You are about to fill out your new patient paperwork using our online tool. You may also fill out this paperwork using physical paper by contacting our front office staff and requesting a physical copy.

This form is only to be filled out by the patient in question or by their authorized legal representative.

Smoking is associated with an increased risk of pseudoarthrosis and other surgical complications. I will refrain from tobacco use for at least six (6) weeks prior to any planned surgery.

I authorize my Authorized Representative and any holder of medical or other information about me to (i) release any information necessary to my health benefit plan (or its administrator) regarding my illness and treatments (including the Social Security Administration or its Medicare Administrative Contractors if I am a Medicare beneficiary); (ii) process insurance and other payment claims generated in the course of examination or treatment; and (iii) allow a photocopy of my signature to be used to process insurance and other payment claims. This authorization will remain in effect until revoked by me in writing. I authorize Provider to discuss my medical/health care with the following family members or close friends:

I authorize Provider to discuss my account finances with the following family members or close friends:

Financial Responsibility
Lifetime Assignment and Instruction for Direct Payment to Physician
Private and Group Accident and Health Insurance
Authorization to Release/Request Records

ASSIGNMENT OF INSURANCE BENEFITS; APPOINTMENT OF AUTHORIZED REPRESENTATIVE; PRIVACY; PAYMENTS; APPOINTMENTS
Assignment of Insurance Benefits: Appointment as Legal Authorized Representative: I (i) assign all applicable health insurance payments and benefits, all rights and obligations that I and my dependents have under my health plan to Total Spine (“Provider”); (ii) authorize payment of authorized insurance benefits, including Medicare, if I am a Medicare beneficiary, be made on my behalf to Provider; and (iii) appoint Provider as my authorized representative (“Authorized Representative”) with the power to (i) file medical claims, appeals and grievances with the health plan; (iii) any necessary litigation and/or complaints against my health plan naming me as plaintiff in such lawsuits and actions if necessary (for me as guardian of the patient if the patient is a minor); and (iv) discuss and divulge any of my personal health information or that of my dependents with any third party including the health plan. I also understand that Provider is not responsible for the terms of the contracts which I have with my health benefit plan or insurance companies. I certify that the health insurance and coverage information I provided to Provider is accurate as of the date set forth below and that I am responsible for keeping it updated. I am fully aware that health insurance and/or Medicare coverage does not absolve me of my responsibility to ensure that my bills for professional services from Provider are paid in full. I also understand that (i) I am responsible for all amounts not covered by my health insurance and/or Medicare, including co-payments, co-insurance, deductibles and out of pocket; and (ii) with respect to Medicare/ Secondary Insurance, should my insurance or not pay all or part of the secondary balance, I am responsible for all remaining allowed charges.

ERISA Authorization:I designate, authorize and convey to my Authorized Representative to the full extent permissible under law and under any applicable insurance policy and/or employee health care benefit plan: (i) the right and responsibility to act as my Authorized Representative in connection with any claim, right or cause of action including litigation against my health plan (even to name me as a plaintiff in such action) that I may have under such insurance policy and/or benefit plan; and (ii) the right and ability to act as my Authorized Representative to pursue such claim, right or cause of action in connection with said insurance policy and/or benefit plan (including but not limited to the right and ability to act my Authorized Representative with respect to a benefit plan governed by the provisions of ERISA as provided in 29 CFR § 2560.503-1(b)(4) with respect to any health care expense incurred as a result of the services I received from Provider and to the extent permissible under that law, to claim on my behalf, such benefits, claims or reimbursements, and any other applicable remedy, including fines. This authorization will remain in effect until revoked by me in writing. A photocopy of this Authorization shall be as effective and valid as the original.

