Patient Resources

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PATIENT INFORMATION

Patient Name

Address

Street Address City State / Province / Region ZIP / Postal Code

Date of Birth

SSN

Phone #

Cell #

Email

Marital Status

# of Children

Highest Level of Education

Employer

Phone

Primary Care Physician

Phone

Referring Physician

Phone

Primary Language Spoken

Interpreter Needed:

Preferred Pharmacy

EMERGENCY CONTACT

Name

Phone

Relationship

INSURANCE INFORMATION

Primary:

Insurance Carrier

Member ID

Effective Date

Secondary:

Insurance Carrier

Member ID

Effective Date

SOCIAL HISTORY

Do you smoke?

Packs/Day?

If yes, how many years?

Have you quit smoking?

Year Quit

Do you drink alcohol?

If yes, Amount

Per

History of drug abuse?

History of alcohol abuse?

Do you currently use recreational drugs?

If yes, which?

What is your current/most recent occupation?

What is your current employment status?

What are your hobbies/interests?

Do you currently exercise?

If yes, how often?

Are you receiving compensation or disability payments now?

Do you have an application for compensation or disability pending?

If yes, what is the current status?

FAMILY HISTORY

DISEASE

Heart Attack

High Blood Pressure

Asthma

Liver Disease

Kidney Disease

Gout / Arthritis

Osteoporosis

Stroke

Neuromuscular Disorder

Type

Epilepsy/Seizure

Bleeding Problem

Sickle Cell Anemia

Diabetes

Thyroid Problem

Cancer

Type

Alcohol or Substance Abuse

Anxiety or Depression

Glaucoma

Scoliosis

Other:

I,

_ have read this form and the general office policies form in its entirety or have had it read to me. I understand all of it and have had an opportunity to have all of my questions regarding this treatment answered to my satisfaction. I agree that this agreement is essential to my medical care and the ability to treat my pain effectively, and that my failure to comply with the terms of this Agreement may result in the following: 1) Withdrawal of all prescribed medication and regenerative services by US Pain Relief physicians or providers. 2) Termination of the physician-patient relationship. 3) Immediate discharge by US Pain Relief. By signing this form, I voluntarily give my consent for the treatment of my pain with opioid pain management medications and agree to abide by these policies.

This Agreement is entered into on this

Patient Name

Patient Signature

ER/Urgent Care/PCP Provider

Financial Responsibility Disclosure Statement

This agreement between is made and entered into on this

Between

and US Pain Relief is the provider of medical services, and you the patient receiving medical services, herein after referred to as PATIENT. All Charges for medical services rendered by US Pain Relief are due and payable by PATIENT at the time of service.
By initialing and signing below, the Patient agrees to and accepts the following statements:

I understand that the responsibility for payment of medical services in this office for myself and my dependents is mine; due and payable at the time services are rendered unless financial arrangements have been made. Insurance claims are filed as a courtesy, but it is my responsibility to see that the claims are paid. I fully understand that I am responsible for payment of fees not covered by insurance. I assign all benefits to US Pain Relief & Wellness. I authorize the submission of claims without obtaining my signature on each claim submitted. I give my authorization and consent for treatment after having a full explanation of proposed treatment, alternatives, and risks by my doctor. I have been advised of my privacy rights as provided by the Healthcare Information Portability and Accountability Act of 1996. I understand that I am responsible for all costs of collection including attorney fees, collection fees of 30% and court costs. I understand that any unpaid balance will be assessed interest at the rate of 18.00% (1.5% monthly). I hereby authorize US Pain Relief & Wellness and its employees, agents, and assignees to contact me via e-mail, text messaging and to my cellular devices using automated telephone dialing systems.

FOR MEDICARE PATIENTS ONLY:

Untitled

Authorization to release Information and Payment Request: PATIENT hereby request that payment of authorized Medicare benefits be made on PATIENT’s behalf to US Pain Relief for any services rendered by US Pain Relief. PATIENT authorizes any holder of medical or other information about PATIENT to be released to the Health Care Financing Administration or its agents, intermediaries or carriers any information needed to determine these benefits or the benefits payable for related services. PATIENT further understands that deductibles, coinsurance, and any other charges not covered by Medicare are PATIENT’s responsibility.

