I authorize Orthopedic Spine Center to release any medical or other information necessary to process claims and coordinate payment with my insurance plan(s), employer, attorney, or any third-party payer. I further authorize direct payment of medical benefits to Orthopedic Spine Center for services provided. This authorization applies to all current and future claims unless revoked by me in writing.

I understand that I am financially responsible for all charges not covered by my insurance, including co-pays, deductibles, coinsurance, and any non-covered or denied services. I acknowledge that it is my responsibility to obtain any required referrals or prior authorizations as outlined by my insurance plan, and I agree to pay for services rendered in accordance with Orthopedic Spine Center’s financial policies.

If I am being seen for a work-related injury, I authorize Orthopedic Spine Center to submit claims directly to my employer and/or workers’ compensation insurance carrier. I agree to provide all necessary claim information, including my employer’s name, date of injury, claim number, and adjuster contact. I understand that I may be held financially responsible for any services not covered or denied by workers’ compensation.

If I am receiving care related to a motor vehicle accident, personal injury claim, or other legal matter, I understand that Orthopedic Spine Center does not accept liens or letters of protection unless explicitly agreed to in writing in advance. I may be required to pay out of pocket or use my personal health insurance for treatment. I acknowledge that I am ultimately responsible for all charges not paid by a third party, attorney, or legal settlement. If services are provided as part of an Independent Medical Evaluation (IME), I understand that payment must be arranged by the requesting third party in advance, and I will not be financially responsible for those fees.

If I do not have active insurance or choose to self-pay, I agree to the financial terms outlined prior to treatment. I understand that payment in full is due at the time of service unless a written payment arrangement has been approved in advance.

This agreement remains in effect for all current and future visits to Orthopedic Spine Center unless revoked by me in writing. I certify that I have read, understand, and agree to the terms outlined above.

Orthopedic Spine Center provides this Financial & Scheduling Agreement to help you understand your financial responsibility, our appointment expectations, and the terms related to scheduling surgery. Our goal is to create a transparent, supportive process so you always know what to expect. Please review this information carefully.

FINANCIAL RESPONSIBILITY

I agree to be financially responsible for all charges incurred for services rendered by Orthopedic Spine Center to or on behalf of the patient, regardless of insurance coverage or reimbursement. Orthopedic Spine Center will bill my insurance company as a courtesy; however, it is ultimately my responsibility to verify coverage, obtain any required referrals or prior authorizations, and comply with the terms of my insurance plan. This includes deductibles, copays, coinsurance, and charges for non-covered services.

I understand that:

• Insurance benefit quotes are not a guarantee of payment.
• Prior authorization—when obtained—does not ensure approval or coverage from my insurance carrier.
• My insurance company may adjust, reduce, or deny payment after the procedure, and any resulting balance is my responsibility.

Orthopedic Spine Center will make reasonable efforts to verify insurance coverage and eligibility, but I understand that:

• I must provide accurate and up-to-date insurance and demographic information.
• Failure to do so may result in delays or denials for which I am financially responsible.

After my insurance processes a claim, any remaining balance will be billed directly to me and is due upon receipt.

If a payment made by check or electronic method is returned or deemed invalid for any reason:

• A returned-payment fee will be applied to my account.
• Any discounts associated with time-of-service payment may be void.

If my account becomes delinquent and is referred to a collection agency or attorney, I agree to be responsible for all costs incurred in the collection process, including collection agency fees, court costs, interest, and reasonable attorney’s fees, whether or not a formal lawsuit is filed.

I authorize Orthopedic Spine Center and its representatives to contact me via telephone, voicemail, text message, or email regarding scheduling, billing, insurance updates, or collections activity. Standard messaging rates may apply. This agreement remains in effect for all current and future services unless revoked in writing.

MISSED OR LATE-CANCELLED APPOINTMENTS

Your appointment time is reserved specifically for you. If you do not arrive for your appointment, or if you cancel or reschedule with less than 24 business hours’ notice:

• A $50 missed-appointment fee may be charged to your account.

