. ASSIGNMENT OF BENEFITS Private insurance authorization for assignment of benefits and information release: I, the undersigned, authorize payment of medical benefits to Hill Country Pain for any services furnished to me by the physician. I understand I am financially responsible for any amount not covered by my insurance policy. I also authorize Hill Country Pain to release to my insurance company, referring physician and other consultants on my case information concerning health care, advice, treatment or supplies provided to me. This information will be used for the purpose of evaluating and administering claims of benefits. Date Signed MEDICARE LIFETIME SIGNATURE ON FILE I request that payment of authorized Medicare benefits be made on my behalf Hill Country Pain for any services furnished to me by the physician. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits payable for related services. Date Signed CERTIFICATION Hill Country Pain is pleased to offer you treatment for your injury or suffering. However, you are advised that according to most commercial insurance policies and generally accepted practice, treatment for work-related chronic injuries must first be filed under Texas Workman s Compensation. We will be happy to assist you in this process. Also, if this is a litigation case, our office needs to be informed before services are rendered. I hereby certify that I am /am not seeking treatment for an illness or injury that resulted from an incident/accident at my place of work or from a motor vehicle accident. MVA / Date of Incident If applicable, Attorney s Name Phone # Print Patient Name Patient Signature Date Health Insurance Portability and Accountability Act By signing this document, I acknowledge that I have been given the opportunity to read the Notice of Privacy Practices of Hill Country Pain. Print Patient Name Date Patient Signature 1
14800 San Pedro, Ste 115 San Antonio, Texas 78232 210-582-6600 phone 210-582-6601 fax www.hillcountrypain.com CONSENT TO PHOTOGRAPH I hereby authorize, Hill Country Pain to take my photograph for inclusion in my medical chart retained by the office. I understand this photograph is solely for the purpose of identification and familiarization by the office staff and the pain management physician(s). Patient Signature RELEASE OF MEDICAL RECORDS Please fill out and sign the following release form so we can obtain copies of any medical records that may be needed in order to assess your condition more thoroughly. I, hereby authorize the release of my medical records to Hill Country Pain. (PRINT NAME) Patient Signature Date Witness Date 2
PATIENT INFORMATION Patient Name Last First Middle Address Street City State ZIP Code Home Phone ( ) Cell Phone ( ) Date of Birth Social Security No. Drivers License No: State Expiration Date: Email address: Preferred language: English Spanish Other Preferred Reminder Method: Mail Home Phone Cell Phone Email Patient Portal* (*must sign consent form) Gender: M F Marital Status: Single Married Widowed Divorced Race: Declined White Black or African American Asian Other Ethnic Group: Declined Hispanic Not Hispanic or Latino Other Emergency Contact : Phone: ( ) Last First Middle *Can the provider discuss medical issues with this person? YES NO Limitations? Are you seeking treatment for an injury related to WORK MOTOR VEHICLE ACCIDENT OTHER Primary Insurance Secondary Insurance none Address Telephone Policy # Group # Address Telephone Policy # Group # Subscriber Subscriber Subscriber Date of Birth Subscriber Date of Birth Relation to patient: self spouse parent Relation to patient: self spouse parent For internal office use: - Demographics entered/updated by : Date: *** Scan this form into Docman folder Patient Demographic Form *** 3
Referring Doctor? List of doctors you have seen for this pain problem: Names of other doctors you see for other medical reasons: Give details of injury or circumstances causing your pain: Were you injured on the job? YES NO How and when were you treated for this problem? Have you had surgery for this problem? YES NO If yes, give: Date Hospital Name of surgeon Tests performed: X-Rays MRI CT Scan EMG Bone Scan Discogram Other Tests Where & When: What is your pain status now? Worse Better Same Has it changed? How? What other treatments have you received? (i.e., bedrest, physical, therapy, hypnosis, chiropractic manipulation, acupuncture, injections) Please list details: Treatment: Where: When: 4
MEDICATION HISTORY Please list your medication ALLERGIES: Please list PAIN medications you have PREVIOUSLY TAKEN AND STOPPED: MEDICATION HELPFUL? REASON FOR STOPPING USE Please list medications you are CURRENTLY TAKING FOR PAIN: MEDICATION DOSAGE HELPFUL? DOCTOR Please list OTHER medications you are CURRENTLY TAKING (include vitamins, etc.): MEDICATION DOSAGE DOCTOR Please circle on a scale of 0 to 10 (0 is no pain 10 is the worst imaginable) AT ITS BEST 0 1 2 3 4 5 6 7 8 9 10 MOST OF THE TIME 0 1 2 3 4 5 6 7 8 9 10 AT ITS WORST 0 1 2 3 4 5 6 7 8 9 10 PAIN DESCRIPTIONS. Place a SINGLE number for each word that describes your pain: NONE = 0 MILD = 1 MODERATE = 2 SEVERE = 3 THROBBING GNAWING SPLITTING SHOOTING HOT/BURNING TIRING/EXHAUSTING STABBING ACHING SICKENING SHARP TENDER FEARFUL CRAMPING HEAVY PUNISHING/CRUEL 5
What type of work do you do? Have you lost or gained weight in the last six months? Yes No How many pounds? Lost lbs. Gained lbs. Do you: Drink alcoholic beverages? Yes (How many drinks) (frequency) (last drink) No Alcohol in the past? Yes Quit when? Have you ever smoked? Yes (How many cigarettes/day) (How long) (last ) No Have you quit? If yes, when? Interested in quitting? Exposed to second-hand smoke? Yes No Drink caffeinated beverages? Yes (Amt) NO Take vitamins? Yes No If yes, what kind? How often? Any substance use or abuse? Yes No What kind? Last used? Have you ever been treated for addiction? Yes No FAMILY HISTORY (Circle all that apply TO YOUR FAMILY) Asthma Genetic Disorders Kidney Problems Arthritis Headaches Lung Problems Cancer Heart Problems Seizures Diabetes High Blood Pressure Tuberculosis Other: Please circle any of the following that APPLY TO YOU Anxiety Constipation GI Bleed Heart Problems Kidney Problems Tuberculosis Arthritis Depression Glaucoma HIV Lung Problems Suicide Asthma Diabetes Hepatitis High Blood Pressure Stomach Ulcer Cancer Genetic Disorder Headaches Impotence Seizures Oher: SURGICAL HISTORY DATE PROCEDURE SURGEON HOSPITAL 6
PAIN DIAGRAM Please mark the diagrams where you feel the symptoms described. You may have more that one body area affected by these symptoms and you may have more than one symptom in one specific area. Mark each area with each symptom you feel in each location. As an example, if the symptom is described as burning: the mark for burning is XXX, put the XXX in the area where you feel a burning sensation. You may also experience perspiration in a specific area, but nowhere else; The symbol to mark in that area on the diagram is PPP. In addition, you may feel numbness in your fingers, but dull/aching pain in your shoulder. Mark these body areas with the corresponding symbols +++ and NNN. Burning = XXX Blueness = BBB Dull/Aching = NNN Muscle Cramps = SSS Numbness = +++ Perspiration = PPP Pins & Needles = ::: Redness = RRR Stabbing/Sharp =!!! Sensitive to touch = ### (clothes, jewelry, pressure) Sensitive to temp. changes = 000 (to or from indoor/outdoor: cold to hot air) Swelling = *** 7
Informed Consent to Obtain Medication History Hill Country Pain Associates (HCPA) has adopted an electronic medical record system in order to improve the quality of our services. This system also allows us to collect and review your medication history. A medication history is a list of prescription medicines that we or other doctors have recently prescribed for you. This list is collected from a variety of sources, including your pharmacy and your health insurer. An accurate medication history is very important to helping us treat you properly and in avoiding potentially dangerous drug interactions. By signing this consent form you give us permission to collect, and give your pharmacy and your health plan permission to disclose, information about your prescriptions that have been filled at any pharmacy or covered by any health insurance plan. This includes prescription medicines to treat AIDS/HIV and medicines used to treat mental health conditions, such as depression. This information will become part of your medical record. This medication history is a useful guide, but it may not be completely accurate. Some pharmacies do not make drug history available to us, and the drug history from your health plan might not include drugs that you purchased without using your health insurance. Your medication history might not include over the counter medicines, supplements or herbal remedies. It is still very important for us to take the time to discuss everything you are taking, and for you to point out to us any errors in your medication history. Patient Acknowledgement By signing below, I give permission for Hill Country Pain Associates to obtain my medication history from my pharmacy, my health plans and other healthcare providers. Patient Signature Date For internal office use: Medication History Consent updated by: (Patient demographics- misc tab.) Date: ***Scan this form into Docman folder Medication History Consent *** 8
I agree to the following: PATIENT-PROVIDER TREATMENT AGREEMENT 1. To disclose all pain medications prescribed by other providers. Failure to do so will be considered a violation of the agreement. 2. To take the medication only as directed and to contact the office with questions regarding altering the medication dosage. The dosing schedule will not be routinely changed over the phone and you may be required to make a follow-up appointment to discuss these changes. Self-increasing the medications over the prescribed amount or dosage will be considered a violation of the agreement. 3. To use only one pharmacy to obtain medications. 4. To keep medications in a secure place to prevent theft, loss or damage. 5. To never share these medications with any person, no matter what the reason. 6. To inform the doctor of any scheduled surgeries or emergency room visits which would possibly require additional pain medication. 7. To call the office during office hours, giving the office personnel ample time (3days) to process refill requests. This is the responsibility of the patient to keep track of the medications and not wait until the last moment. 8. To agree to routine office evaluations, even if the problem is stable and no changes are needed. Remember that these medications are highly regulated and it is the standard of care to require these frequent office evaluations. Failure to do this is considered a violation of the agreement. 9. To make scheduled appointments. No shows or unreasonable cancellations will be considered a violation of the agreement. 10. To agree to random drug screens for urine, oral swab or blood. This is to detect non-prescribed controlled medications, street drugs or to detect the absence of prescribed medications. Failure to submit or an inappropriate screen will be considered a violation of the agreement. 11. To agree to bring in all controlled medications if requested for specific pill count. 12. To agree to psychological, psychiatric or addictionology counseling if deemed appropriate by the doctor. I, (initials) have read the Patient-Provider Treatment Agreement provided to me by Hill Country Pain Associates about medications and I have read and understood the possible side effects that these drugs can cause, including possible addition. I, (initials) understand that I may be asked to come into a Hill Country Pain Associates office for a random pill count and/or to give a urine sample to monitor compliance with medication. By signing this document, the patient and doctor agree to the above items. Patient Signature: Physician/Representative Signature Date: Date: 9