Cain E. Dimon, M.D. Craig S. McCardell, M.D. Helen Puffenberger, PA C Pain Management Specialists of Southfield Michigan A Division of: South Oakland Anesthesia Associates Providing Services at Michigan Orthopaedic Institute 26025 Lahser Rd. 3 rd Floor Southfield, MI 48033 248 663 1923 248 663 2184 Michael H. Sikorsky, D.O. Angela L. West, PA C Thank you for choosing us for your Pain Management Services. Attached is your new patient paperwork. **Please complete and bring with you the day of your appointment or arrive early to complete in the office.** If you have any questions regarding your paperwork, please arrive early as to not put your appointment behind. Delaying the start time of your appointment may cause a need to reschedule. If you have an MRI or CT scan related to your appointment please have them with you the day of your appointment. If you are having a cervical injection you must have your MRI disc or you may only be seen as a consultation. Please make sure that you have stopped taking any antibiotics or blood thinners prior to your appointment. (Plavix, Coumadin, or Aspirin over 81mg) Please have your Identification Card / Driver s License and Insurance Card available at every appointment. If you have any questions regarding your appointment, please call our office. Thank you, Appointment Date: Pain Management Staff Appointment Time: With Dr.
PAIN MANAGEMENT SPECIALISTS OF SOUTHEAST MICHIGAN A division of South Oakland Anesthesia Associates PATIENT FINANCIAL POLICY Thank you for choosing Pain Management Specialists of Southeast Michigan for your care. Our doctors and staff are committed to providing quality, affordable medical care. We sincerely hope that by sharing our financial expectations we will strengthen the practice-patient relationship and keep the lines of communication open. This financial policy helps the practice provide quality care to our valued patients. Insurance: We participate in most insurance plans, including Medicare. As a courtesy, we will bill your insurance carrier on your behalf; however, you are ultimately responsible for timely payment of any non-covered services, co-payments and deductible in full before your next scheduled visit. Knowing your insurance benefits and coverage limitations is your responsibility. If your insurance requires you to have a referral or authorization before a service is performed, it is your responsibility to obtain this information and supply it to our office before your scheduled visit. This requirement is part of your contract with your insurance company. Please bring your insurance card(s) with you to each appointment. If your need for our services is due to a work or auto related accident, you must provide our office with the name, address and phone number of your insurance company, along with your claim number and adjuster / Case Managers contact information. You will receive a statement for uncovered services each month. It is our expectation that your entire balance be paid in full before your next scheduled visit. If for any reason you are not able to do this, you must contact our billing office and set up payment arrangements. You will be expected to make your agreed payments in a timely fashion. Failure to do this may result in rescheduling your appointment or procedure. There will be a $30.00 fee for any returned checks. It is your responsibility to notify the office of any changes in your address, phone, employment, or insurance coverage. We reserve the right to report delinquent accounts to your insurance carrier, credit bureaus, and take further collection actions if necessary. If you fail to comply with our financial policy, this may result in the termination of the patient physician relationship, and dismissal from our practice. Self-Pay Accounts If you do not have insurance coverage, we do offer a discount for uninsured patients; however your visits must be paid in full before the time of service. You will be asked to contact our billing department to make payment. Assignment of Benefits I hereby authorize my insurance company(s) to pay directly to South Oakland Anesthesia Associates, PC (SOAA) and Pain Management Specialists of Southeast Michigan,(PMSSM) and assign the benefits accorded to me under my hospital, surgical, accident or workman s compensation policy(s) for services rendered (anesthesia or chronic pain management). I hereby authorize SOAA / PMSSM to release information to my insurance company(s) which may be requested regarding my present illness or injury. I have read Pain Management Specialists of Michigan Patient Financial Policy and Assignment of Benefits, and I agree to abide by its terms. Patient Name (PRINT) Signature - Patient or Legal Guardian Date of Birth Today s Date: Pain Management Specialists of Southeast Michigan 08/11 1
PAIN MANAGEMENT SPECIALISTS OF SOUTHEAST MICHIGAN A Division of : South Oakland Anesthesia Associates NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO US. Overview The law requires us to keep your protected health information ( PHI ) private in accordance with this Notice of Privacy Practices ( Notice ), as long as this Notice remains in effect. We are also required to provide you with a paper copy of this Notice, which contains our privacy practices, our legal duties, and your rights concerning your PHI. From time to time, we may revise our privacy practices and the terms of our Notice at any time, as permitted or required by applicable law. Such revisions to our privacy practices and our Notice may be retroactive. Our Notice will be updated and made available to our patients prior to any significant revisions of our privacy practices and policies. Our Privacy Practices Use and Disclosure: We may use or disclose your PHI for treatment, payment, or health care operations. For your convenience, we have provided the following examples of such potential uses or disclosures: Treatment: Your PHI may be used by or disclosed to any physicians or other health care providers involved with the medical services provided to you such as hospitals, doctors, nurses, technicians, emergency service and transportation providers, pharmacies, and others involved in your care. Payment: Your PHI may be used or disclosed as needed to get paid for the medical care that we provide to you or to assist others who care for you to get paid for the care. Health Care Operations: Your PHI may be used or disclosed as part of our internal health care operations. Such health care operations may include, among other things, quality of care audits, to get legal, auditing, accounting and other services, business management, planning purposes, conducting training programs, accreditation, certification, licensing, or credentialing activities. We may disclose your information to businesses and individuals (e.g. medical transcription service) who perform services for us involving medial information as long as they agree to protect the privacy of that information. Appointments: We may use your medical information to contact you about upcoming appointments and to obtain registration and pre-surgical screening information. We may leave a message on an answering machine or voicemail. Follow-Up Care: We may use your medical information to contact you following your appointment and to obtain information regarding the status of your health condition. We may leave a message on an answering machine or voicemail. Individuals Involved in Your Care or Payment for Care. We may release health information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. A disclosure of your PHI may also be made if we determine it is reasonably necessary or in your best interests for such purposes as allowing a person acting on your behalf to receive filled prescriptions, medical supplies, X rays, etc. Authorizations: We will not use or disclose your medical information for any reason except those described in this Notice, unless you provide us with a written authorization to do so. We may request such an authorization to use or disclose your PHI for any purpose, but you are not required to give us such authorization as a condition of your treatment. Any written authorization from you may be revoked by you in writing at any time, but such revocation will not affect any prior authorized uses or disclosures. Patient Access: We will provide you with access to your PHI, as described below in the Individual Rights section of this Notice. Locating Responsible Parties: Your PHI may be disclosed in order to locate, identify or notify a family member, your personal representative, or other person responsible for your care. If we determine in our reasonable professional judgment that you are capable of doing so, you will be given the opportunity to consent to or to prohibit or restrict the extent or recipients of such disclosure. If we determine that you are unable to provide such consent, we will limit the PHI disclosed to the minimum necessary. Community/Public Health Activities and Reports: We may disclose health information as required by State and Federal laws and regulations including disease control, abuse or neglect, and health and vital statistics. 1
Disasters: We may use or disclose your PHI to any public or private entity authorized by law or by its charter to assist in disaster relief efforts. Required by Law: We may use or disclose your medical information when we are required to do so by law. For example, your PHI may be released when required by privacy laws, workers' compensation or similar laws, public health laws, court or administrative orders, subpoenas, certain discovery requests, or other laws, regulations or legal processes. Under certain circumstances, we may make limited disclosures of PHI directly to law enforcement officials or correctional institutions regarding an inmate, lawful detainee, suspect, fugitive, material witness, missing person, or a victim or suspected victim of abuse, neglect, domestic violence or other crimes. We may disclose your PHI to the extent reasonably necessary to avert a serious threat to your health or safety or the health or safety of others. We may disclose your PHI when necessary to assist law enforcement officials to capture a third party who has admitted to a crime against you or who has escaped from lawful custody. Deceased Persons: After your death, we may disclose your PHI to a coroner, medical examiner, funeral director, or organ procurement organization in limited circumstances. Military and National Security: We may disclose to military authorities the medical information of Armed Forces personnel under certain circumstances. When required by law, we may disclose your PHI for intelligence, counterintelligence, and other national security activities. Your Individual Rights Access and Copies: In most cases, you have the right to review or to purchase copies of your PHI by requesting access or copies in writing to our Privacy Officer. Please contact our Privacy Officer regarding our copying fees. Disclosure Accounting: You have the right to receive an accounting of the instances, if any, in which your PHI was disclosed for purposes other than those described in the following sections above: Use and Disclosures, Facility Directories, Patient Access, and Locating Responsible Parties. For each 12-month period, you have the right to receive one free copy of an accounting certain details surrounding such disclosures that occurred after April 13, 2003. If you request a disclosure accounting more than once in a 12-month period, we will charge you a reasonable, cost-based fee for each additional request. Please contact our Privacy Officer regarding these fees. Additional Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your PHI, but we are not required to honor such a request. We will be bound by such