By signing below, PATIENT agrees to accept full financial responsibility as a PATIENT who is receiving medical services from US Pain Relief. PATIENT’s signature verifies that PATIENT authorizes assignment of benefits, has read the disclosure statement, understands PATIENT responsibilities, and agrees to the terms and conditions described therein.

Patient Name

Patient Signature

Date

US Pain Relief Privacy Policy Notice

As required by the privacy regulations created because of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) this notice describes how health information about you (as a patient of US Pain Relief) may be used or disclosed and how you can get access to your individually identifiable health information.

PLEASE REVIEW THIS NOTICE CAREFULLY.

A. Our commitment to your privacy:

Our practice is dedicated to maintaining the privacy of your individually identifiable health information (also called protected health information, or PHI). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your PHI. By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect at the time.

We realize that these laws are complicated, but we must provide you with the following important information:

How we may use and disclose your PHI.
Your privacy rights in your PHI.
Our obligations concerning the use and disclosure of your PHI.

The terms of this notice apply to all records containing your PHI that are created or retained by our practice. We reserve the right to revise or amend this Privacy Policy Notice. Any revision or amendment to this notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our offices in a visible location at all times, and you may request a copy of our most current Notice at any time.

C. We may use and disclose your PHI in the following ways:

The following categories describe the different ways in which we may use and disclose your PHI.

Treatment:

Our practice may use your PHI to treat you. For example, we may ask you to have laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might use your PHI in order to write a prescription for you, or we might disclose your PHI to a pharmacy when we order a prescription for you. Many of the people who work for our practice including, but not limited to, our doctors and nurses may use or disclose your PHI in order to treat you or to assist others in your treatment. Additionally, we may disclose your PHI to others who may assist in your care, such as your spouse, children or parents. Finally, we may also disclose your PHI to other health care providers for purposes related to your treatment.

Payment:

Our practice may use and disclose your PHI in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your PHI to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your PHI to bill you directly for services and items. We may disclose your PHI to other health care providers and entities to assist in their billing and collection efforts.

Health care operations:

Our practice may use and disclose your PHI to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our practice may use your PHI to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our practice. We may disclose your PHI to other health care providers and entities to assist in their health care operations.

Disclosures required by law:

Our practice will use and disclose your PHI when we are required to do so by federal, state or local law.

D. Use and disclosure of your PHI in certain special circumstances:

The following categories describe unique scenarios in which we may use or disclose your identifiable health information:

Public health risks:

Our practice may disclose your PHI to public health authorities that are authorized by law to collect information for the purpose of:

Maintaining vital records, such as births and deaths,
Reporting child abuse or neglect,
Preventing or controlling disease, injury or disability,
Notifying a person regarding potential exposure to a communicable disease,
Notifying a person regarding a potential risk for spreading or contracting a disease or condition,
Reporting reactions to drugs or problems with products or devices,
Notifying individuals if a product or device they may be using has been recalled,
Notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information,
Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.

Health oversight activities:

Our practice may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.

Lawsuits and similar proceedings:

Our practice may use and disclose your PHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your PHI in response to a discovery request, subpoena or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.

Law enforcement:

We may release PHI if asked to do so by a law enforcement official:

Regarding a crime victim in certain situations, if we are unable to obtain the person's agreement,
Concerning a death, we believe has resulted from criminal conduct,
Regarding criminal conduct at our offices,
In response to a warrant, summons, court order, subpoena or similar legal process,
To identify/locate a suspect, material witness, fugitive or missing person,
In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator).

Serious threats to health or safety:

Our practice may use and disclose your PHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.

Military:

Our practice may disclose your PHI if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.

National security:

Our practice may disclose your PHI to federal officials for intelligence and national security activities authorized by law. We also may disclose your PHI to federal officials to protect the president, other officials or foreign heads of state, or to conduct investigations.

Inmates:

Our practice may disclose your PHI to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary under the following circumstances:

For the institution to provide health care services to you,
For the safety and security of the institution,
To protect your health and safety or the health and safety of other individuals.

