e-sign or download and sign the PDF consent form
As part of your surgery, your doctor may use a manufacturer to supply your implant device(s), biologics, and/or supplies used in your surgical procedure. IPG handles the billing and reimbursement from your health insurance plan(s) for your medical device.
You will be billed separately by IPG for your deductible and/or co-insurance and may be responsible for paying the balance based on your benefits at the time of your procedure.
For IPG to process the medical device service request and to obtain reimbursement, IPG will need specific Personal Health Information (PHI) including, but not limited to: name, address, date of birth, phone number(s), insurance information and pertinent medical information to process the claim with your health insurance plan(s).
Your healthcare provider is permitted by federal laws to release this information for payment purposes. You can revoke this authorization at any time, according to your patient rights, listed in the document.