restrictions only if we agree to do so in writing signed by our Privacy Officer. Alternate Communications: You have the right to request that we communicate with you about your PHI by alternative means or in alternative locations. We will accommodate any reasonable request if it specifies in writing the alternative means or location, and provides a satisfactory explanation of how future payments will be handled. Amendments to PHI: You have the right to request that we amend your PHI. Any such request must be in writing and contain a detailed explanation for the requested amendment. Under certain circumstances, we may deny your request but will provide you a written explanation of the denial. You have the right to send us a statement of disagreement to which we may prepare a rebuttal, a copy of which will be provided to you at no cost. Please contact our Privacy Officer with any further questions about amending your medical record. Confidentiality: You have the right to request that your medical information be shared with you in a confidential manner, such as at home rather than at work. Copies of our Notice of Privacy Practices: You can ask for a copy of our current Notice of Privacy Practices at any time. If this Notice was sent to you electronically, you may request a paper copy. Complaints If you believe we have violated your privacy rights, you may complain to us or to the Secretary of the U.S. Department of Health and Human Services. You may file a complaint with us by notifying our Privacy Officer. We support your right to protect the privacy of your medical information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services. Pain Management Specialists of Southeast Michigan Privacy Officer 1719 W. Big Beaver Road Troy, MI 48084 888-719-0008 2
PAIN MANAGEMENT SPECIALISTS OF SOUTHEAST MICHIGAN Acknowledgement of Receipt of Notice of Privacy Practices Authorization for Disclosure of Health Information I acknowledge that I have received a copy of the Notice of Privacy Practices for SOAA / PMSSM. I have read them and agree to the terms of use of my personal heath information. Patient Name (Label) Patient Signature; or Legal Guardian Date I hereby authorize SOAA / PMSSM to discuss my medical information, condition and treatments, and billing account information as necessary to the following person(s). I further understand that failure to do so will result in my sole responsibility of all communication regarding my care and financial responsibility. I authorize release of my personal information to: Please Print (Name: First Last) Relationship to patient Please Print (Name: First Last) Relationship to patient Please list any specific information that is NOT to be disclosed: I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the physicians and or staff of SOAA / PMSSM. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event, or condition: If I fail to specify an expiration date, event or condition, this authorization will expire in 1 year. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. Signature of patient or legal representative Date Signature of Witness Printed Name of Witness Date PAIN MANANGEMENT SPECIALISTS OF SOUTHEAST MICHIGAN A DIVISION OF SOUTH OAKLAND ANESTHESIA ASSOCIATES
PAIN MANAGEMENT SPECIALISTS OF SOUTHEAST MICHIGAN A Division of: South Oakland Anesthesia Associates Controlled Substance Agreement Form PAIN MANAGEMENT SPECIALISTS OF SOUTHEAST MICHIGAN are committed to providing patient care consistent with the recommendations of your physician. In your case, your Physician has recommended Controlled Substances as a component of your overall treatment plan. Controlled Substances include medications for pain (such as opioid analgesics), anxiety, and sleep. PATIENT AND PMSSM EXPECTATIONS: Purpose of Treatment: I understand that the goals of my treatment with Controlled Substances are to decrease my pain and increase my ability to participate in activities of daily living, and/or participate in your physician s recommended treatment plan. Comprehensive Treatment Plan: I understand that taking Controlled substances is only one part of my overall treatment. The renewal of my Controlled Substance prescriptions depends on both my medical needs and my consistent participation with the overall recommended treatment plan as set forth by my physician. Disclosure of Medications: I have disclosed to my Physician ALL medications, including, but not limited to Controlled Substances, I take for any reason. I must update the Physician named above of ANY changes. I understand that this list will become part of my permanent medical record. Moreover, I give my physician, or his designee, the express permission to discuss my medication history, and current medication practice, with any physician or pharmacy. This Practice is Your Exclusive Provider of Controlled Substances: I will not attempt to obtain prescriptions for Controlled Substances from any source other than my above named Physician. If I require treatment with Controlled Substances because of an emergency medical or dental situation, I will notify my Physician within Seventy (72) hours of beginning the treatment. Use of Medications: I will take ALL Controlled Substances exactly as prescribed to me. This means I will not change the dose, frequency or alter the form of drugs themselves (such as opening capsules, cutting in half, crushing, or chewing medications). I understand that increasing the dose or frequency of any medication, including Controlled Substances, or altering its form, may result in harmful effects including overdose, and risk of dependency / addition. Pharmacy Identification: I agree to fill all of my Controlled Substances exclusively at the Pharmacy named below: Pharmacy Address: Telephone PMSSM Policy Dictates Refills: My Physician will only refill my prescriptions consistent with PMSSM policies and procedures. 