Workers' compensation:

Our practice may release your PHI for workers' compensation and similar programs.

E. Your rights regarding your PHI:

You have the following rights regarding the PHI that we maintain about you:

Confidential communications:

You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request specifying the requested method of contact, or the location where you wish to be contacted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request.

Requesting restrictions:

You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your PHI, you must make your request in writing to the office manager of US Pain Relief. Your request must describe in a clear and concise fashion:

The information you wish restricted,
Whether you are requesting to limit our practice's use, disclosure or both,
To whom you want the limits to apply.

Inspection and copies:

You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to the office manager of US Pain Relief in order to inspect and/or obtain a copy of your PHI. Our practice may charge a fee for the costs of copying, mailing, labor, and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.

Amendment:

You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for if the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to the office manager of US Pain Relief. You must provide us with a reason that supports your request for amendment. Our practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that, in our opinion, falls under the following criteria:

Accurate and complete,
Not part of the PHI kept by or for the practice,
Not part of the PHI which you would be permitted to inspect and copy,
Not created by our practice, unless the individual or entity that created the information is not available to amend the information.

Accounting of disclosures:

All our patients have the right to request an "accounting of disclosures." An "accounting of disclosures" is a list of certain non-routine disclosures our practice has made of your PHI for purposes not related to treatment, payment or operations. Use of your PHI as part of the routine patient care in our practice is not required to be documented; for example, the doctor sharing information with the nurse or the billing department using your information to file your insurance claim. To obtain an accounting of disclosures, you must submit your request in writing to the office manager of US Pain Relief. All requests for an "accounting of disclosures" must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge, but our practice may charge you for additional lists within the same 12-month period. Our practice will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.

Right to a paper copy of this notice:

You are entitled to receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact the office manager of US Pain Relief

Right to file a complaint:

If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact the office manager of US Pain Relief. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

Right to provide an authorization for other uses and disclosures:

Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization. Please note: We are required to retain records of your care.

As required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) this notice describes how health information about you (as a patient of US Pain Relief) may be used or disclosed and how you can get access to your individually identifiable health information. We would be glad to provide our patients a text version of this upon request.

Printed Name

Signature

Date

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

HIPAA Privacy Authorization Form
(Required by the Health Insurance Portability and Accountability Act - 45 CFR Parts 160 & 164)

Print Name:

Date of Birth:

*****REQUIRED*****

Acknowledgement of Privacy Practices

By signing below, I hereby acknowledge that I have received a copy of US Pain Relief Notice of Privacy Practices as of the date set forth below.

Signature

Today’s date

Acknowledgement of Practice Policies

Signature

Today’s date

*****BELOW IS OPTIONAL*****

The following individuals can have both written and verbal access to any of my medical records and information pertaining to my care:

List

Name:

Relationship:

Patient’s Signature

Today’s date

New Patient Paperwork

PATIENT INFORMATION

EMERGENCY CONTACT

INSURANCE INFORMATION

PAIN INFORMATION

How have you treated your pain in the past? Fill all that apply.

HEALTH SUMMARY

PRESENT OR PRIOR HEALTH CONDITIONS

SOCIAL HISTORY

FAMILY HISTORY

US Pain Relief PLLC Medication Policy – Pain Agreement

GOALS OF TREATMENT:

APPROPRIATE PATIENT BEHAVIOR, RESPONSIBILITY & COMPLIANCE WITH TREATMENT:

MODIFYING/DISCONTINUING TREATMENT:

PATIENT EDUCATION (PROPER USE, RISKS OF ADDICTION, ALTERNATIVES):

Financial Responsibility Disclosure Statement

FOR MEDICARE PATIENTS ONLY:

US Pain Relief Privacy Policy Notice

A. Our commitment to your privacy:

C. We may use and disclose your PHI in the following ways:

D. Use and disclosure of your PHI in certain special circumstances:

E. Your rights regarding your PHI:

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

Acknowledgement of Privacy Practices

Acknowledgement of Practice Policies

The following individuals can have both written and verbal access to any of my medical records and information pertaining to my care:

Address:

Phone Number:

Fax Number: