Meet Our Specialists
Our interventional spine and pain physician, Dr. Daryoush Payman, is a leading practitioner of state-of-the-art techniques specializing in the use of minimally-invasive techniques to treat spinal disorders.
Office Policies
Medical Consent
I consent to all care, treatment, diagnostic imaging, laboratory testing, and other medical procedures performed or prescribed by a physician of Spine Intervention Specialists, Inc. or his/her designees.
Right to Refuse Treatment
I understand that I have the right to make informed decisions regarding all aspects of my care. I may ask my healthcare provider to clarify or explain any information I do not understand. I also understand that I have the right to refuse treatment.
Acknowledgment of Receipt of Patient Rights & Privacy Practices
I acknowledge that I have received and reviewed both the Notice of Patient Rights and Responsibilities and the HIPAA Notice of Privacy Practices.
Release of Medical Information
I authorize Spine Intervention Specialists, Inc. to release any information necessary to facilitate healthcare claim processing or payment audits related to my care and treatment. I also consent to the release of medical information to other facilities, agencies, or healthcare providers at the discretion of Spine Intervention Specialists, Inc.
This authorization will remain in effect until I revoke it in writing.
Financial Policy
I certify that the insurance information I have provided is accurate, complete, and current, and that no additional coverage exists. I understand it is my responsibility to know the terms and benefits of my insurance plan.
I acknowledge that I am financially responsible for all charges not covered by my insurance, including copayments, coinsurance, and deductibles, which may be due at the time of service unless prior arrangements have been made.
If my insurance company has not paid my bill in full within 60 days, I agree to pay the remaining balance within 30 days. In cases of large balances (such as from surgical procedures), a payment plan may be arranged at the discretion of Spine Intervention Specialists, Inc.
Forms & Medical Records
- The first disability, FMLA, school/work, or personal form is completed free of charge.
- Each additional form incurs a $15.00 fee. Forms are processed within 10–14 business days.
Requests for medical records require a signed Medical Records Release Form. A fee of $1.00 per page for the first 25 pages, and $0.25 per page thereafter, will apply. Requests are completed within 10–14 business days.
Appointment Cancellations & No-Shows
Please provide at least 24 hours’ notice if you need to cancel or reschedule your appointment.
Failure to cancel in advance or a missed appointment (“no-show”) will result in a $25.00 fee, payable by the patient. This fee is not billable to insurance.
Procedure/Surgery Cancellations
If you must cancel a scheduled procedure or injection, please notify our office by 12:00 PM at least three (3) business days (Monday–Friday) prior to the scheduled date to avoid a $150.00 cancellation fee.
Controlled Substance Policy
In compliance with the State of Florida Controlled Substances Bill (CS/CS/HB 21), regulations govern the prescribing of Schedule II and Schedule III medications.
Patients must adhere to the Controlled Substance Agreement. Any violation of this agreement may result in termination of the physician–patient relationship and cancellation of future treatment.
Return of Imaging CDs/Films
Our providers review your imaging studies to ensure accurate diagnosis and treatment. While a copy of your images is uploaded to our system during your visit, we cannot store the original CDs or films long-term.
Images will be returned to you at the end of your appointment. If left behind, we will store them for up to 90 days as a courtesy.
- You may pick them up in-office at no charge within this period, or
- Request shipment for a $10.00 service and handling fee.
After 90 days, any unclaimed CDs or films will be disposed of in accordance with HIPAA guidelines.
