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