Payment Policy: Out of Network Disclosure/Patient Acknowledgment of Responsibility:I understand that (i) Provider accepts most forms of payments including checks, debit cards, credit cards and credit facilities like Care Credit and MedFin; (ii) Provider reserves the right t charge 1.5% interest per month, compounded daily, after 90 days of non-payment on all outstanding balances; (iii) credit cards and other revolving credit programs have charge back provisions to allow, for example, return of purchased goods, but that such chargeback features are not appropriate at Provider, such that I waive my rights for chargebacks; (iv) if a chargeback occurs, Provider may initiate legal action to recoup the charges and I will be responsible for all resulting legal fees and other appropriate expenses to recoup the charges; and (v) Provider will assess a $50.00 fee on all checks that are returned as unpaid. I understand that Provider is an out of network provider and that, consequently: (i) I am responsible for the difference between charges and payments made by my health plan and any coinsurance, deductible and out of pocket required by my health plan; and (ii) Provider cannot waive any such patient responsibility.

I do hereby authorize and direct the below named attorney who represents me in my personal injury claim, to pay directly from my settlement to TOTAL SPINE for medical services and goods provided by its employees such as may be due and owing for medical services rendered to me, and to withhold such sums from any settlement, judgment or verdict as may be necessary to adequately protect TOTAL SPINE.

I further give lien on my case to TOTAL SPINE against any and all proceeds of any settlement, judgment and/or verdict paid to my attorney as a result of the injuries for which I have been treated or injuries in connection therewith.

I fully understand that I am directly and fully responsible to TOTAL SPINE for all medical bills submitted for medical services rendered to me and that this agreement is made solely for TOTAL SPINE as additional protection and in consideration of awaiting payment. I further understand that such payment is not contingent on any settlement, judgment, or verdict by which I may eventually recover said fee.

I also fully understand that in the event that I should decide to secure a different attorney other than the attorney’s name below, the new attorney will also honor this further disbursement and agrees to sign a copy of this agreement consenting to its terms and provisions. Any photocopy will be as valid as the original.

I agree that if any legal action is brought for the enforcement of this Lien, or because of an alleged dispute, breach, or default in connection with any or all of this Lien, the prevailing party shall be entitled to recover reasonable attorney’s fees, court costs, and all reasonable expenses, even if not taxable as court costs (incurred in that action) in addition to any other relief to which such party may be entitled. Attorney’s fees shall include, without limitation, paralegal fees, investigative fees, administrative costs, sales and use taxes and all other charges billed by the attorney to the prevailing party.

Patient and physician acknowledge that recovery is often uncertain owing to the strategies, tactics, and opinions offered at trial by physicians hired by defense lawyers who are working for insurance companies with significant resources to combat the reasonable claims brought by permanently injured clients/patients. These resources are often utilized by insurance companies against their own insureds even though they have paid premiums for their own protection.

Regardless of the outcome of the trial and regardless of what the jury awards, the patient shall remain liable to the physician for medical services rendered. The patient’s bill is not contingent on testimony from his/her healthcare provider and the healthcare provider shall only be required to testify if subpoenaed to testify.

Insurer and Patient Please Read the Following in its Entirety Carefully!

I, the undersigned patient/insured knowingly, voluntarily and intentionally assign the rights and benefits of my automobile Insurance, a/k/a Personal Injury Protection (hereinafter PIP), and Medical Payments policy of insurance to the above health care provider. I understand it is the intention of the provider to accept this assignment of benefits in lieu of demanding payment at the time services are rendered. I understand this document will allow the provider to file suit against an insurer for payment of the insurance benefits or an explanation of benefits and to seek §627.428 damages from the insurer. If the provider’s bills are applied to a deductible, I agree this will serve as a benefit to me and I authorize and request such litigation. This assignment of benefits includes the cost of transportation, medications, supplies, overdue interest and any potential claim for common law or statutory bad faith/unfair claims handling. If the insurer disputes the validity of this assignment of benefits, then the insurer is instructed to notify the provider in writing within five days of receipt of this document. Failure to inform the provider shall result in a waiver by the insurer to contest the validity of this document. The undersigned directs the insurer to pay the health care provider the maximum amount directly without any reductions & without including the patient’s name on the check. To the extent the PIP insurer contends there is a material misrepresentation on the application for insurance resulting in the policy of insurance is declared voided, rescinded, or canceled, I, as the named insured under said policy of insurance, hereby assign the right to receive the premiums paid for my PIP insurance to this provider and to file suit for recovery of the premiums. The insurer is directed to issue such a refund check payable to this provider only. Should the medical bills not exceed the premium refunded, then the provider is directed to mail the patient/named insured a check which represents the difference between the medical bills and the premiums paid.

Disputes: The insurer is directed by the provider and the undersigned to not issue any checks or drafts in partial settlement of a claim that contain or are accompanied by language releasing the insurer or its insured/patient from liability unless there has been a prior written settlement agreed to by the health provider (specifically the office manager) and the insurer as to the amount payable under the insurance policy. The insured and the provider hereby contest and object to any reductions or partial payments. Any partial or reduced payment, regardless of the accompanying language, issued by the insurer and deposited by the provider shall be done so under protest, at the risk of the insurer, and the deposit shall not be deemed a waiver, accord, satisfaction, discharge, settlement or agreement by the provider to accept a reduced amount as payment in full. The insurer is hereby placed on notice that this provider reserves the right to seek the full amount of the bills submitted. Any effort by the insurer to pay a disputed debt as full satisfaction must be mailed to the address above, after speaking with the office manager, and mailed to the attention of the Office Manager. See 673.3111.

EUOs and IMEs: If the insurer schedules a defense examination or examination under oath (hereinafter “EUO”) the insurer is hereby INSTRUCTED to send a copy of said notification to this provider. The provider or the provider’s attorney is expressly authorized to appear at any EUO or IME set by the insurer. The health care provider is not the agent of the insurer or the patient for any purpose.

EUOs and IMEs: If the insurer schedules a defense examination or examination under oath (hereinafter “EUO”) the insurer is hereby INSTRUCTED to send a copy of said notification to this provider. The provider or the provider’s attorney is expressly authorized to appear at any EUO or IME set by the insurer. The health care provider is not the agent of the insurer or the patient for any purpose.

This assignment applies to both past and future medical expenses and is valid even if undated. A photocopy of this assignment is to be considered as valid as the original. I agree to pay any applicable deductible, co-payments, for services rendered after the policy of insurance exhausts and for any other services unrelated to the automobile accident. The health care provider is given the power of attorney to: endorse my name on any check for services rendered by the above provider; and to request and obtain a copy of any statements or examinations under oath given by patient.

Release of Information: I hereby authorize this provider to: furnish an insurer, an insurer’s intermediary, the patient’s other medical providers, and the patient’s attorney via mail, fax or email, with any and all information that may be contained in the medical records; to obtain insurance coverage information (declaration sheet & policy of insurance) in writing and telephonically from the insurer; request from any insurer all explanation of benefits (EOBs) for all providers and non-redacted PIP payout sheets; obtain any written and verbal statements the patient or anyone else provided to the insurer; obtain copies of the entire claim file and all medical records, including but not limited to, documents, reports, scans, notes, bills, opinions, X-Rays, IMEs, and MRIs from any other medical provider or any insurer. The provider is permitted to produce my medical records to its attorney in connection with any pending lawsuits. The insurer is directed to keep the patient’s medical records from this provider private and confidential and the insurer is not authorized to provide these medical records to anyone without the patients and the provider’s prior express written permission.

Demand: Demand is hereby made for the insurer to pay all bills within 30 days without reductions and to mail the latest non-redacted PIP payout sheet and the insurance coverage declaration sheet to the above provider within 15 days. The insurer is directed to pay the bills in the order they are received. However, if a bill from this provider and a claim from anyone else is received by the insurer on the same day the insurer is directed to not apply this provider’s bill to the deductible. If a bill from this provider and claim from anyone else is received by the insurer on the same day then insurer is directed to pay this provider first before the policy is exhausted. In the event of the provider’s medical bills are disputed or reduced by the insurer for any reason, or amount, the insurer is to; set aside the entire amount disputed or reduced; escrow the fill amount at issue; and most pay the disputed amount to anyone or any entity, including myself, until the dispute is resolved by a Court. Do not exhaust the policy. The insurer is instructed to inform, in writing, the provider of any dispute.

Certification: I certify that; I have read and agree to the above; I have not been solicited or promised anything in exchange for receiving health care; I have not received any promises or guarantees from anyone as to the results that may be obtained by any treatment or service; and I agree the provider’s prices for medical services, treatment and supplies are reasonable, usual and customary

Caution: Please read before signing. Please ask to view a copy of our charges. If you do not completely understand this document, please ask us to explain it to you. If you sign below, we will assume you understand and agree to the above.