1) My Physician will not fill any prescriptions early if I run out of Controlled Substances before my scheduled refill or appointment. 2) My Physician will only renew my Controlled Substances prescriptions during an appointed office visit during the Practice s regular clinic hours. No refills of any controlled substance will be written or called in after regular clinic hours or on the weekends. 3) My Physician will not replace lost, stolen, damaged or otherwise rendered useless Controlled Substances or Controlled Substance prescriptions. Appointment Responsibilities: I will bring ALL medications, including Controlled Substances, in their prescription bottles to EVERY appointment. Compliance with Appointment Schedule: I agree to attend ALL scheduled appointments. Drug Testing/Pill Counts: I agree that my Physician, or his designee, may order me to be tested for drug use at any time in his sole discretion. I agree to comply with any and all drug tests, instructions, and pill counts that may be ordered by my physician, or his designee, including, but not limited to urine or blood samples even if requested on days when I have no scheduled appointment. Patient Initials: Risks of Birth Defects (Female Patients): (please initial appropriately) Opiod Agreement Revised 1/20/2011 PATIENT LABEL HERE
1. I am not pregnant : My physician, or his designee, has explained the risks to my unborn child if I become pregnant while taking Controlled Substances. I have also been informed of the importance of using safe and effective birth control while taking Controlled Substances. If I become pregnant, I will notify PMSSM PHYSICIAN IMMEDIATELY. 2. I am pregnant : I have informed my Physician of my pregnancy. I acknowledge that I have a complete understanding of the risks of taking Controlled Substances, including Opioids, while pregnant. I have chosen to take Controlled Substances despite these risks. Illegal Drug Use and/or Activity: I will not use any illegal substances/drugs or prescription drugs obtained through illicit means, and I will not share, sell, or trade any of my medications, including Controlled Substances prescribed by my Physician, with anyone. Use of Alcohol: Controlled Substances should not be taken with alcohol. I acknowledge that I have a complete understanding of the risks of consuming alcohol while taking controlled substances. Should I consume alcohol while taking the Controlled Substances prescribed to me, I do so despite these risks. Notification of Change in Mental Status: Opioids may impair mental and/or physical ability required for the performance of potentially hazardous tasks. I agree to inform my Physician of ALL effects from ALL of my medications, including Controlled Substances, as they arise, including, but not limited to: feelings of over sedation (fatigue), nausea, vomiting, constipation, confusion, euphoria (high feelings), and dysphoria (down feelings). If my level of consciousness is altered, I will not drive or operate heavy machinery. Authorization to Share Protected Health Information: I agree to waive my right to privacy and authorize the above named physician, or his designee, to discuss my medical care and to disclose my use of medications, or possible misuse with any health care Provider, Pharmacy, legal authority, or regulatory agency in his sole discretion. I further authorize the above named Physician to cooperate fully with any city, state or federal law enforcement agency (including the DEA), in the investigation about my care or actions. Termination of Treatment at PMSSM: I understand that my Physician may stop treating me as a patient, in his sole discretion. Moreover, I acknowledge that my Physician may, in his sole discretion, stop treating me with Controlled Substances, refer me to a substance abuse specialist, and/or terminate my patient status if I break any portion of this agreement or am arrested for any unlawful conduct. My signature confirms that I understand and agree to all of the above requirements of the Controlled Substances Agreement. MY SIGNATURE BELOW ACKNOWLEDGES THAT: 1. I have executed this Controlled Substances Agreement voluntarily after having sufficient time to review it. 2. I agree to all of the above requirements of the Controlled Substances Agreement with full understanding of the risks of being prescribed Controlled Substances. 3. I have read, understand and agree to the statements set forth above in this document. 4. I have had the opportunity to ask questions about this document of a physician or a physician s designee. Patient Signature: Date of Birth: I have received a copy of this signed Agreement Witness Signature: PMSSM Provider Signature: Patient Initial: Date: Date: Opiod Agreement Revised 1/20/2011 PATIENT LABEL HERE
Patient Name: PAIN MANAGEMENT SPECIALISTS OF SOUTHEAST MICHIGAN (PMSSM) A division of SouthOakland Anesthesia Associates Please PRINT LAST FIRST Middle Initial Date of Birth: mm/dd/yyyy Social Security Number: Address: Street / Apt. # City State Zip Code Home Phone: ( ) Cell: ( ) Employer Name: Employer Address: Work Phone: ( ) City State Zip Code Emergency Contact: ( ) First & Last Name Contact Number Relationship e.g.: Spouse / Referring Physician: Phone #: ( ) Primary Care (PCP) Phone #: ( ) Is your treatment related to an Auto or Workman's Comp Claim? No Yes Date of Injury: / / Primary Insurance Group #: Subscriber Name: Patients Relationship to Subscriber: SELF SPOUSE DEPENDENT SIGNIFICANT OTHER Subscribers Employer Name: Employer Address: COVERAGE INFORMATION Last / First / Middle Initial Employer Phone: Street Secondary Coverage Information Subscriber Date of Birth: ( ) Secondary Insurance Group #: City State ZIP Subscriber Name: Last / First / Middle Initial Date of Birth: Patients Relationship to Subscriber: SELF SPOUSE DEPENDENT SIGNIFICANT OTHER Subscribers Employer Name: Employer Address: Street Page 1 of 2 Employer Phone: ( ) City State ZIP