Name of Practice
Address of Practice
Pre-Service Benefit Notice
Neurologic Relief Centers Technique (NRCT) is for patients suffering from Fibromyalgia and may, in the future, be used for other illnesses that respond favorably to the testing protocol. NRCT is a unique adjusting procedure that may require three treatments per day which include spinal manipulations, adjustments, soft tissue work and/or massage. This procedure is new and its overall effectiveness is still being tested, but patients who respond favorably to the testing protocol are expected to have positive results from NRCT.
You, the Patient, acknowledge that the provider of these services has explained to you the overall plan of care and the treatment and services that will be provided to you. You understand that the provider makes no promises or warranties with regards to your overall response to the treatment and that all patients are different and can expect different results. You further agree that if you do not complete the plan of care, then it is less likely that you will have favorable results. You further understand that favorable results are not guaranteed.
1. For Patients with No Insurance: You understand that you are at all times financially responsible for the entire bill or balance of the bill as determined by us and explained to you prior to commencement of treatment. The estimated cost of the entire service is: ______.
By signing below, you acknowledge that you have received and understand this notice and you accept the terms as indicated herein. A copy of the signed notice will be maintained with patient’s medical records.
______Date:
patient
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2. For Insurance Patients Only: Since your insurance benefits may not cover any or all of the treatment or care to be provided to you, even some care that you or your health care provider has good reason to think you need, we expect that your insurance company may not pay for some or all of the procedures in the technique, deeming said procedures “experimental and investigational”.
The following procedures may be deemed experimental and/or investigational:
· All treatment that is provided beyond the first treatment on any given day
· Any treatment beyond three treatments per week
· Other procedures (these should be specifically listed):
You understand that you are at all times financially responsible for the entire bill or balance of the bill as determined by us and/or your health care insurer. If claims are submitted to your insurance payer and any part of them are denied for payment you are responsible for payment. You are also responsible for payment of any applicable co-pays, co-insurance or deductibles. If you are covered under insurance, we will submit all potential experimental/investigational claims as identified above using CPT Code 97799, an unlisted physical medicine procedure code, in anticipation of denial of payment from your insurance carrier as explained above. Since the Carrier’s treatment of said claims is unknown, this office will submit paper claims along with a copy of your medical records and other relevant documentation. The insurance company will determine whether said procedures are a covered benefit to you and reimbursable. Therefore, you are asked to pay now, but the services will be billed to your insurance company for an official decision on payment. If your insurance company does not pay, you are responsible for payment, but you can appeal the insurance company’s decision. If the insurance company does pay, we will refund to you any payments made by them that have already been paid.
Assignment of Benefits. You authorize direct remittance of payment of all insurance benefits to us for all covered medical services and supplies provided to you during all courses of treatment and care provided by us. You understand and agree this Assignment of Benefits will have continuing effect for so long as you are being treated or cared for by us and will constitute a continuing authorization, maintained on file by us, which will authorize and allow for direct payment to us of all applicable and eligible insurance benefits for all subsequent and continuing treatment, services, supplies and/or care provided to you by us.
Authorization to Release Information/Statement of Confidentiality. You authorize the release of any medical or any other information to the any insurance carrier or other entity necessary to determine insurance benefits or the benefits payable for related medical services and/or supplies provided to me by us. A copy of this authorization will be sent to your insurance carrier or other medical entity, if requested or if necessary for determining payment as described above.
By signing below, you acknowledge that you have received and understand this notice and you accept the terms as indicated herein. A copy of the signed notice will be maintained with patient’s medical records.
______Date:______
Patient