1) Privacy and Ratings Total Spine agrees not to provide medical information for the purpose of marketing directly to the Patient. Regardless of legal privacy loopholes, Total Spine will never attempt to leverage its relationship with the Patient by seeking Patient’s consent for marketing products for others. We want your feedback. If our office gets it right, tell us. If we could do something better, tell us. We take quality improvement seriously. While there are scores of “rating sites” in cyberspace, many fail to provide useful information. Let’s get it done right. We can make recommendations as to which sites follow minimum standards for fairness and balance. Just ask us. Total Spine has invested significant financial and marketing resources in developing the practice. Nothing in this Agreement prevents a patient from posting commentary about Total Spine - our practice, expertise, and/or treatment - on web pages, blogs, and/or mass correspondence. In consideration for treatment and the above noted patient protection, if Patient prepares such commentary for publication on web pages, blogs, and/or mass correspondence about Total Spine, the Patient exclusively assigns all Intellectual Property rights, including copyrights, to Total Spine, for any written, pictorial, and/or electronic commentary. This assignment shall be effective at the time of creation (prior to publication) of the commentary. This Agreement shall be for a period of five years from Total Spine’s last date of service to the Patient. Total Spine requires all patients in its practice to sign the Mutual Agreement to establish that any anonymous publishing or airing of commentary will be covered by this agreement. Further, this Agreement will survive for a minimum of three years beyond any termination of the Total Spine - Patient relationship. Patient and Total Spine acknowledge that breach of this Agreement may result in serious, irreparable harm. Patient and Total Spine agree to the right of equitable relief (including but not limited to injunctive relief). Should a breach of this provision result in litigation, the prevailing party in the litigation shall be entitled to reasonable costs, expenses, and attorney fees associated with the litigation.

2) Surgical Consent Modification We recognize that you have a choice in receiving care. We take great pride in our reputation for providing the highest levels of quality medical care to our patients. However, we realize there are times when some patients might not be satisfied with the outcomes of their treatments. Every patient has a right to file a complaint with the Division of Medical Quality Assurance, Board of Medicine. But that right is not unlimited. For example, those who file complaints in bad faith can be subject to civil liability (Florida Statutes§ 456.073 (11). In the context of balancing your rights with those of the physician, I, the patient, agree to the following: a) If a complaint related to my care is ever filed (by my agent or me) with the Division of Medical Quality Assurance, I will only do so in good faith, addressing matters only related to my health and welfare. b) In particular, I understand that there are risks inherent to any surgical procedure and these risks have been explained to me prior to the procedure. I have signed that consent voluntarily and with my free will. And I have had an opportunity to ask questions and have them answered to my satisfaction. In that context, a complaint to the Division of Medical Quality Assurance, founded on any such realized risks, unless there is clear and convincing evidence to the contrary, will be construed as bad faith. c) Next, should a complaint be filed with the Division of Medical Quality Assurance related to standard of care, I, the patient, will explicitly request that the complaint be reviewed by a member of my specialty; that specialty being Neurosurgery, Spinal Surgery, Orthopedic Surgery, Pain Management or Neurology d) Finally, should the complaint allege facts that can be disrupted by the clear medical record, I, the patient, will voluntarily withdraw my complaint if that portion of the medical record is drawn to my attention. I will have the right to inspect and review the medical record to correct any perceived error in the medical history. Such corrections must be performed within two weeks of the treatment received.

