Medical Consent. The undersigned consents to services that do not require informed written consent.

Release of Information. The undersigned acknowledges receiving North County Neurosurgery Notice of Privacy Practices; copies available upon request.

Financial Agreement. The undersigned agrees to pay all monies due at NCN’s regular rates and terms. Co-payments, co-insurance, non-covered services, and deductibles are due at time of visit; amounts not collected are the patient’s responsibility.

Eligibility Guarantee. Patient must be eligible with their plan at time of visit. Lack of benefits may result in patient responsibility. If coverage is not provided within 30 days, patient assumes full financial responsibility; retroactive termination also results in responsibility.

Accounts/Collections. Accounts are due upon receipt. Patient/person responsible agrees to pay interest, court costs, and attorney fees if collection/legal action is necessary.

Missed Appointments. 24-hour advance notice is required; otherwise, a missed appointment fee may be charged.

Credit Verification. NCN is authorized to verify references and financial information, including credit reports.

Common Interest Disclosure. Your physician may have a financial interest in facilities/services/devices utilized; you may choose alternatives.

Non-Responsibility. NCN and its physicians are not responsible for errors/omissions of other providers’ employees/contractors who render services during your care at NCN.

Medicare Assignment. Patient requests payment of authorized Medicare benefits to NCN and authorizes release of information as necessary to process claims. Physician accepts Medicare determination as full charge; patient responsible for deductible, co-insurance, and non-covered services.

Duration: This authorization is valid for one year from the signature date unless otherwise noted.

Additional Copy: You have the right to receive a copy of this authorization on request.

Re-disclosure: Information disclosed pursuant to this authorization may or may not be subject to re-disclosure by the recipient and may no longer be protected by the Privacy Rule.

Revocation: You may revoke this authorization in writing any time before disclosure. Revocation is effective upon receipt, except when disclosure is required or permitted by law.

Explanation: Your treatment is not conditioned on signing this authorization; you may refuse to sign.

Patient Billing: I understand I will be charged $15 plus $0.25/page for personal requests.

I hereby acknowledge that I have received a copy of this medical practice’s Notice of Privacy Practices. A copy of the current notice is posted in the reception area and I will be offered a copy of any amended Notice of Privacy Practices at each appointment.

Practice Address: North County Neurosurgery, 6125 Paseo Del Norte, Suite 140, Carlsbad, California 92011.

“I fully understand the explanations regarding the benefits and risks of this method of treatment. I agree to the use of narcotic medication in the treatment of my pain… I agree to the terms of this contract.”

1. By signing, I understand narcotic medications (incl. side effects) and agree to treatment under the terms set by NCN.
2. I will take medications only as prescribed; I will not exceed the dose; no early refills for running out early.
3. I am fully responsible for safekeeping my medication; lost or stolen medication will not be replaced.
4. I will never share my medications with others.
5. I will not use illicit drugs or abuse alcohol.
6. No narcotic prescriptions will be refilled after hours or on weekends.
7. I will not drive or operate/use dangerous equipment while taking pain medications; if narcotics are in my system while driving, I may be subject to DUI charges.
8. I am aware that narcotic medications are addicting.
9. I am aware that suddenly stopping these medications may be dangerous.
10. I will inform NCN of any new medications written by another provider.
11. Medication is typically prescribed after surgery or extenuating circumstances; if I have a pain management doctor I must return to them for chronic management.
12. Typical protocol: prescribe only when surgery is imminent and only as medically necessary; post-op prescriptions are typically limited to 6 weeks while I am weaned; duration may be extended at NCN’s discretion and may involve a pain management physician.