Neurology: (480) 776-2982  Pain Management: (480) 444-7480

Patient Disclosure

When you became a patient at the Phoenix Neurological and Pain Institute, you agree to abide by the rules of our practice and our Patient/Provider Pain Management Agreement.

Financial Policy & Notice of Privacy Practices Insurance Benefits:
Arizona State Law (HB2600) requires that medical claims be paid by insurance carriers within 30 days. If your insurance carrier has not appropriately paid the submitted claim within 30 days, I understand that outstanding balances will become the responsibility of the policy holder.

Insurance Co-Payments:
In accordance with my insurance contract. I understand that Co-payments are due at time of service.

If my Insurance deductible has not boon met. I understand that outstanding deductible amounts will be collected at the time of service and at the time Interventional procedures are scheduled.

I understand that co-insurance amounts may be collected at time of service, and at the time interventional procedures are scheduled.

Private Pay:
If I have no insurance coverage, or insurance with which Practice does not participate, or is unable to verify current insurance coverage, I understand full payment is expected at time of service and at the time interventional procedures are scheduled. A full fee schedule will be provided u n request.

Notice to Medicare Patients:
If we are unable to verify from Medicare that there is automatic submission of claims to the secondary insurance carrier, you may be responsible for secondary insurance balances at the time of service and at the time interventional procedures are scheduled.

Refund Policy:
I understand that amounts collected from me (including co - payments, co - insurance and deductibles) are based on information received by Specialty Pain Management from my insurance carrier. Refunds are made only after a written request is submitted, and there has been full insurance reimbursement for all medical services on the account, regardless of the date of service. Please allow 4- 6 weeks for the request to be processed.

Verification of Benefits and Non-Covered Services:
Insurance policies are individualized per patient plan Specialty Pain Management may provide services that my insurance plan excludes. I understand that it is my responsibility to verify coverage benefits and exclusions. I understand that all non-covered services are my responsibility.

I understand that once an account is placed in a collection status, all future services must be paid in full at time of service (no checks accepted). If my account is placed into collections, I will be responsible for all collection and interest costs.

Returned Checks:
Returned checks will be subject to a $30.00 returned check fee.

Missed Appointment Fine:
When you do not show for scheduled appointment you cause an unnecessary expense to the practice as we have reserve a place for you in our schedule. There will be a fine of $25.00 charged for missed appointments unless you reschedule 24 hours in advance ($3.00 for Medicaid AHCCCS patients).

You will be discharged from our practice for:  
    •    Three consecutive missed appointments.
    •    On one or more occasion s, you have not complied with the terms of your Pain Management Agreement.
    •    Illegal behavior and/or actions.
    •    Abusive or rude behavior with staff and/or providers
    •    Disruptive behavior in the office and/or waiting room
    •    Inappropriate behavior in the examining and/or procedure rooms.