At Brain and Spine Institute for Children (BASIC), we are committed to providing you with quality care, and we are pleased to discuss our professional fees with you at any time. Your clear understanding of our financial policy is important to our professional relationship. Please ask if you have any questions about this financial policy.
To assist us in establishing your BASIC financial account, please:
- Supply all necessary information for the accurate billing of your claim, including your insurance card, employer information and demographic information.
- Satisfy all insurance co-payments, deductibles and non-covered services on the day services are rendered.
- Provide your insurance company and BASIC with any additional information requested to complete the processing of claims filed on your behalf.
- Authorize release of information necessary for insurance filing and pre-certification (sign on this sheet below).
Minor needs to have an authorization for medical treatment signed by his/her parent/guardian and is responsible for providing current insurance information for self. Please provide co-payments and/or deductibles at the time of service.
BASIC cannot get involved in disputes between divorced parents regarding financial responsibility for their child’s medical expenses. By signing as guarantor below, you agree to be financially responsible for the care we provide to your child, regardless of whether a divorce decree or other arrangement places that obligation on your former spouse.
Indemnity/Fee for Service: We request full payment at the time of service. We will supply you with a copy of your itemized statement so that you can file for reimbursement from your insurance company. Should your insurance company require a more detailed description of services, please have them request it in writing. Please keep in mind that insurance is a contract between you and your company. We cannot become involved in disputes between you and your insurance company regarding deductibles, non-covered charges, co-insurance, secondary insurance, coordination of benefits, pre-existing conditions, or “reasonable and customary” charges other than to supply the factual information as necessary. You are responsible for timely payment of your account.