1A – F3 – Financial Policy

Financial Policy

First Name

Last Name

Date of Birth

Phone

Read carefully before signing

Thank you for choosing Vertex Spine and Dr. Rupert as your health care provider. Your clear understanding of our Patient Financial Policy is important to our professional relationship. Please carefully review the following information and return this form with your signature and today's date. Your signature indicates that you understand our policy and that you agree to meet all the financial responsibilities explained below.

By signing, I confirm the following:

Check all that apply to indicate your understanding and authorization.

I understand that charges for services rendered are my responsibility regardless of insurance coverage.

I am responsible for applicable co-pays, co-insurance, deductibles, and non-covered services.

I am responsible for providing accurate insurance information and notifying the office of changes.

If applicable, I will obtain any required HMO referral BEFORE my appointment.

I authorize this practice/physician to apply for benefits on my behalf for covered services rendered.

I certify the insurance information I reported is correct to date. I will notify Vertex Spine immediately with any changes.

I authorize release of necessary information, including medical documentation, to my insurance carrier for this or related claims.

I authorize payment of all medical insurance benefits payable to me under my policy to be paid directly to this practice for services rendered.

I understand payment is required for all services at the time they are rendered and that insurance contracted billing does not eliminate my responsibility for applicable patient amounts.

I understand missed appointments with less than 48-hours notice and returned check policies may apply as described in the Financial Policy: New Patient Visit ($150); Follow-up Visit ($75); Routine Interventional Procedures ($250); Regenerative Medicine or Implantable Therapy Procedures or Surgeries ($500); Returned Checks ($95).

I understand that outstanding balances may be sent to third-party collections and may impact credit, and that collections fees will be added.

I understand that Payments for Services are accepted via cash, check, or major credit/debit card. Outstanding balances on patient accounts reflect the base cost of services rendered. Cash and check payments will be credited directly at face value. For electronic transactions, a merchant-calculated card processing fee will be added automatically to your total at checkout, which is collected directly by the processing vendor. Your patient account balance will be credited for the actual baseline amount owed.

Signature Section

By signing below, you acknowledge the information provided and agree to the statements selected above. By selecting "I Agree" below, you acknowledge and agree that you are signing this Consent for Treatment electronically. You agree that your electronic selection is the legal equivalent of your manual/physical signature on this document, meeting all criteria under the Federal ESIGN Act and state law. You consent to be legally bound by this agreement's terms and conditions.

Check if the Responsible Party is different than the Patient

Patient First Name

Patient Last Name

Responsible Party Name (If other than the Patient)

Relationship to Patient

Responsible Party Email (If other than the Patient)

Responsible Party Phone (If other than the Patient)

Electronic Signature Status

I Agree to the Electronic Signature Terms

Today's Date