REGISTRATION FORM Name (First) (Middle) (Last) M F Social Security of Birth Age Marital Status Single Married Civil Union Widow/ Widower Home Address City State Zip Code Work Address (Cell) (Home) (Work) Emergency Contact (Name) Primary Insurance Commercial Medicare Automobile Accident Workers Compensation Policy Holder Relationship to Patient Insurance Company Address Member ID Effective s of Accident Claim # Name of Adjustor Fax Secondary Insurance Policy Holder Relationship to Patient Insurance Company Policy # Group # Address Fax Preferred Pharmacy (For electronic prescribing) Name Fax Address Referring Physician Signature Initial07162016 1
MEDICAL HISTORY Patient Name Where does it hurt? (Please describe) Shade The Corresponding areas Right Left Left Right Allergies No known drug allergies Iodine/ Shell fish Latex Others Current Medication (Name, Dose, Frequency) I m on blood thinners Past History of Pain Management Procedures Epidural Steroid Injection Medial Branch Block Radiofrequency Ablation Others (Please describe) Initial07162016 2
What pain medicines have you used in the past? Tylenol Ibuprofen/ Advil Naproxen/ Aleve Diclofenac Gabapentin Pregabalin/ Lyrica Nortriptyline Baclofen Flexeril Soma Percocet Vicodin Oxycodone Morphine Dilaudid Methadone MS Contin OxyContin Fentanyl Patch Buprenorphine Others Past History of Conservative Therapy Physical therapy Chiropractic therapy Heat & Massage Exercise regimen Acupuncture Past Medical History Recent ER/ Hospital Visits Currently taking antibiotics Past Surgical History Pacemaker/ Defibrillator/ Foreign Body Implant Initial07162016 3
Tax ID: 272117441 ASSIGNMENT OF BENEFITS & LIMITED POWER OF ATTORNEY I,, irrevocably assign to you, EPIC PAIN MANAGEMENT & ANESTHESIA CONSULTANTS, LLC my medical provider, all of my rights and benefits under my insurance contract for payment for services rendered to me. I authorize you to file insurance claims on my behalf for services rendered to me and this specifically includes filing arbitration/litigation in your name on my behalf against the PIP carrier/health care carrier. I irrevocably authorize you to retain an attorney of your choice on my behalf for collection of your bills. I direct that all reimbursable medical payments go directly to you, my medical provider. I authorize you to act on my behalf. I consent to your acting on my behalf in this regard and in regard to my general health insurance coverage pursuant to the benefit denial appeals process set forth in the NY & NJ Administrative Code. As medical provider I agree to comply with the PIP carrier s decision point review/precertification plan and to hold the patient harmless if I fail to comply with same, in consideration for the carrier s consent to this assignment. In the event the insurance carrier responsible for making medical payments in this matter does not accept my assignment, or my assignment is challenged or deemed invalid, I execute this limited/special power of attorney and appoint and authorize your collection attorney as my agent and attorney to collect payment for your medical services directly against the carrier in this case in my name including filing an arbitration demand or lawsuit. I specifically authorize that attorney to file directly against that carrier in my name or in your name as a medical provider rendering services to me and designate your collection attorney as my attorney in fact. I further grant limited power of attorney to you as my medical provider to receive and collect directly from the insurance carrier money due you for services rendered to me in this matter, and hereby instruct the insurance carrier to pay you directly any monies due you for medical services you rendered to me. If Epic Pain Management & Anesthesia Consultants, LLC, must take any action to collect an outstanding balance on my account, I will be responsible for payment and will reimburse all costs of such collection efforts, including, but not limited to, all court costs and attorney fees. I authorize you and or your attorney to obtain medical information regarding my physical condition from any other health care provider, including hospitals, diagnostic centers, etc., and I specifically authorize such health care provider(s) to release all such information to you about me, including medical reports, X-ray reports, narrative reports, and any other report or information regarding my physical condition. Initial07162016 4
FINANCIAL HARDSHIP WAIVER OF PAYMENT Patient Name Address Please be advised that I would not be able to pay any out of pocket expenses Co-payment Deductible to this medical clinic beyond $ The reason is due to financial hardship (Please explain below) : Staff signature Initial07162016 5
