Pleasure Island Pain Management

Transcription

1 Patient Information Patient Name DOB Sex Last First M. Drivers License Social Security Number Home Phone Cell Phone Address Street City State Zipcode Employer Postion Referring Physician Address Employer Address Employer Phone Marital Status (Circle One) Married Single Divorced Separated Widowed Spouses Name Spouses Phone Emergency Contact Emergency Contact Relationship Home Phone Cell Phone Insurance Insured Party Name Relationship to Patient Insurance Company Phone Number Address Street City State Zipcode Policy Number Group Secondary Insurance Company Address Street City State Zipcode Policy Number Group I verify that the above information is factual and true to the best of my knowledge. I understand that payment, proof if insurance, and /or copay is due at time of service. I authorize this office to apply benefits on my behalf for the covered services rendered. I certify that the insurance information I have provided is factual and correct. Print name Signature Date

2 Patient Health and Medication History Patient Name DOB Age Sex Last First M. Are you currently or have you ever been treated for any of the following? Condition Yes No Condition Yes No Condition Yes No Anxiety/Depression History of Drug Abuse Sciatica Asthma GERD Scoliosis Osteoarthritis Gout Sickle Cell Disease Rheumatoid Arthritis Heart Disease Sleep Disorders Thoracic Back Pain Kidney Disease Spinal Stenosis Neck Pain Low Back Pain Stroke Bursitis/Hip Pain Degenerative Disc Spondylosis Bursitis/Elbow Neuropathy High Cholesterol Carpel Tunnel Syndrome Phantom Limb Syndrome Shoulder Pain COPD Plantar Fascitis Thyroid Disease Diabetes Psychological/Psychiatric Trigeminal neuralgia High Blood Pressure Rotator Cuff Injury Vertebral Fracture Fibromyalgia CRPS/RSD Sexual Abuse Social History (Circle One) Caffeine: Yes No Amount Tobacco: Yes No Amount Alcohol: Yes No Amount Recreational drugs or steroids? Marital Status: Married Single Divorced Widowed Separated Employment: Employed Unemployed Retired Disabled Allergies: YES / NO if yes, please list: Surgical History List all Past Surgeries Surgery Date Surgery Date Family History Please indicate any Family Medical History Condition Osteoarthritis Rheumatoid Arthritis Lupus Drug Abuse YES /NO Family Member (Mother, Father, Sibling, Grandparent) Medications (Please Use Space on Back of Page if Needed) Condition Alcohol Abuse Cancer Degenerative Disc Other, please explain YES /NO Family Member (Mother, Father, Sibling, Grandparent) Name of Medication Dosage Frequency Name of Medication Dosage Frequency Pharmacy Name Address/Location

3 Controlled Substance Patient/Physician Contract We here at are making a commitment to work with you in your efforts to get better. To help you in this work, we agree that: We will help you schedule regular appointments for medicine refills. If we have to cancel or change your appointment for any reason, we will make sure you have enough medication to last until your next appointment. We will make sure that this treatment is as safe as possible. We will check regularly to make sure you are not having bad side effects. We will keep track of your prescriptions and test for drug use regularly to help you feel like you are being monitored well. We will help connect you with other forms of treatment to help you with your condition. We will help set treatment goals and monitor your progress in achieving those goals. We will work with any other doctors or providers you are seeing so that they can treat you safely and effectively. We will work with your medical insurance providers to make sure you do not go without medicine because of paperwork or other things they may ask for. If you become addicted to these medications, we will help you get treatment and get off of the medications that are causing you problems safely, without getting sick. Controlled substance medications (i.e. narcotics, tranquilizers, and barbiturates) are very useful, but have a high potential for use and misuse. Therefore, these medications are closely controlled by local, state, and federal government. They are only intended to relieve pain in order to improve function, increase activity and ability to work. Because my provider is prescribing such medication to help manage my pain, I agree to the following conditions. I,, agree to the following conditions: A. I understand that: I may become dependent on such medications. If medications are stopped suddenly, I may experience withdrawal symptoms such as chills, shaking, stomach cramps, irritability, and pain. While using such medications, my ability to drive and/or operate machinery or equipment may be impaired. These medications may cause me to feel sleepy and delay my reaction time this placing others at risk if I ignore these warnings. I authorize the release of any information by to other physicians, medical facilities, my family, my insurance company, or other reimbursing agencies. It may become necessary for me to stop taking such medications entirely.

4 B. While under the treatment of I am required to adhere to the following rules and regulations: All prior and current prescribed medications by any other physicians must be disclosed upon initial visit and each office visit thereafter. Pain medications of any type will only be obtained from. I will not request or accept any controlled substance from any other physician or individual while I am receiving such medications from. Any controlled substance given in a special circumstance such as hospitalization must be reported to the office immediately. Medications are to be taken as prescribed. Doses cannot be increased without specific without specific instructions from your provider. Medications must last 30 days. If running out early, the remaining days will be endured without medication. Overuse and/or running out of medication early will be cause for dismissal. Repeat calls for early refills may result in dismissal. Refills or changes of all controlled substances will be made only during regular office hours, in person, during a scheduled office visit. Refills will not be made at night, on holidays, or weekends or as an emergency such as Friday afternoon if you realize you will run out the following day. If I encounter a problem or allergy with a medication I must bring in the remaining amount of the medication to the clinic before any other medications will be issued. Lost or stolen medications will not be addressed or replaced even with a police report. Prescriptions will not be rewritten if I lose or misplace my prescription. Prescriptions shall not be altered in any way. This is a felony offense, punishable by large fines, considerable jail time and will result in dismissal from the practice. Any such offense will be reported to law enforcement. Urine drug screening will be ordered by the provider at each appointment. If I refuse drug screening my controlled substance medications may be terminated immediately. Tampering with the urine drug screen, will result in immediate dismissal from the practice and immediate termination of controlled substance medications. Random pill counts may be ordered at any time by the provider for any reason. Failure to pass a random pill count may result in immediate termination of controlled substance medications and dismissal from the practice. Illegal substance abuse of any kind will not be tolerated by this clinic and will result in immediate termination of controlled substance medications. Obtaining narcotic medication from any individual is a violation of the law and of this contract. Violators will be dismissed from the practice and reported to law enforcement. Selling and controlled substance to any individual is a violations of the law and of this contract. Violators will be dismissed from the practice and reported to law enforcement. If you are on greater than 100mg per day of morphine equivalent you may be required to come in more often and monitored more closely for compliance. If I am discharged a weaning prescription, if warranted and indicated, will be given at a reduction of 25-50% per week. I can be discharged at any time if the provider is no longer comfortable prescribing my medications. I will maintain a working phone number with voice mail/answering machine and inform practice of any change in phone number. If I don t contact office with new or changed phone number, it may be considered grounds for dismissal from practice. I must have an annual physical with complete blood work up, including liver function test. New or worsening symptoms related to pain diagnosis must be reported to my primary care physician, surgeon, or referring doctor. C. I understand that prescriptions that can increase the risk of respiratory depression and/or overdose cannot be taken without the expressed written consent of my primary care physician with full knowledge of pain medication and dose currently taken. D. I understand that failure to comply with any of the above conditions will be considered a breach of contract, and at the sole discretion of my provider, may result in the immediate termination of controlled substance medications and/or termination from. All consulting and referring physicians will be notified of all treatment and any noncompliance or discharge issues in order to maintain continuity of care.

5 I, understand and voluntarily agree that (initial each statement after reviewing): Goals of treatment are: Improved physical function Improved quality of life Improved psychological function Restoration of participation in activities Meet above mentioned goals, safely Drug therapy may be changed or discontinued for violations of policies contained within this agreement; or when medications fail to provide analgesic benefit, improvement in function; and/or quality of life. I will keep (and be on time for) all my scheduled appointments with the doctor and other members of the treatment team. I will participate in all other types of treatment that I am asked to participate in. I will keep the medicine safe, secure and out of the reach of children. If the medicine is lost or stolen, I understand it will not be replaced until my next appointment, and may not be replaced at all. I will take my medication as instructed and not change the way I take it without first talking to the doctor or other member of the treatment team. I will not call between appointments, at night, or on the weekends looking for refills. I understand that prescriptions will be filled only during scheduled office visits with the treatment team. I will make sure I have an appointment for refills. I will treat the staff at the office respectfully at all times. I understand that if I am disrespectful to staff or disrupt the care of other patients my treatment will be stopped. I will not sell my medicine or share it with others. I understand that if I do, my treatment will be stopped. I will sign a release form to let the doctor speak to all other doctors or providers that I see. I will tell the doctor all other medicines that I take, and let him know right away if I have a prescription for a new medicine. I will not get any opioid pain medicines or other medicines that can be addictive such as benzodiazepines (Klonopin, Xanax, Valium) or stimulants (Ritalin, Amphetamine) without telling a member of the treatment team before I fill that prescription. I understand that the only exception to this is if I need pain medicine during an emergency at night or on the weekends. I will not drive if impaired by my medication I will not take any old medication that was previously prescribed. I will not use illegal drugs such as heroin, cocaine, marijuana, or amphetamines. I understand, if I do, my treatment may end. I will come in for drug testing and counting of my pills within 24 hours of being called. I understand that I must ensure the office has current contact information in order to reach me, and that any missed tests will be considered positive for drugs. I will keep up to date with any bills from the office and tell the doctor or member of the treatment team immediately if I lose my insurance or can't pay for treatment anymore. I understand that I may lose my right to treatment in this office if I break any part of this agreement. For emergencies, I will call 911. I am aware that any treatment needed after hours and on weekends must be provided by an urgent care, emergency room, or my primary care provider Patient Name Date Print Name Signature Physician Signature Date Kenneth C, Farmer, ANP-BC

6 PATIENT FINANCIAL RESPONSIBILITY FORM Thank you for choosing. We are committed to providing you with the highest quality healthcare. Please read and sign this form to acknowledge your understanding of our patient appointment cancellation/financial policies. CANCELLATION AND MISSED APPOINTMENT POLICY At, our goal is to provide quality individualized medical care in a timely manner. In order to do so, we have an appointment/cancellation policy. This policy enables us to better utilize available appointments for our patients in need of medical care. "No-shows" and late cancellations inconvenience those individuals who need access to medical care in a timely manner. As a courtesy, we agree to confirm your appointment by or phone call to your primary phone number one day before your scheduled appointment. You will at that time have the opportunity to cancel, confirm, or submit a request to have someone from the office contact you to reschedule. How to Cancel Your Appointment If it is necessary to cancel your scheduled appointment, we require that you call at least 24 hours in advance. Appointments are in high demand, and your early cancellation will give another person the possibility to have access to timely medical care. To cancel appointments, please call (910) Late cancellations will be considered as a "no-show. No Show Policy A "no-show" is a missed appointment without 24 hours notice. A failure to be present at the time of a scheduled appointment will be recorded in your medical record as a "no-show." If you are more than 15 minutes late without communication to the office it will be considered as a no-show First missed appointment no-show, or cancellation with a reasonable excuse: there will be no charge. Second missed appointment no-show a $25 fee will be billed to your account and must be paid prior to your next appointment. Third missed appointment no-show a $50 fee will be billed to your account and you may be discharged from our practice. PATIENT FINANCIAL RESPONSIBILITIES The patient is ultimately responsible for the payment for his or her own treatment and care. The patient is required to provide us with the most correct and updated information about his or her insurance, and will be responsible for any charges incurred if the information provided is not correct or updated. We will not accept insurance if patient s address or information is not updated at the time of visit. Patients are responsible for the payment of copays, coinsurance, deductibles, and all other procedures or treatment not covered by their insurance plan. Payment is due at the time of service. For your convenience, we accept cash, check, and most major credit cards at our office. Patient Authorizations By my signature below, I hereby authorize, Provider, and staff to release medical and other information acquired in the course of my examination and/or treatment to the necessary insurance companies, third party payors, and/or other physicians or healthcare entities required to participate in my care. I hereby acknowledge that I am aware and accept the financial responsibility for fees assessed to my account for failing to provide a 24-hour cancellation notice of any scheduled appointment at. I understand that this fee is not reimbursable by my insurance carrier. I further authorize assignment of financial benefits directly to Pleasure Island Pain Management and any associated healthcare entities for services rendered as allowable under standard third party contracts. Print name Sign Name Date

7 Medical Information Release Form (HIPAA Release Form) Name: Date of Birth: / / Release of Information I authorize the release of information including the diagnosis, records; examination rendered to me and claims information. This information may be released to: [ ] Spouse (Name) [ ] Child(ren) (Name) [ ] Other (Name) [ ] Information is not to be released to anyone This Release of Information will remain in effect until terminated by me in writing. For Voice Mail Messages Please call [ ] my home [ ] my work [ ] my cell If unable to reach me: [ ] You may leave a detailed message [ ] Please leave a message asking me to return your call Signed: Date: / / Witness: Date: / /

8 HIPAA PATIENT CONSENT AND ACKNOWLEDGEMENT FORM Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office. You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment, and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The patient understands that: Protected health information may be disclosed or used for treatment, payment, or health care operations. The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice. The Practice reserves the right to change the Notice of Privacy Practices. The patient has the right to restrict the uses of their information but the Practice does not have to agree to the restrictions. The patient may revoke this Consent in writing at any time and all future disclosures will then cease. The Practice may condition receipt of treatment upon the execution of this Consent. The patient acknowledges that he/she has received a copy of our HIPAA practices brochure. ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I acknowledge that I was provided a copy of the Notice of Privacy Practices for, PLLC. The Consent was signed by: Patient Name Date Print Name Signature Witness Name Date Print Name Signature If person signing is not the patient, please print your name and relationship to patient: Name Relationship For Office Use: Did patient or representative request a copy of the Notice of Privacy Practices? Yes No If patient/representative requested copy of Notice, date copy was provided: