new patient packet 04202018 - pain doctor...emily bowden, rn, fnp-c shannon o’neill, rn, fnp-c...

Phone: 512.416.7246 Fax: 512.275.2828

Toll Free: 888.299.9290 www.paindoctor.com/austin

Brannon R. Frank, M.D. John W. Wages, M.D. Christine M. Anderson, M.D. Martin V. Thai, M.D.

Donna Teague, PA-C Jessica Horwath, PA-C Amy Gonzales, PA-C Jessica Holley, PA-C Joshua Smith, PA-C

Emily Bowden, RN, FNP-C Shannon O’Neill, RN, FNP-C Tessa Gibbs, RN, FNP-C Allison Turner, RN, DNP, FNP-C

Dear Patient, Welcome to Pain Doctor! It is our goal and mission to help you improve your level of everyday function and reduce your level of pain. The most important part of your treatment plan is YOU! In order to develop an effective treatment plan, we need to obtain some detailed medical information about your health. To better serve you, please complete the information provided and utilize the checklist below to ensure you have everything ready for your initial appointment. Please note that your visit may be rescheduled if you have not completed all of the required information by your scheduled appointment time. We ask that the following items are sent to our office prior to your appointment date:

o Medical records from your referring and/or your primary care physician

o If required, referral or prior authorization from referring physician or insurance carrier You will need to bring the following required information to your initial appointment:

o New Patient Packet (Please allow 45 minutes to complete this packet)

o Medical insurance card(s) (primary and secondary- if applicable)

o State or government issued identification (example: driver’s license, passport)

o Payment for visit

If your insurance requires that you obtain a referral or prior authorization for office consultation, please contact your primary care physician or referring physician and have it faxed to 512.275.2828. If you have any further questions about referrals, authorizations, co-payments, deductibles, or coinsurance amounts, feel free to call our office and ask to speak to our Patient Account Representative or Preauthorization Department at 512.416.7246. Thank you for choosing Pain Doctor. We look forward to seeing you at your appointment on: Date: ____ / ____ / ____ Arrival Time: _____: ______ Appointment Time: _____: ______ Provider: _______________________________________ Office Location: ______________________________

South Austin Office: 2501 W. William Cannon Dr., Suite 401

Austin, TX 78745

North Austin Office: 2200 Park Bend Dr., Bldg. 1, Suite 201

Austin, TX 78758

Georgetown Office: 3201 S. Austin Ave., Suite 265

Georgetown, TX 78626

Cedar Park Office: 351 Cypress Creek Road, Suite 201,

Cedar Park, TX 78613

GENERAL INFORMATION

Your initial visit at Pain Doctor will be with one of our U.S. Anesthesia Partner’s (USAP) Board Certified pain management physicians and advanced practice providers. After visiting with the physician, you will receive a comprehensive treatment plan. We use a multidisciplinary approach to treat pain, so your plan may include diagnostic/therapeutic procedures, physical therapy, psychological evaluation/treatment, medication management, lab tests, and/or radiological examinations. For your convenience, we offer a majority of these treatments at many of our office locations. DIAGNOSTIC/THERAPEUTIC PROCEDURES Depending on your situation, your physician may prescribe an injection that may be used for diagnosis and/or treatment. The details of the injection will be explained by your medical provider and through educational materials. You can also learn more about these procedures by viewing our website. Click on the “Education” heading and select the “Pain Treatments” section to find information about the procedures. PHYSICAL THERAPY Through exercise, massage, and stretching, physical therapy can increase your strength, improve the movement of your joints, decrease your pain, and improve your function. PSYCHOLOGICAL EVALUATION/TREATMENT Behavioral Health therapists working with patients that suffer with chronic pain are not trying to decide whether a patient’s pain is real or imaginary. We understand that we cannot visualize pain and that it is real to the person that suffers with it every day. Pain can affect multiple parts of your life, including your ability to participate in your hobbies or job, interact with your family members, or even perform simple household chores. This can lead to significant frustration and possibly even depression. Behavioral Health therapists can help with these problems by using psychology-based treatment approaches that can reverse some of these effects of pain. Our goal is to help you regain the life you had before you started experiencing pain. MEDICATION MANAGEMENT All medications have the potential for side effects and may require multiple adjustments to find the best dosage that reduces your pain while minimizing side effects. These adjustments will typically take place during your office visits. NOTICE TO PATIENTS: Brannon R. Frank, M.D., John W. Wages, M.D., Christine M. Anderson, M.D., directly or indirectly, hold ownership interests in one or more of the following companies and will receive, directly or indirectly, remuneration for services provided to patients by these companies: Stonegate Surgery Center, Cedar Park Surgery Center, Hays Surgery Center, and Arise Austin Medical Center.

Patient Name________________________________________________________________________DOB:________________________ 1

NOTE: Please complete in BLACK ink, as other ink colors may not show when scanning into the computer system.

Date: ____/____/____ Name: _____________________________________________________________________ Last First Middle Sex: Male Female Date of Birth ____/____/____ Height: ______ Weight: _______ Marital Status: Single Married Significant Other’s Name: ____________________________

Emergency Contact: _________________ Relationship to Patient: _____________Contact number: ( ) ________

Preferred Language: English �SpanishFrench �German �Vietnamese �Italian �Mandarin Other

Race: �American Indian/ Alaska Native �Asian �Black/ African American

�Native Hawaiian/ Other Pacific Islander White

Ethnicity: Hispanic or Latino Non-Hispanic or Latino

Referring Physician: _____________________________________________________________

Treating/Primary Care Physician: ___________________________________________________

Other Physicians you have seen specifically for this pain problem: _________________________

______________________________________________________________________________

______________________________________________________________________________

Patient Name________________________________________________________________________DOB:________________________ 2 CONTACT PERMISSION In the event that Pain Doctor needs to contact you about your medical care but is unable to reach you directly, we would like to know if you would like us to attempt any of the following commonly requested alternatives. Before you check one or more of the options below, please take into consideration that these messages could include information about your medication(s), test results, insurance coverage, appointment details, payment collection, or other personal information regarding your care at Pain Doctor. If unable to contact me directly, I authorize Pain Doctor to (please check the applicable boxes):

□ Leave a voice mail message at this phone number ( ) -

□ Speak to my spouse or significant other whose name is__________________________

□ Speak to or leave a message with the family members/friends listed below.

Name: __________________ Relationship to Patient: __________________Contact number: ( ) -

Name: __________________ Relationship to Patient: __________________Contact number: ( ) -

I understand should I no longer want to authorize Pain Doctor to share information regarding my care with any of the individuals listed above or leave a voicemail at the phone number listed above it will be my responsibility to notify Pain Doctor of such in writing. __________________________________________________________________________ Patient/Guardian Signature Date

Patient Name________________________________________________________________________DOB:________________________ 3 INSTRUCTIONS: Please fill out each section; if a section does not apply, please answer with ”N/A” for “not applicable”. PAIN DESCRIPTION

1. Where is your worst pain? __________________________________________________________

________________________________________________________________________________

2. When did your pain begin? __________________________________________________________

________________________________________________________________________________

3. My pain is the result of an (check one): accident illness I do not know what caused my pain

a. Please describe illness or accident:______________________________________________

__________________________________________________________________________

b. If accident, is there litigation involved? Yes No Please explain:

__________________________________________________________________________

4. Please shade the locations of your pain in the diagrams below.

Patient Name________________________________________________________________________DOB:________________________ 45. Please check the word/words that best describe your pain.

Aching Dull Constant Numbing Coldness Burning Sharp Stinging Stabbing Tingling Cramping Radiating

6. Please indicate if any of the following increases, decreases, or causes no change to your pain.

PAIN SCALES 7. Please rate your lowest pain level. (0 = No pain 10= Worst pain)

0 1 2 3 4 5 6 7 8 9 10

8. Please rate your worst pain level. (0 = No pain 10= Worst pain) 0 1 2 3 4 5 6 7 8 9 10

9. Please rate your present pain level. (0 = No pain 10= Worst pain)

0 1 2 3 4 5 6 7 8 9 10

FUNCTIONAL SCALES 10. Please rate your ability to cope with pain. (0 = Not able 10 = Very able)

0 1 2 3 4 5 6 7 8 9 10

11. Please rate your ability to perform activities of daily living such as hygiene, household chores, transportation, etc. (0 = Not able 10 = Very able) 0 1 2 3 4 5 6 7 8 9 10

12. Please rate your ability to function and interact well with family and friends. (0 = Not able 10 = Very able)

0 1 2 3 4 5 6 7 8 9 10

13. Please rate your ability to work in your usual occupation. (0 = Not able 10 = Very able) 0 1 2 3 4 5 6 7 8 9 10

Stimulus/Treatment Increase Pain Decrease Pain No ChangeHeatColdWeather ChangesLying DownSleepPhysical ActivitySexual IntercourseSittingStandingSneezing/CoughingPhysical TherapyMassage TherapyUrinationBowel MovementTensionFatigue

Patient Name________________________________________________________________________DOB:________________________ 5PAIN TREATMENT HISTORY 14. Please check all medications that you have tried in the past.

Opioids

Fentanyl (Actiq, Fentora,

Duragesic) Demerol Hydrocodone (Lortab, Norco,

Vicodin, Vicoprofen) Tramadol (Ultram ER

Ultram) Morphine (Avinza, kadian,

Embeda, MS Contin) Oxymorphone (Opana,

Opana ER) Methadone Other: ____________

Oxycodone (Oxycontin, Percocet)

Hydromorphone (Dilaudid, Exalgo)

Tapentadol (Nucynta) __________________

Propoxyphene (Darvocet, Darvon)

Buprenorphine (Suboxone, Subutex, Butrans Patch)

Codeine

Anti-inflammatories & Tylenol

Diclofencac (Arthrotec, Voltaren, Voltaren Gel) Oxaprozin (Daypro) Meloxicam (Mobic) Nabumetone (Relafen)

Aspirin Indomethacin (Indocin) Ibuprofen (Motrin, Advil) Acetaminophen (Tylenol) Celecoxib (Celebrex) Etodolac (Lodine) Naproxen (Naprosyn) Flector patch Other:____________________________________________________________________

Muscle Relaxants Baclofen Methocarbamol (Robaxin) Carisoprodol (Soma) Cyclobenzaprine (Flexeril, Amrix) Metaxalone (Skelaxin) Tizanidine (Zanaflex) Other:___________________________________________________________________ Antidepressants Cymbalta Nortriptyline (Pamelor) Remeron Wellbutrin Effexor Paxil Serzone Zoloft Amitriptyline (Elavil) Pristiq Imipramine (Tofranil) Lexapro Fluoxetine (Prozac) Trazodone Other:___________________________________________________________________ Sleep Aids Zolpidem (Ambien, Ambien CR) Lunesta Rozerem Xyrem Restoril Sonata Other:___________________________________________________________________ Other

Axert Hydroxyzine Lyrica Tegretol Zonegran Buspar Imitrex Maxalt Topamax Frova Keppra Gabapentin (Neurontin) Vistaril Gabitril Lidoderm Patch Relpax Zomig Other:______________________________________________________________________

Patient Name________________________________________________________________________DOB:________________________ 615. Please list the diagnostic tests you have received. Include the approximate date and location in which the

testing was performed.

Diagnostic Test Area of Body Date Location X-Ray MRI Scan CT Scan EMG Myelogram

16. Have you had any of the following treatments for your pain?

Treatment Yes No If yes, last date Surgery Traction Spinal Injection Joint Injection Muscle Injection Ketamine Infusion Nerve Block Physical Therapy Chiropractic Care Psychotherapy Acupuncture TENS Unit

TREATMENT GOALS 17. We are dedicated to helping you improve your function in everyday life. Please list goals (i.e. running,

gardening, riding a bike, etc…that you would like to achieve. ___________________________________

_____________________________________________________________________________________

_________________________________________________________________________________

SLEEP BEHAVIOR 18. Have you been evaluated for sleep apnea with a sleep study? Yes No

If yes, were you diagnosed with sleep apnea? Yes No

19. If you were diagnosed with sleep apnea, are you currently using a CPAP or

BiPAP machine? Yes No

Patient Name________________________________________________________________________DOB:________________________ 7 REVIEW OF SYSTEMS 20. Are you currently experiencing any of the following?

MEDICAL HISTORY 21. Have you ever been diagnosed with the following? (check all that apply)

AIDS Epilepsy High Blood Pressure Peripheral Vascular Disease

Asthma Fibromyalgia Kidney Disease Shingles

Cancer HIV Positive Lupus Sleep Apnea

Diabetes Heart Disease Migraines Stroke

Emphysema Hepatitis (A, B, C, D) Osteoarthritis

Other: ________________________________________________________________________

22. Are you currently pregnant? Yes No

23. Do you currently have an Advanced Directive? Yes No

24. Have you had a pneumonia vaccination in the past? Yes No

25. Please list all medications including pain medications, over the counter medications and supplements. Medication Strength Directions Prescribing Doctor

General Gastrointestinal PsychYes No Yes No Yes No

Chills Constipation Hallucinations Night sweats Nausea Muscular Fever Vomiting Yes No

Eyes Genitourinary SwellingYes No Yes No Stiffness Visual changes Pain with urination Joint pain

Cardiovascular Difficulty controlling urine Bone painYes No Erectile dysfunction Neurological Abnormal heart beat Skin Yes No

Chest pains Yes No Memory changesRespiratory Sores HeadachesYes No Rashes Numbness Shortness of breath Loss of body hair Endocrine Persistent cough Hematologic Yes No

Yes No Decreased sex drive Bleeding Disorders Absence of menstrual cycle

Patient Name________________________________________________________________________DOB:________________________ 8

26. Do your pain medications provide relief? Yes No I do not take pain medications

If yes, how much relief do you receive?

10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

27. Do your pain medications improve your function? Yes No I do not take pain medications

If yes, how much improvement in function do you receive?

10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

28. Do you experience any side effects or adverse effects? Yes No

We would like to access your pharmacy records and drug formulary information through a third party database. This service provides us with accurate prescription information from other prescribing physicians and will allow our system to check which medications are on your drug formulary. I authorize Pain Doctor to access my prescription history through my pharmacy, pharmacy benefits manager and or Surescripts. _____________________________________

(Patient Signature)

ALLERGIES AND OR SIDE EFFECTS 29. If you are allergic to any medications, please list the medication name and reaction below.

Medication Reaction

SURGICAL HISTORY 30. Do you currently have an implanted ICD, pacemaker, or defibrillator? Yes No

31. Please list prior surgeries or procedures in the table below.

Date Surgery/Procedure Physician

Patient Name________________________________________________________________________DOB:________________________ 9FAMILY MEDICAL HISTORY Do any of your family members have a history of or are currently suffering from any of the following medical and/or psychiatric conditions:

32. Father Addiction/substance abuse Cancer Hypertension

Alcoholism Chronic pain Multiple personality disorder

Alzheimer’s Dementia Schizophrenia

Anxiety Depression Stroke

Arthritis Diabetes Other __________________

Bipolar disorder Heart disease

33. Mother Addiction/substance abuse Cancer Hypertension






34. Brother Addiction/substance abuse Cancer Hypertension






35. Sister Addiction/substance abuse Cancer Hypertension






36. Other relative (please specify): _____________________________________________ Addiction/substance abuse Cancer Hypertension






Patient Name________________________________________________________________________DOB:________________________ 10

LIFESTYLE 37. What is your current work status?

Employed Retired Disabled Unemployed 38. If you are unemployed, employed part-time or have work restrictions, is this due to your present pain

condition? Yes No

39. What are your current work restrictions, if any? ___________________________________________

______________________________________________________________________________ 40. Do you smoke? Yes, currently Yes, in the past No, never

a. If currently, how many packs do you smoke per day? 0-1/2 1/2-1 1-2 More than 2

b. How long have you smoked? Years:________

41. Do you use alcohol? Yes No

If currently, how many drinks do you consume? (Answer 1 of the options below)

a. I consume _____ drinks every day.

b. I consume _____ drinks every week.

c. I consume _____ drinks every month.

If you have abused alcohol in the past, have you abused alcohol within the last year? Yes No

42. Have you ever had a problem with prescription medications (misuse, abuse, addiction, etc)?

Yes, currently Yes, in the past No, never

If in the past, was it within the last year? Yes No

43. Have you ever used any drugs that are considered illegal in your state of residence? (cocaine, marijuana,

intravenous drugs, etc.)?

Yes, currently Yes, in the past No, never

If in the past, was it within the last year? Yes No

44. Have you ever been treated for addiction or alcoholism? Yes No

If yes, please explain: ____________________________________________________________

______________________________________________________________________________

Patient Name________________________________________________________________________DOB:________________________ 11 PSYCHOLOGICAL TREATMENT 45. Have you ever been diagnosed with or received psychiatric, psychological, or social work

treatments/evaluations for any of the following diagnosis/problems? (check all that apply) Alzheimer’s Anxiety Bipolar Disorder

Dementia Depression Multiple Personality Disorder

Schizophrenia Other: _______________________________________________

a. If yes, have you ever been treated for any of the above diagnoses?

