550 N Carroll Ave, Southlake, TX 76092

Interventional Pain & Regenerative Medicine

Specializing in minimally invasive interventions for the treatment of spine and musculoskeletal disorders

For Regenerative Spine & Joint Care, Visit Us At

Patient Forms

Online Patient Forms

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Office Policies

Referral – Most patients are referred by a physician, who is educated about the benefits of interventional pain medicine. Self-referred patients are accepted on occasions, based on the nature and complexity of the condition.

If your insurance plan requires a referral from your doctor, you will have to have secured that referral before you can be seen in our office. Unfortunately, if you do not have the referral, we will have to reschedule for you, unless you wish to personally pay for the appointment.

First Visit – A package will be mailed to you or downloaded from our web site (Online Patient Form). In the package there is a medical questionnaire. It is essential to complete the form entirely, which will help expedite your visit. There are other documents such as our financial policy, notice of privacy, insurance information and practice information that is important to read and sign. Plan on arriving 30 minutes (at least) prior to you schedule time. You will need this time to complete the forms, if you already have not done so. If you have any difficulty, please ask our staff to assist you.

Please be sure to bring your insurance cards and a picture ID. If your injury is being filed under worker’s compensation, you will need to have had your claim approved and to bring the information such as claim number, insurance company, adjuster, etc. If you have questions about this, please call our office.

Payment – We would like to thank you for the opportunity to participate in your medical care. The following information is provided for your consideration. It contains information concerning payment for our services.

We will collect your co-pay deductible, and any other payment for charges for which you are responsible at the time of service. We recommend that you call the member services 800 number on your insurance card before coming to your visit, if you have questions regarding your deductible, co-insurance, or coverage. We will also verify your eligibility and benefits so that we may properly collect at your visit. We accept cash, checks, debit cards, and Visa/MasterCard.

Any non-covered services that are rejected by your insurance plan will be billed directly to you and will be your responsibility.

When scheduled for a procedure, payment for your co-pay and deductible is expected in full prior to the procedure date.

Our practice firmly believes that a good physician/patient relationship is based upon understanding and good communication. Questions about financial arrangements should be directed to our billing office. Please sign that you have read and agree to this policy.

Insurance Filling – We will bill primary and secondary insurances, if you provide insurance information. However, you are ultimately financially responsible for the bill. Insurance companies may require you to fill in an accident report, which they will mail to your home. If you do not complete and return the form, they will not pay for your services. If this happens, you are then liable for the entire bill. We recommend that you talk directly with your insurance company regarding payment for your service.

Be sure to notify us of any changes in either your address, phone number, or insurance company. If you change insurance companies to another HMO, you must secure a new referral or your services will not be covered.

Cancellations – We Greatly appreciate your calling at least 48 hours before an appointment that you will be unable to keep. This will enable us to give the appointment to another patient. Cancellation of office visits without prior notification, will result in a $ 25 .00 cancellation fee per visit. This may also lead to termination of physician-patient relationship.