ROCKY MOUNTAIN SPINE CLINIC, P.C. Eric R. Jamrich, M.D. John R. Barker, M.D. Chad J. Prusmack, M.D.

Name_________________________________________________________________________ Birthdate ___________________

Last First Middle Initial SSN_______________________

Address ___________________________________Apt. # ______City____________________State________Zip_____________

Home Phone ( )__________________Work Phone ( )_________________ Cell Phone ( )____________________

E-mail Address_________________________________________ Preferred method of contact: □ Phone □ E-mail □ Text

❑ YES, e-mail info on PruTectRx supplements ❑ NO, I do not want info on PruTectRx supplements Gender ❑ Male ❑ Female Marital Status ❑ Single ❑ Married ❑ Widowed ❑ Divorced Employer _________________________________________ Occupation_______________________________________________ Employer’s Address______________________________________City_______________________State________Zip___________ Employment Status ❑ Full-Time ❑ Part-Time ❑ Retired ❑ On Leave ❑ Other In case of emergency contact _______________________________________________ Relationship _______________________ Home Phone ( ) _________________ Work Phone ( ) ___________________ Cell Phone ( ) _____________________

REFERRING PHYSICIAN /COMPLETE NAME AND ADDRESS:

___________________________________________________________________________________________________________

PCP (if different from Referring Physician) COMPLETE NAME AND ADDRESS ___________________________________________________________________________________________________________

Pharmacy__________________________________________________ Phone ________________________________________

INSURANCE INFORMATION ~ We will need a copy of your insurance card(s).

Primary Insurance Address (Street/City/State) Employer

___________________________ __________________________________________ ____________________________________ Group #____________________ ID #________________________ Policy Holder ❑ Self ❑ Spouse ❑ Parent/Guardian Secondary Insurance Address (Street/City/State) Employer ___________________________ __________________________________________ ____________________________________ Group #____________________ ID #________________________ Policy Holder ❑ Self ❑ Spouse ❑ Parent/Guardian

INSURED RESPONSIBLE PARTY INFORMATION – If other than self Name________________________________Relationship_________________Birthdate____________ SSN___________________ Address (if different from patient)_______________________________________________________________________________ Home Phone ( )___________________ Work Phone ( )________________ Employer________________________________

ACCIDENT INFORMATION Is this a ❑ Work Comp or ❑ Motor Vehicle Accident? ❑ Yes ❑ No If YES, on what date did the injury occur? _______________ Work Comp / Motor Vehicle Claim Number _____________________________________ Adjuster’s Name _________________________________________________________ Phone Number ( ) ________________________ Fax Number ( ) _______________________________ I authorize that payment of any insurance benefits for health care services be made directly to Rocky Mountain Spine Clinic, P.C. NOTE: If patient is a minor under the age of 18 years, these forms must be signed by parent or legal guardian. They cannot be signed by a minor. ___________________________________________________________ __________________________ Signature of Patient, Parent or Legal Guardian Date

DATE AGE HEIGHT WEIGHT B/P PULSE

______________________________________________________________________________________ ______

(Please do not write above this line)

PATIENT’S NAME: AGE: BIRTHDATE:

JOB TITLE: __________________________________________________________________________________

JOB DESCRIPTION: __________________________________________________________________________

____________________________________________________________________________________________

COMPLETE NAME & ADDRESS OF REFERRAL SOURCE (Physician/Friend/Agency, etc.)

ROCKY MOUNTAIN SPINE CLINIC, P.C.

ERIC R. JAMRICH, M.D. JOHN R. BARKER, M.D. CHAD J. PRUSMACK, M.D.

Financial Arrangements and Insurance

We are committed to providing you with the best possible care. If you have health insurance, we

will help you receive your maximum allowable benefits. In order to achieve this, we need your

assistance and understanding of our payment policy. Please always bring your current insurance

card with you to all appointments. We will collect your co-payment at the time of service.

If you cannot pay your co-pay at the time of service, your appointment will need to be

rescheduled.

We participate with Medicare. We accept Medicare assignment and will bill Medicare for you. If

you have supplemental insurance, please bring that information with you to your appointment.

You may be responsible for a portion of your charges such as Medicare deductible and co-insurance.

If you belong to an insurance which requires a referral from your primary care physician, please

bring the referral with you to your appointment. We must have a current referral before you

can be seen. If you do not bring a current referral with you to your appointment, your

appointment will have to be rescheduled.

If you are being treated for a work-related injury, injuries occurring from an automobile accident,

or a third party liability (for example, injured on the property of another person), we must have

approval from your adjuster prior to seeing you. We will also need the following information: name

of your insurance carrier, their address and phone number, your adjuster's name, your claim

number and the date of your injury/accident.

If your claim is denied by workmen's compensation, auto insurance or third party liability, you will

be responsible for the entire bill for services. If the automobile insurance fails to pay 100

percent of the billed charges, you will be held responsible for any amount the insurance

does not cover.

Returned checks and balances older than 30 days are subject to additional collection fees. You will

be assessed a $25.00 fee on any returned checks, in addition to collection and legal fees (13-21-109

C.R.S.). Charges may also be made for broken appointments and appointments cancelled without

24 hours advance notice.

