Patient Authorizations

(Please read carefully. You are authorizing these actions.)

I hereby authorize the Neurology Center of Fairfax, Ltd. (NCF) to apply for benefits on my behalf for covered services rendered by NCF, to myself or to my dependent. Authorization is effective as of today. I request payment from my insurance carrier and/or Medicare Part B to be made directly to NCF.

I certify that the information I have reported with regard to my insurance coverage is correct and further authorize the release of any necessary information, including protected health information (PHI) for this or any other related claim, to my insurance carrier or in the case of Medicare Part B benefits to the Social Security Administration and Centers for Medicare and Medicaid Services (CMS). I permit a copy of this authorization to be used in place of an original. It is possible that services provided to me by NCF may not be covered by Medicare or by my insurance. I agree to assume responsibility for full payment of all services if Medicare or other insurance payment is denied. I further agree to be responsible for the outstanding balance on this account and to pay all reasonable costs of collection including attorney’s fees at 40% of the outstanding balance and monthly interest at 1.5%, should this account become overdue.

I understand that payment for all services is due and payable in full at the time of service, and that full payment for services may be required at the time of service. This includes, but is not limited to, my co-payment, co-insurance and deductibles. I agree to provide NCF with my current insurance card, government issued identification, and a valid referral (if required) at the time services are rendered. I understand that it is my responsibility to obtain required referrals.

I understand that although my insurance may pay part or all of the charges I incur, I am still ultimately liable and responsible for all charges. I understand that it is my responsibility to know the correct amount of my co-payment and deductible. I understand that my co-payments, co-insurance, and any deductibles are due at the time of service. I understand there is a $10 administrative fee if I do not pay my co-payment, co-insurance, and deductible at the time of service, and a separate $10 administrative fee each time a bill is generated for payment due, but not paid at the time of service. I understand I will be charged a “no-show” fee for any missed appointment, or any appointment not cancelled more than 48 hours in advance.

I authorize NCF to release my medical records (protected health information) to my treating physicians and other healthcare providers and to discuss my care with those providers, as my physician deems necessary. I authorize NCF to contact the people whom I list as emergency contacts in the event of an emergency. I authorize NCF to obtain contact information from my other health care providers, my emergency contacts, my employer or my health insurance carrier, if NCF is unable to contact me directly for any reason. I authorize my treating NCF physician to provide information to my caregiver or a family member, if my physician judges this disclosure to be important for my well-being. I authorize NCF to access my prescriptions in the Pharmacy Benefit Manager history. I authorize NCF to leave messages for me on answering devices attached to my telephones or to contact me by email or text message. I authorize NCF to contact me by email to inform me that information is available for me on the NCF secure patient portal. These authorizations may be revoked by me at any time in writing. I agree that a facsimile or a scanned copy of this agreement may be treated as an original for all purposes. I take these actions in Fairfax County, Virginia.

I acknowledge I have received a copy of the Neurology Center of Fairfax, Ltd.’s Notice of Privacy Practices dated February 28, 2023. I have read, I understand, and I agree to the terms and conditions specified in the Notice of Privacy Practices.

For Patients Who Do Not Have Their Insurance Card, and/or Referral, If Required, (includes Work Comp)

I acknowledge that I did not bring a referral as required by my insurance company and/or do not have my insurance card. I am electing to be seen today and agree to pay in full today for the services rendered today since I do not have a valid referral and/or insurance card, or worker’s comp authorization.