Maryland Pain Specialists
410 825-6945

WELCOME LETTER

Greetings and Welcome!

We look forward to meeting you at your upcoming appointment. Please find attached our practice’s intake packet. In advance of your appointment, please note the following:

1. Please complete this packet in advance of your appointment.

2. Please bring your photo ID, insurance card(s) and referral if required.

3. Please plan to arrive 60 minutes before your scheduled appointment so that the registration process may be completed. Due to Covid-19, we need to limit the number of people in our office so please arrive as close to your specified arrival time as possible.

4. If you are more than 15 minutes late, you may have to reschedule.

5. Copays are due at the time of service.

6. Additional information and map are available on our website, www.marylandpainspecialists.com

Regards,

Maryland Pain Specialists

PATIENT LETTER

The physicians at Maryland Pain Specialists are all board-certified in Pain Medicine and each are fellowship trained through Johns Hopkins University. 

In addition to patient-driven clinical care, our physicians have published research in scientific journals and book chapters on pain management. Our team of providers has over fifty years of combined experience in managing chronic pain. Our philosophy is guided by evidence-based, outcome-oriented medical science.  We provide comprehensive evaluations required to understand each person's individual circumstances. Part of the evaluation may include questionnaires or surveys to gather valuable information on all important aspects of the pain problem. These tools can provide details on both physical health and mental well-being that help determine what types of treatment will be most effective.  

All patients are treated with respect and compassion and your medical information is HIPAA protected for your privacy. We offer all patients scientifically-based therapies using the most effective, non-opioid (non-narcotic), multidimensional treatment options.  We do not believe in fostering or maintaining drug dependence or addiction.  For the best results possible, each patient's treatment plan is individualized to reduce pain, restore physical function, and improve quality of life.

PRIVACY PRACTICES

We Care About Your Privacy

Our Pledge Regarding Medical Information

The privacy of your medical information is important to us. We respect your privacy and treat all healthcare information about our patients with care under strict policies of confidentiality that all of our staff are committed to following. This Notice will tell you about the ways we may use and share medical information about you. We also describe your rights and certain duties we have regarding the use and disclosure of medical information.

Privacy Notice is available on our website at:
https://www.marylandpainspecialists.com/webdocuments/NOTICE-OF-PRIVACY-PRACTICES-MPS-2020.pdf

Questions and Complaints

You have the right to complain to us or to the Secretary of the United States Dept. of Health and Human Services if you believe your privacy rights have been violated. You will not be retaliated against for filing a complaint with us or to the government. 

Should you have any questions or complaints you may direct all inquiries to the Privacy Officer.

 

Privacy Practices Acknowledgement

I have received the Notice of Privacy Practices and I have been provided an opportunity to review it.

Please initial to indicate your agreement* 

PATIENT PREFERRED CONTACT INFORMATION

Gender     

I wish to be contacted in the following manner (check all that apply):

 

 

 

 

By listing their names here, I authorize Maryland Pain Specialists to discuss my treatment, schedule appointments, or send records to the following persons:
PLEASE NOTE: Referring physicians are automatically eligible to receive this information so do not list them on this form.

 

YOU MAY RECEIVE A SEPARATE BILL FROM YOUR PHYSICIAN AND THE FACILITY

Please initial to indicate your agreement* 

 

PATIENT'S AUTHORIZATION

I request that payment of authorized insurance benefits be made either to me or on my behalf to Maryland Pain Specialists. I authorize any holder of medical information about me to release to the insurance company and its agents any information needed to determine these benefits or the benefits for related services.

Please initial to indicate your agreement* 

FINANCIAL POLICY

Insurance Participation

We participate with most major insurance companies, including but not limited to:

AETNA

CAREFIRST BCBS 

CIGNA/GREAT WEST HEALTHCARE

COVENTRY OF DELAWARE – Not the Diamond Plan

EHP 

MEDICAID – Amerigroup, Maryland Physician Care, Priority Partners, University of Maryland Health Partners (Riverside), UHC Community Health Plan

MEDICARE 

MEDICARE RAILROAD

PHCS or MULTIPLAN 

TRICARE STANDARD HUMANA MILITARY PPO

UNITED HEALTHCARE 

WORKER’S COMPENSATION 

Proof of Insurance

The responsibility of providing complete and accurate insurance information to our office staff belongs to you, the patient. A current copy of your insurance card and driver’s license is required at each visit in order to verify proof of insurance. As a courtesy, we will gladly submit a claim to your insurer. 

Failure to supply us with correct insurance information in a timely manner may result in being responsible for the balance of a claim.

Co-Pays, Deductibles and Coinsurance 

Legally, we cannot waive co-pays, deductibles, or coinsurance amounts. Contractually, your insurance company requires us to collect the portion for which you are responsible at the time services are rendered. Payment made at the time of service allows us to keep administrative costs to a minimum.  

If you are uninsured, payment is expected in full on the day of your visit.

Non-Covered Services

There are some services that may not be considered reasonable or necessary by Medicare or other insurers. You may be asked to pay for these services at the time they are rendered. In some cases, we will ask you to make a decision to receive covered services that we expect may be denied by Medicare. The fact that Medicare may not pay for a particular item or service does not mean that you should not receive it. The physician will explain why he feels you should receive the service. This will be done in writing on a form called an Advance Beneficiary Notice (ABN). The ABN will also provide you the opportunity to agree or refuse the services. It also explains that we will not know if the service will be denied until Medicare processes the actual claim. 

Acceptable Forms of Payment

We accept the following forms of payment:

*Cash

*Check

*Credit Card (Visa, MasterCard and Discover)

*Money Order

Payment Policy

Balances must be paid in full within 30 days of the visit. Partial payments will not be accepted unless otherwise negotiated through the Billing Department. In such cases, a minimum of thirty five percent (35%) of the balance will be due on a payment date as discussed with the Billing Department. This does not include any copay that is due at the time of visit. Appointments may be cancelled if a balance remains unpaid. 

Payment plans may be available under certain circumstances; however, advance notice and pre-approval is required. Please contact our Billing Office at 410-825-8973 for more information.

Past Due Accounts

Every attempt will be made, including the services of a collection agency, to collect past due accounts. If it is necessary to utilize a collection agency you may be assessed a fee for such services up to 33% of the total owed.

Returned Checks

A fee of $35 will be assessed to your account for each personal check returned by your financial institution for “non-sufficient funds”. Furthermore, all future payments on your account must be in CASH.

Missed Appointments

We require twenty four (24) hours notice if you are unable to keep your appointment. 

A fee of $25 may be charged to you and would be your responsibility. Please help us serve you better by keeping your scheduled appointment. 

Medical Records

Authorized written requests for copies of medical records will be honored. Our fees are in accordance with Maryland State Law.

Forms Completion

Payment for the completion of forms must be made at the time of service. The fees are as follows:

Simple/single page forms: $10 (each form)

Complex/multi-page forms: $25 (each form)

Processing requests for medical records and forms completion requires ten (10) working days. This office does not complete disability forms. When these forms are required, it is our policy to refer patients for Functional Capacity Evaluations (FCE’s).

Motor Vehicle Accident Related Injuries

Patient must supply auto insurance carrier information (including claim number and adjustor name and contact information) as well as personal healthcare insurance information because we still need to make sure we are a participating provider. It will be necessary to confirm PIP (Personal Injury Protection) benefits prior to scheduling your appointment and if benefits are no longer available, a PIP exhaustion letter will need to be obtained. It will also be necessary for the patient to sign our MVA Release Waiver.

Self Pays

Patients without healthcare insurance will need to make arrangements with our billing office prior to appointment scheduling. The total estimated cost will need to be paid prior to that visit.

Billing Office

Representatives are available Monday through Friday, 6:30 AM - 2:30 PM at 410-825-8973 to assist you with account inquiries and the resolution of billing issues.

Payments can be mailed to the address on the statement.

I have read and fully understand the Financial Policy described above. I further understand that my signature signifies that I accept the terms as set forth in this agreement.

Please initial to indicate your agreement* 

Your Rights and Protections Against Surprise Medical Bills

When you get emergency care or get treated by an out-of-network provider at an innetwork hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

What is "balance billing' (sometimes called "surprise billing")?

"Out-of-network" describes providers and facilities that haven't signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called "balance billing." This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

"Surprise billing" is an unexpected balance bill. This can happen when you can't control who is involved in your care-like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.

You are protected from balance billing for:

Emergency services -

lf you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan's in-network cost-sharing amount (such as copayments and coinsurance). You can't be balance billed for these emergency services. This includes services you may get after you're in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center -

when you get services from an in-network hospitalor ambulatory surgical center, certain providers there may be out-of-network. ln these cases, the most those providers may bill you is your plan's in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can't balance bill you and may not ask you to give up your protections not to be balance billed. lf you get other services at these in-network facilities, out-of-network providers can't balance bill you, unless you give written consent and give up your protections.

You're never required to give up your protections from balance billing. You also aren't required to get care out-of-network. You can choose a provider or facility in your plan's network.

When balance billing isn't allowed, you also have the following protections:

  • You are only responsible for paying your share ofthe cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will payoutof- network providers and facilities directly.
  • Your health plan generally must:
    • Cover emergency services without requiring you to get approval for services in advance (prior authorization).
    • Cover emergency services by out-of-network providers.
    • Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
    • Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

 

lf you believe you've been wrongly billed, you may call 1-877-696-6775,

Visit https://www.cms.gov/nosurprises for more information about your rights under federal law.

Medications

It is imperative that we have a complete medication list.

Please include prescribed medications, supplements, herbals, and regularly taken over-the-counter medications.

 
 
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Primary Care Provider
Referring Physician/Surgeon/Provider

Patient Agreement and Signature


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