If payments are not paid as agreed and your account is placed for collection, you agree to pay all

reasonable costs of collection, including but not limited to attorney fees, court costs and interest at

18% per annum from the date of service.

We will gladly discuss your proposed treatment and answer any questions relating to your

insurance. You must realize, however, that:

1. Your insurance is a contract between you, your employer and the insurance company. We are not

a party to that contract.

2. Our fees are generally considered to fall within the acceptable range by most companies, and

therefore are covered up to the maximum allowance determined by each carrier. This applies only

to companies who pay a percentage (such as 50% or 80%) of "U.C.R." which is defined as “usual,

customary and reasonable” fees for this region. Thus, our fees are considered usual customary and

reasonable by most companies.

This statement does not apply to companies who reimburse based on an arbitrary "schedule" of

fees, which bears no relationship to the current standard and cost of care in this area.

3. Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select

certain services they will not cover.

We must emphasize that as health care providers, our relationship is with you, not your insurance

company. While the filing of insurance claims is a courtesy we extend to our patients, all charges

are your responsibility from the date the services are rendered. We realize that temporary

financial problems may affect timely payment of your account. If such problems do arise, we

encourage you to contact us promptly for assistance in the management of your account.

DISABILITY/FMLA FORMS - Our charge for filling out disability forms is: First form:

No charge. Subsequent forms: $25.00 per form. All charges for completing disability

forms must be paid in advance.

If you have any questions about the above information or are uncertain regarding your insurance

coverage, PLEASE don't hesitate to ask us. We are here to help you.

I have read and understand the financial policy of Eric R. Jamrich, M.D., John R. Barker, M.D.,

and Chad J. Prusmack, M.D. and agree to abide by the policy as stated.

_________________________________________________________

Signature of Patient or Person with Authority to Sign for Patient

________________________

Date

This contract will be governed by and construed and enforced in keeping with the laws of the

State of Colorado. Venue for any action to enforce the terms and conditions of this contract will

be in Douglas County, Colorado.

SURGICAL ASSIST SERVICES AUTHORIZATION OF DIRECT PAYMENT, DESIGNATION OF AUTHORIZED REPRESENTATIVE, AND/OR ASSIGNMENT AGREEMENT 

I,_________________________(Patient/Guardian) the undersigned, hereby request that Surgical Assist services ("SA Services") be provided to me during my surgery scheduled on______________by______________________________and/or its affiliate (collectively, "Provider"). 

I hereby transfer all of my rights to payment, rights to appeal, rights to request and to participate in mediation and/or in arbitration, and rights to bring suit against my health insurance carrier or other third party payor ("Payor") in relation to the provision of  Surgical Assist Services and all payment disputes related to Surgical Assist Services to Provider and to Acquisition Billing Services, LLC ("Claim Processor").  

Acknowledgment of patient financial liability 

I understand and agree that I am financially responsible to Provider for any charges not covered and not directly paid to Provider by my Payor or by my workers' compensation claim. By signing this form, I am accepting full financial responsibility for all fees and costs related to Surgical Assist Services performed during my surgery if my Payor denies payment of such fees and/or costs to Provider. I understand and acknowledge that Provider is an OUT‐OF‐NETWORK healthcare provider and is not contracted with my health insurer, Payor. I further acknowledge that I had a choice to select any healthcare provider to perform Surgical Assist Services and, after due consideration, I have voluntarily chosen to seek the care of an out‐of‐network provider. I understand that Provider may bill me for my ordinary out‐of‐network coinsurance and deductible amounts. I acknowledge that if specifically required by state law, Provider is obligated to also send me a balance bill statement setting forth any amount remaining after all payments made by Payor are deducted. I understand that Provider has instituted a Charity Care Financial Hardship Policy which affords me an opportunity to receive a discount or a waiver of balances if I qualify. 

Authorization to receive insurance benefits 

I hereby authorize Provider, directly and/or through an agent, to bill my current insurance carrier (including but not limited to private health insurance and employer‐sponsored health insurance) for reimbursement for the Surgical Assist Services provided to me. By this authorization, I direct that payments from my insurance carrier for any and all Surgical Assist Services provided to me by Provider be made directly to Provider, or to its agent that has billed for the services, as applicable. I hereby designate Provider as the person entitled to benefits pursuant to ERISA, 29 U.S.C. Â§ 1002(8), as applicable to my insurance. 

If any checks or other forms of payment are issued by my Payor and sent directly to me, I will promptly contact Provider at 1‐855‐598‐ 2800 and advise Provider that I have received such payment as reimbursement for serviced rendered. I will also immediately forward the payment to Provider. If I fail to timely do so, I will be held liable for the entire amount of the payment and any additional fees, including but not limited to legal fees, incurred by Provider. 

Transfer of Rights 

In addition to the foregoing, it is my intention to give Provider the right to bring on my behalf any and all legal and equitable claims (including claims for benefits and claims for breach of fiduciary duty) that I have against my Payor, which relate to my claim for insurance coverage for the Surgical Assist Services rendered by Provider. It is further my intention to, as an alternative basis for giving Provider the right to bring any and all such claims, to transfer, give, and assign my benefits under my insurance plan, and/or my right to sue under my insurance plan, to Provider. 

A. Limited Power of Attorney designation. To the extent any dispute arises between Provider and my health insurance carrier and/or any other third party payor with respect to reimbursement for the Surgical Assist Services provided to me, it is my intention that Provider and/or Acquisition Billing Services, LLC ("Claim Processor") possess any and all rights to which I would otherwise be entitled under my healthcare insurance policy. I therefore irrevocably appoint each of Provider and Claim Processor as my true and lawful‐ attorney‐in‐fact for the purpose of exercising the following powers on my behalf with respect to the Surgical Assist Services provided to me: 

Patient:  

DOS:  

DOB: 

Sex / Age:  

MRN: 

Hospital:  

Patient Number:  

Procedure:  

Surgeon: 

Surgical Assist: 

(Date)  (Company) 

(i) To do all acts necessary for the purpose of pursuing administrative or internal appeals or mediation. 

(ii) To do all acts necessary for the purpose of investigating, filing, pursuing, and resolving litigation and/or mediation and/or arbitration on my behalf (including but not limited to selecting and retaining legal counsel) in any and all legal and equitable claims that I could bring against my health insurance carrier, health benefit plan, and/or relevant fiduciaries. Such claims shall include, but not be limited to, any and all claims (including breach of fiduciary duty claims) that I could bring pursuant to ERISA, other federal or state statutes, or the common law ("Causes of Action"). If Provider and/or Claim Processor bring such an action, I agree to be bound by a final determination of such action rendered by a court or regulatory proceeding. 

(iii) To sign on my behalf settlement agreements, releases or other documents relating to the settlement of the Causes of Action. I hereby agree to be bound by any settlement, compromise, or release reached by Provider and/or Claim Processor. 

(iv) To claim on my behalf any applicable remedy or relief, including but not limited to benefits, reimbursements, damages, surcharges, fines or injunctive relief, to which I am entitled in connection with the Causes of Action. 

(v) I hereby confirm and ratify all actions taken by Provider and/or Claim Processor as my attorney‐in‐fact pursuant to the authority granted herein. 

B. Designation of authorized representative. To the extent the Limited Power of Attorney designation described in Section A above is deemed ineffective or limited for any reason, I hereby designate Provider and/or Claim Processor as my Authorized Representative, including as my Authorized Representative as provided under ERISA, 29 C.F.R. Â§ 2560.5031(b)(4) where applicable, for exercising the powers described in Section A or authorized under law, whichever is greater. I hereby designate Provider, directly and/or through its agent, Acquisition Billing Services, LLC, to act as my representative to appeal for any insurance benefits with respect to the Surgical Assist Services in the event of a coverage denial. I understand that Provider has the right to decline or accept this designation at the time a denial is received. I understand that, if Provider accepts the designation, the outcome of any appeal is not guaranteed. 

C. Assignment of insurance benefits and legal rights. To the extent that any powers and/or rights conveyed by Sections A and B above are deemed ineffective or limited for any reason or in any way, I specifically assign the right to any benefit to which I may be entitled under any policy of insurance to Provider, or its agent, Acquisition Billing Services, LLC, that will be processing a claim and/or appeal for the Surgical Assist Services, as applicable. This assignment encompasses (i) all of my right, title, and interest in such insurance benefits; and (ii) all legal and equitable rights that I may have in relation to such benefits, including but not limited to bringing suit based on any claims pursuant to ERISA, other federal or state statutes, or the common law to obtain such benefits; to enforce the fiduciary duties owed to me; or to obtain any other appropriate legal or equitable relief that is available. This assignment is made in exchange for good and valuable consideration, the receipt and sufficiency of which is hereby expressly acknowledged. 

Disclosure of Financial Interest of Referring Provider 

I understand that my attending physician may have a financial interest in Provider, the medical practice that he/she has referred me to for Surgical Assist Services. I understand that I, the patient, have the right to choose the providers of my healthcare services and/or products and, as such, I have the option of receiving healthcare services from any healthcare provider and/or facility that I choose. After due consideration, I chose Provider to furnish Surgical Assist Services for me. 

Right to Appeal 

I hereby authorize Provider and/or Acquisition Billing Services, LLC, directly and/or through an agent, to appeal on my behalf to my current insurance carrier (including but not limited to private health insurance and employer‐sponsored health insurance) any and all decisions and/or determinations with respect to reimbursement for the Surgical Assist Services provided to me by Provider. 

Release of Information 

I hereby authorize the release of all medical records or other information to Provider and/or Claim Processor necessary to determine the benefits available and amounts payable with respect to the Surgical Assist Services furnished to me by Provider. 

Certification 

By signing below, I agree and certify that I have read and understood the above and, therefore, request and consent to the procedures and financial responsibility described above, and provide the designations, authorizations, and assignment of rights as specified above. 

Patient Signature:  Date:  Witness Signature: