William F. Ganz, M.D., FACS

Phone: 208.664.5467
Fax: 208.765.4696

   
     
 
 

Patient Info

We are pleased that you have chosen Dr. Ganz and his staff at Neurosurgery and Spine Northwest for your neurosurgical care. We strive to provide the highest quality of medical care and to give each of our patients the individualized treatment needed to meet their unique neurosurgical needs. After your primary care physician has referred you to our office and you have been scheduled for an appointment, you will receive a packet by mail with the following forms to be completed and returned to our office.

All forms must be completed, signed and returned to our office one week prior to your scheduled appointment or the appointment may be cancelled.

 

New Patient In-take Forms

MRI Forms Information

Steps In The Spine Surgery Process

 

 

 
 

Review these items included in your patient packet before your first appointment:

New Patient Medical History Questionnaire - Cranial:

Please complete in as much detail as possible, sign, and return to our office one week prior to your appointment.
Download Here (pdf).

New Patient Medical History Questionnaire - Spine

Please complete in as much detail as possible, sign, and return to our office one week prior to your appointment.
Download Here (pdf).

Patient Demographics Form:

Please complete, sign and return to our office one week prior to your appointment.
Download Here (pdf).

Patient Financial Responsibilities:

Please complete, sign and return to our office one week prior to your appointment.
Download Here (pdf).

Notice of Privacy Practices Form:

All patients will be asked to sign our Acknowledgment of Receipts of Notice of Privacy Practices form after having the opportunity to review our Notice of Privacy Practices at our office. Our Notice of Privacy Practices may also be viewed here:
Notice of Privacy Practices (pdf).

Medicare Signature Form:

In addition, patients with Medicare coverage will be required to sign our Medicare Signature form.
Download Here (pdf).

 

Review these items included in your patient packet before your first appointment:

MRI:

MRI or other images and written reports if not available electronically. Imaging studies performed at Kootenai Medical Center, Northwest Specialty Hospital and other local providers are generally available via computer. Studies not performed locally need to be brought to your appointment on a CD.

Other Items:

- Any other pertinent written reports, i.e. physical therapy or pain management treatment reports.

- all insurance cards, including Medicare and Medicaid

- any authorization forms required by your individual insurance carrier

- worker’s compensation claim information

- payment for services not covered by insurance, including co-payment, coinsurance and
deductible, to be collected prior to your appointment.

Steps In The Spine Surgery Process

Download Here (pdf).

Preparing for Surgery

Download Here (pdf).

Care at Home After Surgery

Download Here (pdf).

Insurance and Payment:

Depending on whether you have insurance, and the extent of your coverage, you may be asked to make a payment at the time of your visit. We suggest that you contact your health insurance provider before your appointment to verify benefits and coverage, and to confirm that Dr. Ganz is a participating provider.

Your copayment, coinsurance and deductible are due at the time of your visit. If you require surgery, a payment request may be made prior to scheduling. For your convenience, Neurosurgery and Spine Northwest accepts cash, personal checks, Visa and MasterCard.
Please remember to bring your insurance card, Medicare or Medicaid card with you to your office visit. If you do not bring your card, we will ask that you pay at the time of your visit.

HEALTH PLAN OR MANAGED CARE PLAN: If you are enrolled in a health plan or managed care plan, your copayment will be collected before you see the doctor.

MEDICARE/MANAGED MEDICARE: If you are enrolled in traditional Medicare, a 20% coinsurance payment will be collected at the time of service. However, if you have coverage secondary to Medicare, no payment is required. If you are enrolled in Managed Medicare (a Medicare policy administered by a private insurer such as Blue Cross), your copayment will be collected at the time of service.

WORKER'S COMPENSATION AND SELF-INSURED EMPLOYER: If you are being seen for a work-related injury, your claim must be approved by the Bureau of Workers' Compensation or self-insured employer.

If approved, please provide the following information: date of injury, claim number, the name and billing address of the managed care organization that administers your benefits, and the name of your treating physician.

If your claim is not approved, Neurosurgery and Spine Northwest will submit a claim to your health insurance company. If you do not provide your workers' compensation claim number, and you do not have health insurance, we will ask that you make payment at the time of your visit.

OUT-OF-NETWORK INSURANCE: If Neurosurgery and Spine Northwest is not a participating provider on your insurance plan, we will bill your insurance company as an out of network provider.

 

Have A Question?

 

Neurosurgery and Spine Northwest
William F. Ganz, M.D., FACS
Ph: 208.664.5467
Fax: 208.765.4696
2236 North Merritt Creek Loop, Suite A
Coeur d’Alene, ID 83814

 
 
 
 

Neurosurgery and Spine Northwest
William F. Ganz, M.D., FACS
Ph: 208.664.5467 | Fax: 208.765.4696
2236 North Merritt Creek Loop, Suite A
Coeur d’Alene, ID 83814
Home | Meet the Staff | Patient Info | Procedures | Affiliates | Referrals | Contact

All Rights Reserved | Copyright © 2013
Designed and Developed by Knock - Marketing and Design