• This administrative fee is not covered by insurance.

SURGERY SCHEDULING DEPOSIT

When surgery is scheduled, our team will contact your insurance company to determine your estimated out-of-pocket responsibility, which may include deductibles, coinsurance, and copays.

To reserve your surgery date, a pre-surgical deposit equal to 50% of your estimated out-of-pocket cost is required.

Coordinating surgery requires significant time and resources from our team, including:

• Obtaining insurance authorization
• Coordinating medical clearances
• Securing operating room time and staffing
• Preparing your individualized surgical and post-operative plan

This deposit is a pre-payment, not an additional fee, and will be applied to your final balance after your insurance claim has been processed. If the deposit exceeds the amount you owe, any overpayment will be refunded promptly.

Orthopedic Spine Center may postpone non-emergent appointments or procedures if outstanding balances are not resolved prior to the scheduled date.

SURGERY CANCELLATION & REFUND POLICY

Because our team invests significant time, coordination, and preparation to secure your operating room time, arrange surgical staff, obtain your authorizations, and prepare your individualized surgical and post-operative plan, we ask that you honor the commitment we make on your behalf:

• Cancellations less than 7 days prior to surgery or failure to arrive may result in forfeiture of the deposit.

Exceptions will only be considered for:

• Verified hospitalization, or
• Surgeon-directed medical cancellation

All other circumstances are subject to Orthopedic Spine Center’s sole discretion.

RELEASE OF INFORMATION

I authorize Orthopedic Spine Center to release medical or billing information required by my insurance carrier for the purpose of:

• Claims processing
• Prior authorization
• Coordination of benefits
• Appeals

ACKNOWLEDGMENT

By signing the Financial & Scheduling Agreement in Phreesia, I acknowledge that I have reviewed this policy and accept responsibility for all financial obligations described above.

This Notice explains how your medical information may be used and disclosed, and how you can access it. We are required by law to protect your health information and to give you this Notice.

• Your Rights — You have the right to:
  • Access your medical record. You may request to view or get a paper or electronic copy. Reasonable fees may apply for copies.
  • Request corrections. If you believe your medical record is incorrect or incomplete, you may ask us to correct it.
  • Request confidential communications. You can ask us to contact you in specific ways (e.g., only at home or by mail).
  • Ask us to limit what we use or share. We will consider reasonable requests but are not required to agree.
  • Get a list of disclosures. You may request a list of disclosures made for purposes other than treatment, payment, or operations.
  • Get a copy of this Notice at any time.
  • Choose someone to act on your behalf. A legal guardian or medical power of attorney may make decisions about your health information.
  • File a complaint. You can file a complaint with us or with the U.S. Department of Health and Human Services if you believe your rights have been violated.
• Your Choice — You may tell us your preferences regarding:
  • Sharing information with family, friends, or others involved in your care
  • Disaster relief communications
  • Receiving appointment reminders or health-related benefits
  • We will never sell or share your information for marketing purposes without your written authorization
• How We Typically Use or Share Your Information — We may use your information to:
  • Treat you. We may share information with other healthcare professionals who are involved in your care.
  • Bill for services. We use your health information to submit claims and collect payment.
  • Run our practice. We use information for practice management, staff training, and quality improvement.
  • Other Permitted Uses and Disclosures
    We may share your health information without your authorization in the following circumstances:
  • Public health and safety reporting (e.g., to report disease, injury, or medication reactions)
  • Abuse, neglect, or domestic violence reporting
  • Legal and administrative proceedings (e.g., court orders, subpoenas)
  • Medical examiner or funeral director needs
  • Organ and tissue donation processes
  • Workers’ compensation claims
  • Law enforcement and government agency requirements
  • To prevent a serious threat to health or safety
  • Research, under strict privacy protections
  • Health oversight activities (e.g., audits or inspections)
• Uses and Disclosures That Require Your Authorization
  • We will ask for your written permission before using or disclosing your information for:
    • Marketing communications
    • Sale of your health information
    • Most disclosures of psychotherapy notes
    • You may revoke your authorization in writing at any time.
  • Our Responsibilities
    • We are required by law to maintain the privacy and security of your protected health information.
    • We will notify you promptly if a breach occurs that may compromise the privacy or security of your Information.
    • We will not use or disclose your information without your written permission, except as described in this Notice.
    • We will provide you with a copy of this Notice upon request and will follow the terms of this Notice.
• Changes to This Notice – We may change the terms of this Notice at any time. Changes will apply to all information we maintain. The latest version will always be available at our office and on our website.
• Questions or Complaints – If you have questions or would like to exercise your rights under this Notice, please contact:
  • Privacy Officer, Orthopedic Spine Center, 10296 Big Bend Road, Suite 205, St. Louis, MO 63122, Phone: (314) 788-9907
  • You may also file a complaint with the U.S. Department of Health and Human Services at www.hhs.gov/ocr/privacy/hipaa/complaints. You will not be penalized for filing a complaint.