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT I understand that, under the Health Insurance Portability & accountability act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly. Obtain payment from third party payors. Conduct normal healthcare operations such as quality assessments and physician certifications. I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions. Notice of Minority Stake in Surgical Center I understand that Dr. Amit Goswami has minority financial interest in Barnert Surgical Center & Accelerated Surgical Center, Paterson, NJ. Initial07162016 6
RELEASE OF INFORMATION FORM Patient Name of Birth Information to be released from Organization/ Health Care Provider Street Address City State Zip Code Fax Information to be released to: Amit Goswami, MD/ Sumeet Goswami, MD/ Epic Pain Management s of service: From To Information to be released Discharge summary Operative reports Radiology images/ reports ED records Lab/ Pathology reports Clinic/ Office notes Others Authorization for General Release of Information I understand that: Authorizing the disclosure of this healthcare information is voluntary. I do not need to sign this form in order to assure treatment or payment. I can cancel this authorization at any time by writing to the Amit Goswami, M.D. I understand that once the information has been released according to the terms of this authorization, the information cannot be recalled. Any disclosure of information carries with it the potential for further release or distribution by the recipient that may not be protected by confidentiality laws. This authorization will expire 90-days from the date signed below unless another date or event is entered here: Sensitive Records may require specific patient authorization. Please check the applicable box below to request the following records: Mental Health Treatment AIDS/ HIV Treatment Sexually Transmitted Diseases Alcohol/ Drug abuse Treatment Initial07162016 7
AGREEMENT FOR THE USE OF NARCOTICS FOR CHRONIC PAIN The purpose of this agreement is to prevent misunderstandings about certain medicines you will be taking for pain management. This is to help both you and your doctor to comply with the law regarding controlled pharmaceuticals. I understand that this Agreement is essential to the trust and confidence necessary in a doctor/patient relationship and that my doctor undertakes to treat me based on this Agreement. I understand that if I break this Agreement, my doctor will stop prescribing these pain/controlled medicines. In this case, my doctor will taper off the medicine over a period of several days, as necessary, to avoid withdrawal symptoms. Also, a drug-dependence treatment program may be recommended. I will communicate fully with my doctor about the character and intensity of my pain, the effect of the pain on my daily life, and how well the medicine is helping to relieve the pain. I will not use any illegal controlled substances, including marijuana, cocaine, etc. I will not share, sell or trade my medication with anyone. I will not attempt to obtain any controlled medicines, including opioid pain medicines, controlled stimulants, or antianxiety medicines from any other doctor. I will safeguard my pain medicine from loss or theft. Lost or stolen medicines will not be replaced. I agree that refills of my prescriptions for pain medicine will be made only at the time of an office visit or during regular office hours. No refills will be available during evenings or on weekends. I authorize the doctor and my pharmacy to cooperate fully with any city, state or federal law enforcement agency, including this state s Board of Pharmacy, in the investigation of any possible misuse, sale, or other diversion of my pain medicine. I authorize my doctor to provide a copy of this Agreement to my pharmacy. I agree to waive any applicable privilege or right of privacy or confidentiality with respect to these authorizations. I agree that I will submit to a blood or urine test if requested by my doctor to determine my compliance with my program of pain control medicine. I agree that I will use my medicine at a rate no greater than the prescribed rate and that use of my medicine at a greater rate will result in my being without medication for a period of time. I will bring all unused pain medicine to every office visit. I agree to follow these guidelines that have been fully explained to me. All of my questions and concerns regarding treatment have been adequately answered. A copy of this document has been given to me. Physician signature Initial07162016 8