New England Neurological Associates, PC

New England
Neurological
Associates, PC."
Client Agreement Form
I authorize New England Neurological Associates, P.C. ( "NENA" ) to bill my health
insurance carrier on my behalf. All payments made to NENA will be directly credited to
my account. It is my responsibility to provide NENA with up to date insurance
information. If there is a problem with my insurance andlor my claim or we do not have
your current insurance information, the balance will become my responsibility.
NENA requires all information regarding Auto Accident claims, Workers Compensation
Claims or legal actions prior to any visit.
CO-PAYMENTS
Your insurance company requires that NENA collect your co-payment at the time of your
visit. If we have to bill you, a $10.00 administrative fee will be added. All past due
balances are due at the time of the visit.
Late Cancellations and No Show Charees: $25.00
are unable to keep an appointment, you must notify our office at least 24 hours
before the scheduled appointment time. Since your insurance company will not pay for
missed appointments or late cancellations, you will be billed a late cancellaticn/no show
charge of $25.00 by NENA
If you
Charges for Processing and Copving Medical Records
NENA incurs expenses for the processing and copying of medical records. The charge for
this service is $20.00 it must be prepaid and an appropriate signed release is also
required. The medical records clerk will call you when your records have been copied
and they may be picked up at the reception desk. NENA will not mail medical records.
Completion of Forms on Behalf of Patients
Unless specifically prohibited by the agency in question, patients requesting that a New
England Neurological physician fill out a form regarding insurance, disability, retum to
work, or other reason will be charged a fee of $10.00, to be paid at the time of the
request.
Print Name
Signature of Patient
Date
Nernr England
Neurological
Associates, PC.'
F,o*rm.u
tqrtoJls-A rrp
el o- Cs.rr E l- C lie n t q
que envie todo
Yo autorizo a New England Neurological Associates, P.c. ("NENA")
yo ellla paciente' Es mi
cargo a mi seguro de salud o Seguro genero, en parte de
mas reciente de mi seguro de
respon"sabilidad de proveer a NENA .or lu informacion
reclamacion, o si NENA no
salud o seguro g.n.ro. Si hay algun problema con mi seguro,
mi responsabilidad'
tiene mi informacion de seguro mas reciente, todo balance sera
NENA requiere que toda informacion consistiendo
a un accidente de automor
il'
por telefono antes de su
compensacion de trabajo, o referencias legales se an confirmadas
visita.
Co-Pagos
de su co-pago al tiempo de
Su compania de seguro requiere que NENA hagalacoleccion
tendra un costo adicional
su visita. Si le tenemos que enviar el cargo por el correo,
cuenta debe ser pagado, junto con el
administrativo de $10.0d. Todo balan""
co-Pago del dia de su visita'
., i,
a |a oficina 24 horas antes del
Si no puede asistir el dia de su visita, tiene que notificarlo
que los pacientes no atienden o
dia de su visita. El seguro no hace pagos porla(s) visita(s)
cancelanlPor eso, si no tenemos aviso, habra un cargo de $25.00'
proceso y copia de los.documentos
Todo documento medico requiere gn proceso. Con el
antes de resibir sus
se requiere un pago de $20.00. EI pugo debe se-r colectado
apropiado con su firma'
documentos. famUiei, se requiere q,r. t. ll".re un formulario
se puedan recojer'
Cuando sus documentos esten listos, recibiran una llamadaparuque
que requleran que un
Si no especificamente por la agencia en duda, los pacientes
rncapazidad' regreso de
doctor(a) de Ia oficina ae NENA iene un formulario de seguro,
que el formulario sea recivido a
trabajo, u otra rurorr, t uura un cargo <le $10.00 al tiempo
la oficina.
Nombre
Firma
Fecha