3) Resolution of Concerns I understand that I am entering into a contractual relationship with Total Spine for professional care. I further understand that meritless and frivolous claims for medical malpractice have an adverse effect upon the cost and availability of medical care to patients and may result in irreparable harm to a medical provider. As additional consideration for professional care provided to me by Physician, I, the patient/guardian and/or my representative, agree not to initiate or advance, directly or indirectly, any false, meritless, and/or frivolous claim(s) of medical malpractice against Physician. Furthermore, should a meritorious medical malpractice case or cause of action be initiated or pursued, I (the patient) and/or my representative agree to use American Board of Medical Specialties (“ABMS”) board-certified expert medical witness (es) in the same specialty as Physician. Furthermore, I agree that these expert witnesses will be members in good standing of and adhere to the guidelines and/or code of conduct defined for expert witnesses by the American Board of Neurosurgery, American Board of Interventional Pain Management, American Academy of Pain Management, American Board of Electrodiagnostic Medicine, American Board of Physical Medicine and Rehabilitation, American Board of Orthopedic Surgery and American Board of Psychiatry and Neurology. Patient/guardian and Physician acknowledge that monetary damages may not provide an adequate remedy for breach of this Agreement. Such breach may result in irreparable harm to Physician’s reputation and business. Patient/guardian and Physician agree in the event of a breach to allow specific performance and/or injunctive relief.

4. Waiver Article 1, Section 21 of the Florida Constitution reads as follows: Access to court – The courts shall be open to every person for redress of any injury, and justice shall be administered without sale, denial or delay. The Undersigned patient understands and acknowledges that: I have been advised that signing this waiver releases an important constitutional right; and I have been advised the I may consult with counsel before signing this waiver; and by signing this waiver I agree that if any controversy arises out of or in any way relating to the current, future or past diagnosis, treatment, or care that I have or will receive from Total Spine & Wellness, it’s physicians, agents or employees, the maximum amount of any noneconomic damages that can be awarded in any such action will be $250,000. This limit applies regardless of the number of claimants or defendants in the proceeding. There is no limit on the amount of economic damages that a jury may award; and I have three (3) business days following execution of this waiver in which to cancel this waiver; and I wish to engage the medical services of Total Spine & Wellness, but I am unable to do so because of the provisions of the constitutional limitation set forth above. In consideration of the physician or group of physicians’ agreements to provide medical services to me and my desire to receive medical services from the physician or group of physicians listed below, I hereby knowingly, willingly, and voluntarily waive the right, in an action in a court of law for any controversy, including any malpractice claim, arising out of or in any way relating to the diagnosis, treatment, or care of the patient by Total Spine, including any partners, agents, or employees of the physician, to recover non-economic damages in excess of $250,000; and I have selected Total Spine as my physician group of choice in this matter and would not be able to retain their medical services without this waiver; and I expressly state that this waiver is made freely and voluntarily, with full knowledge of its terms, and that all questions have been answered to my satisfaction. I understand that this waiver will remain in effect for one year from the date that I have signed this form.

I hereby grant Total Spine and Orthopedics, its directors, officers, employees, agents, and designees (collectively “TSO”) non-revocable permission to capture my image and likeness in photographs, videotapes, motion pictures, recordings, or any other media (collectively “Images”). I acknowledge that TSO will own such Images and further grant TSO permission to copyright, display, publish, distribute, use, modify, print and reprint such Images in any manner whatsoever related to TSO business, including without limitation, publications, advertisements, brochures, web site images, or other electronic displays and transmissions thereof. I further waive any right to inspect or approve the use of the Image by TSO prior to its use. I forever release and hold TSO harmless from any and all liability arising out of the use of the Images in any manner or media whatsoever and waive any and all claims and causes of action relating to use of the Images

I, the undersigned patient or person responsible for the patient, do hereby direct and authorize TOTAL SPINE & WELLNESS, “TSW” to furnish my insurance company, attorney, personal physician, or any representative thereof, any and all information which may be pertinent regarding my medical condition and medical treatment rendered to me.

1. I, the undersigned patient or person responsible for the patient, do hereby acknowledge that I am responsible for the payment of fees for medical services rendered to me by TSW to act as my agent in assisting me to obtain payment from my insurance company of bills for medical services rendered. I authorize and direct TSW, to furnish upon request medical or other information necessary to process claims to any insurance company responsible for payment of fees for medical services rendered on my behalf be TSW.

2. I, the patient or person responsible for the patient, do hereby authorize and direct that payment of bills for medical services rendered by TSW, be made directly to TSW on my behalf. I permit a copy of this authorization to be used in place of the original.

3. I hereby declare by my signature below that I read and understand all of the provisions above.