider has instituted a Charity Care Financial Hardship Policy which affords me an opportunity to receive a discount or a waiver of balances if I qualify.
Authorization to receive insurance benefits
I hereby authorize Provider, directly and/or through an agent, to bill my current insurance carrier (including but not limited to private health insurance and employer‐sponsored health insurance) for reimbursement for the Surgical Assist Services provided to me. By this authorization, I direct that payments from my insurance carrier for any and all Surgical Assist Services provided to me by Provider be made directly to Provider, or to its agent that has billed for the services, as applicable. I hereby designate Provider as the person entitled to benefits pursuant to ERISA, 29 U.S.C. § 1002(8), as applicable to my insurance.
If any checks or other forms of payment are issued by my Payor and sent directly to me, I will promptly contact Provider at 1‐855‐598‐ 2800 and advise Provider that I have received such payment as reimbursement for serviced rendered. I will also immediately forward the payment to Provider. If I fail to timely do so, I will be held liable for the entire amount of the payment and any additional fees, including but not limited to legal fees, incurred by Provider.
Transfer of Rights
In addition to the foregoing, it is my intention to give Provider the right to bring on my behalf any and all legal and equitable claims (including claims for benefits and claims for breach of fiduciary duty) that I have against my Payor, which relate to my claim for insurance coverage for the Surgical Assist Services rendered by Provider. It is further my intention to, as an alternative basis for giving Provider the right to bring any and all such claims, to transfer, give, and assign my benefits under my insurance plan, and/or my right to sue under my insurance plan, to Provider.
A. Limited Power of Attorney designation. To the extent any dispute arises between Provider and my health insurance carrier and/or any other third party payor with respect to reimbursement for the Surgical Assist Services provided to me, it is my intention that Provider and/or Acquisition Billing Services, LLC ("Claim Processor") possess any and all rights to which I would otherwise be entitled under my healthcare insurance policy. I therefore irrevocably appoint each of Provider and Claim Processor as my true and lawful‐ attorney‐in‐fact for the purpose of exercising the following powers on my behalf with respect to the Surgical Assist Services provided to me:
Patient:
DOS:
DOB:
Sex / Age:
MRN:
Hospital:
Patient Number:
Procedure:
Surgeon:
Surgical Assist:
(Date) (Company)
(i) To do all acts necessary for the purpose of pursuing administrative or internal appeals or mediation.
(ii) To do all acts necessary for the purpose of investigating, filing, pursuing, and resolving litigation and/or mediation and/or arbitration on my behalf (including but not limited to selecting and retaining legal counsel) in any and all legal and equitable claims that I could bring against my health insurance carrier, health benefit plan, and/or relevant fiduciaries. Such claims shall include, but not be limited to, any and all claims (including breach of fiduciary duty claims) that I could bring pursuant to ERISA, other federal or state statutes, or the common law ("Causes of Action"). If Provider and/or Claim Processor bring such an action, I agree to be bound by a final determination of such action rendered by a court or regulatory proceeding.
(iii) To sign on my behalf settlement agreements, releases or other documents relating to the settlement of the Causes of Action. I hereby agree to be bound by any settlement, compromise, or release reached by Provider and/or Claim Processor.
(iv) To claim on my behalf any applicable remedy or relief, including but not limited to benefits, reimbursements, damages, surcharges, fines or injunctive relief, to which I am entitled in connection with the Causes of Action.
(v) I hereby confirm and ratify all actions taken by Provider and/or Claim Processor as my attorney‐in‐fact pursuant to the authority granted herein.
B. Designation of authorized representative. To the extent the Limited Power of Attorney designation described in Section A above is deemed ineffective or limited for any reason, I hereby designate Provider and/or Claim Processor as my Authorized Representative, including as my Authorized Representative as provided under ERISA, 29 C.F.R. § 2560.5031(b)(4) where applicable, for exercising the powers described in Section A or authorized under law, whichever is greater. I hereby designate Provider, directly and/or through its agent, Acquisition Billing Services, LLC, to act as my representative to appeal for any insurance benefits with respect to the Surgical Assist Services in the event of a coverage denial. I understand that Provider has the right to decline or accept this designation at the time a denial is received. I understand that, if Provider accepts the designation, the outcome of any appeal is not guaranteed.
C. Assignment of insurance benefits and legal rights. To the extent that any powers and/or rights conveyed by Sections A and B above are deemed ineffective or limited for any reason or in any way, I specifically assign the right to any benefit to which I may be entitled under any policy of insurance to Provider, or its agent, Acquisition Billing Services, LLC, that will be processing a claim and/or appeal for the Surgical Assist Services, as applicable. This assignment encompasses (i) all of my right, title, and interest in such insurance benefits; and (ii) all legal and equitable rights that I may have in relation to such benefits, including but not limited to bringing suit based on any claims pursuant to ERISA, other federal or state statutes, or the common law to obtain such benefits; to enforce the fiduciary duties owed to me; or to obtain any other appropriate legal or equitable relief that is available. This assignment is made in exchange for good and valuable consideration, the receipt and sufficiency of which is hereby expressly acknowledged.
Disclosure of Financial Interest of Referring Provider
I understand that my attending physician may have a financial interest in Provider, the medical practice that he/she has referred me to for Surgical Assist Services. I understand that I, the patient, have the right to choose the providers of my healthcare services and/or products and, as such, I have the option of receiving healthcare services from any healthcare provider and/or facility that I choose. After due consideration, I chose Provider to furnish Surgical Assist Services for me.
Right to Appeal
I hereby authorize Provider and/or Acquisition Billing Services, LLC, directly and/or through an agent, to appeal on my behalf to my current insurance carrier (including but not limited to private health insurance and employer‐sponsored health insurance) any and all decisions and/or determinations with respect to reimbursement for the Surgical Assist Services provided to me by Provider.
Release of Information
I hereby authorize the release of all medical records or other information to Provider and/or Claim Processor necessary to determine the benefits available and amounts payable with respect to the Surgical Assist Services furnished to me by Provider.
Certification
By signing below, I agree and certify that I have read and understood the above and, therefore, request and consent to the procedures and financial responsibility described above, and provide the designations, authorizations, and assignment of rights as specified above.
Patient Signature: Date: Witness Signature:
Driving Directions to Rocky Mountain Spine Clinic 10103 RidgeGate Pkwy. Suite 306, Lone Tree, CO 80124
Located in the Aspen Building at Sky Ridge Medical Center
From the North Take I-25 south. Exit at Lincoln Avenue (Exit 193). Stay to the left (there are three lanes to the light; you will want to be in the far right lane) and go to the stoplight at Lincoln Avenue. Turn right (west) onto Lincoln and head one block to Park Meadows Blvd. Turn left (south) on Park Meadows Blvd. The hospital campus is on the left, 1/4 mile south of Lincoln Avenue. You may also use the RidgeGate Parkway exit (Exit 192), one mile south of the Lincoln Avenue exit, to enter the campus from the south.
From the South If coming from the south on I-25, exit at RidgeGate Parkway (Exit 192) and follow signs to the hospital entrance.
From the East If coming from the east on Lincoln Avenue, cross over the I-25 overpass to Park Meadows Blvd. Turn left (south) on Park Meadows Blvd.
From Denver International Airport Exit airport terminal to Pena Blvd. Take Pena Blvd. 4 miles to E-470 south (Exit 6A). Travel south on E-470 for 27 miles. Take the I-25 exit. Head south for 1 mile and exit at Lincoln Avenue (exit 193). Turn right (west) onto Lincoln Avenue and head one block to Park Meadows Drive. Turn left (south) on Park Meadows Drive.