Maryland Pain Specialists
410 825-6945

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* 


Patient Agreement and Signature

I have read and fully understand the agreements described above. I further understand that my signature signifies that I accept the terms as set forth in these agreements.

Printed name of patient (or financially responsible person)

Patient Signature

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