(Revised 05-09-10)
· Retainer fee is due at the time services are requested.
· Payment for completion of Disability Forms, Questionnaires, Letters, and Narrative Reports is due at the time services are requested.
· No requests will be processed until payment has been received. This may be paid in cash or credit card.
· Credit card payment is only accepted for transactions above $100.00. Any services below this amount, must be paid in cash.
· Credit card payments can be done by phone by calling "EJ and Associates, LLC" at (803) 356-2888. Specify that payment is for services provided by Francisco A. Naveira, MD.
· We no longer accept personal checks.
· Cashier's checks are acceptable.
· Neither NC Pain Management Services, PA nor Francisco A. Naveira, MD are owners or custodians of the medical records of patients seen at the Alamance Regional Medical Center Facilities. Please do not address any requests for medical records to either one, as this will only cause delays in processing.
· All requests for medical records or copies should be addressed to:
Alamance Regional Medical Center
Medical Records Department
1240 Huffman Mill Road,
Burlington NC 27215
Tel.: (336) 538-7437
· Insurance Forms or Questionnaires - $30.00 per page.
· Disability Forms or Questionnaires - $30.00 per page.
· Legal Forms or Questionnaires - $50.00 per page.
· Payment for completion of Disability Forms, Questionnaires, Letters, and Narrative Reports is due at the time services are requested. Payment in full must be stapled to the paperwork to be completed. Please see "Payment" section for details.
· Letters and Narrative reports - $100.00 per page
· Payment for completion of Disability Forms, Questionnaires, Letters, and Narrative Reports is due at the time services are requested. Payment in full must be stapled to the paperwork to be completed. Please see "Payment" section for details.
· $600.00 per hour, billed in ten (10) minute increments, or fractions thereof.
· Any time related to the case which is beyond the scope of an initial telephone interview of the consultant may be considered billable time.
· Non-Refundable Retainer fee: $1,200.00
· Base fee (Non-Refundable Retainer fee), is the minimum payment required in advance, before services are rendered, for all work for un-established accounts. Retainer will be credited against the final bill. Retainer fee is non-refundable and required prior to any work being initiated.
· For depositions, the $1,200.00 non-refundable retainer fee is due five (5) working days prior to the deposition. This will be credited towards the total bill.
· Billing is made for preparation time, travel time, expenses incurred, time being deposed, waiting time, and time expended to read and correct transcript if required.
· Cancellation of a scheduled deposition, with less than 48 hours written notice, shall result in a minimum billing of two hours.
· Cancellation must be in writing. May be faxed to (336) 538-7739.
· Estimates of time anticipated to be spent will gladly be provided upon request.
· Upon presentation of reports, any balance due must be paid. Past due invoices shall be charged interest at the rate of 1.5% per month (annual rate of 18%). Prepayment is required for deposition and court testimony. All invoices are due when rendered.
· Conference room facilities may be available at no cost close to our facilities, upon request.
· $5,000.00 per half day, plus expenses.
· $7,500.00 per full day, plus expenses.
· Expenses may include, but are not limited to:
o Preparation time prior to the scheduled court appearance. (Fee is calculated based on "Preparation and/or Deposition" section.)
o travel (which may include charter airplane and pilot expense, mileage, etc.)
o accommodations
o meals
o parking
o any other fees, charges, and/or costs arising out of the physician's court appearance.
· Non-Refundable Retainer fee: $2,500.00, plus expenses.
· Base fee (Retainer fee), is the minimum payment required before services are rendered.
· Base fee (Retainer fee) is due before services are rendered.
· Retainer fee is non-refundable and required before confirming the scheduling of court appearance.
· Fees shall be billed to the attorney requesting the physician's appearance at court.
· Additional court time and expenses will be billed promptly after the court appearance.
· Court appearances require that the physician cancel the regular clinical schedule. This represent a significant loss of income to the practice. Late cancellations may not allow for appropriate recovery of lost schedule, or non-refundable travel expenses.
· The physician requires pre-payment for court appearances, based on the half day or full day daily rates as quoted above, minus the "Retainer Fee".
· The physician, at his sole discretion and with prior arrangements with the attorney, may utilize a fee schedule differing from the schedule quoted above.
· If a court appearance is cancelled due to the case settling prior to the physician's scheduled court appearance, return of the pre-paid fee will be made as follows:
o Two (2) weeks prior to the appearance, 100% of the pre-payment is returned, minus the "Retainer Fee".
o One (1) week prior to the appearance, 50% of the pre-payment is returned, minus the "Retainer Fee".
o There will not be a refund for cancellations less than one (1) week prior to the court appearance.
o Retainer fee: $2,500.00, plus expenses.
o Retainer fee is non-refundable and required before confirming the scheduling of court appearance.
o Cancellation must be in writing. May be faxed to (336) 538-7739.
· Telephone calls from legal representatives (Attorney Conference):
o $600.00 per hour (include preparation time).
o Retainer fee: $300.00 minimum fee.
· Base fee (Retainer fee) is due before services are rendered.
· One (1) hour limit.
· Retainer fee is non-refundable.
· Due to security concerns, this service is not provided by "NC Pain Management Services PA" or Francisco A. Naveira, MD.
· $600.00 per hour
· Retainer fee: $600.00
· Base fee (Retainer) is due before service is rendered.
· Retainer fee is non-refundable.
· Written reports and/or opinions are provided only when requested in writing.
o The report is sent to the attorney upon receipt of any balance due.
o For proper review, all available medical records, x-rays, patient/family statements, and depositions are required.
o No full text articles will be included with Medline Search. Full text articles may be obtained from other sources at an additional cost.
For those parties interested in hiring our medico-legal consulting services, please contact Francisco A. Naveira, MD, at the address below.
Sign and FAX or Mail the "Fee Agreement".
NC Pain Management Services, PA
Attention: Francisco A. Naveira, MD
1236 Huffman Mill Road, Suite 2100
Burlington, NC 27215