This agreement outlines our practice’s policy on the use of opioid medications in spine care. It is intended to protect your health and safety while supporting your recovery and function. It also protects our providers from unsafe, unethical, or noncompliant prescribing.

1. Practice Philosophy on Pain Management

• • We prioritize diagnosis-based, surgical care to resolve structural spine issues and improve function.
  • We believe in multi-modal pain management focused on long-term health and recovery.
  • Dr. Crane does not prescribe opioid medications for chronic pain management.
  • If opioids are prescribed after surgery, it will be for a short duration and only when medically necessary.

2. When Opioids May Be Prescribed

• • A limited supply may be provided immediately after surgery to assist with acute post-operative pain.
  • If prescribed, opioids will be:
    • For a short-term duration (typically no more than 3–7 days).
    • Non-renewable unless specifically discussed and medically indicated.
    • Carefully monitored and documented in your chart

3. What We Will Not Do

• • We do not provide opioids for chronic back or neck pain.
  • We do not manage long-term opioid therapy.
  • We do not refill medications from outside providers or emergency rooms.
  • We do not prescribe lost or stolen medications.
  • We do not prescribe opioids to patients who are already receiving them from another provider.

4. Your Responsibilities as a Patient — By signing this form, you understand and agree that:

• • You will not request opioids unless directed by Dr. Crane.
  • You will inform us of all medications, including supplements and substances that may interact with pain medications.
  • You accept that alternative pain management strategies such as NSAIDs, physical therapy, mindfulness, and injections may be used instead of opioids.
  • If you require ongoing medication management, we may refer you to a pain management specialist.

5. Understanding the Risks of Opioid Use — Even short-term opioid use carries significant risks: (We believe in educating you about these risks so that you can make safe and informed decisions about your care.)

• • Addiction, tolerance, and dependence
  • Overdose, respiratory depression, and death
  • Constipation, drowsiness, mood changes, and reduced hormone levels
  • Interaction with alcohol, benzodiazepines, or sleep aids can be fatal

6. Safe Storage and Disposal — If you are prescribed opioid medications:

• • You agree to store medications in a secure location out of reach of others.
  • You will not share or distribute your prescription to anyone.
  • Any unused medications should be disposed of via an FDA-approved medicine take-back program, or if unavailable, by mixing with cat litter or coffee grounds and discarding in household trash.
  • For further guidance, visit the FDA website or call 1-888-FDA-INFO.

7. No Early Refills or Replacement Prescriptions

• • You understand that lost, stolen, or misplaced prescriptions will not be replaced.
  • Early refills will not be provided under any circumstances.

8. Agreement — By signing below, you confirm that:

• • You understand Dr. Crane’s opioid prescribing policy.
  • You agree not to request opioid medication outside of approved post-operative use.
  • You understand that failure to follow this agreement may result in dismissal from the practice.

Dr. Benjamin Crane, MD