Yes, currently Yes, in the past No

If yes, when were you treated? _____________________________________________

Therapist’s name: _______________________________________________________

46. Have you considered suicide? Yes No

47. Have you ever planned suicide? Yes No

48. Have you ever attempted suicide? Yes No Date: __________

I acknowledge that I have provided you with the most accurate and complete information about my medical history to the best of my ability. __________________________________________________________________________ Patient/Guardian Signature Date

Patient Name________________________________________________________________________DOB:________________________ 12

SOAPP-R The following are some questions given to patients who are on or being considered for medication for their pain. Please answer each question as honestly as possible. There are no right or wrong answers.

Never Seldom Sometimes Often Very Often

1 How often do you have mood swings? 0 1 2 3 4

2 How often have you felt a need for higher doses of medication to treat your pain?

0 1 2 3 4

3 How often have you felt impatient with your doctors? 0 1 2 3 4

4 How often have you felt that things are just too overwhelming that you can't handle them?

0 1 2 3 4

5 How often is there tension in the home? 0 1 2 3 4

6 How often have you counted pain pills to see how many are remaining?

0 1 2 3 4

7 How often have you been concerned that people will judge you for taking pain medication?

0 1 2 3 4

8 How often do you feel bored? 0 1 2 3 4

9 How often have you taken more pain medication than you were supposed to?

0 1 2 3 4

10 How often have you worried about being left alone? 0 1 2 3 4

11 How often have you felt a craving for medication? 0 1 2 3 4

12 How often have others expressed concern over your use of medication?

0 1 2 3 4

13 How often have any of your close friends had a problem with alcohol or drugs?

0 1 2 3 4

14 How often have others told you that you had a bad temper? 0 1 2 3 4

15 How often have you felt consumed by the need to get pain medication?

0 1 2 3 4

16 How often have you run out of pain medication early? 0 1 2 3 4

17 How often have others kept you from getting what you deserve?

0 1 2 3 4

18 How often, in your lifetime, have you had legal problems or been arrested?

0 1 2 3 4

19 How often have you attended an AA or NA meeting? 0 1 2 3 4

20 How often have you been in an argument that was so out of control that someone got hurt?

0 1 2 3 4

21 How often have you been sexually abused? 0 1 2 3 4

22 How often have others suggested that you have a drug or alcohol problem?

0 1 2 3 4

23 How often have you had to borrow pain medications from your family or friends?

0 1 2 3 4

24 How often have you been treated for an alcohol or drug problem?

0 1 2 3 4

I acknowledge that I have provided you with the most accurate and complete information about my medical history to the best of my ability. __________________________________________________________________________ Patient/Guardian Signature Date

Pain Doctor, Inc. Original: 10‐2‐2017 Revised: 11‐8‐2017 USAP Outside Counsel Reviewed and Approved – 11‐2017 M.Stanfield Page 1 of 1

This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. The consent will remain fully effective until it is revoked in writing. You have the right to discontinue services at any time. ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

I certify that the Medical History I provided is complete and accurate to the best of my knowledge and ability.

I voluntarily request that Pain Doctor, Inc. and its affiliate, US Anesthesia Partners of Texas PA (“USAP”)(hereafter referred to as the “Practice”) and any associates, assistants, and other health care providers it may deem necessary, provide general pain management care, treatment, and services to me, as deemed reasonable and necessary by the assigned healthcare provider(s). I consent to reasonable and necessary medical examination, evaluation, testing and treatment which may include diagnostic, radiology and laboratory procedures. I understand I may be asked to provide urine, oral swab, and/or blood samples. I also understand that, if my health care practitioner believes the use of opiates is appropriate to treat my specific pain and condition, I may be asked to enter into a separate pain management agreement which outlines specific obligations and rights related to such treatment as a condition to continued care. I have the right to refuse specific tests or to refuse to enter into an agreement, but understand this may impact my pain management treatment and/or render me ineligible to receive care from Pain Doctor/USAP. If an invasive procedure or other surgical intervention is recommended, I will be informed of the benefits and risks of the procedure/intervention prior to performance and will be provided with a separate consent form outlining such benefits and risk.

I understand that the Practice has physician assistants and/or nurse practitioners to assist in the delivery of interventional pain management care. Under the supervision of a physician, a physician assistant and/or nurse practitioner can diagnose, treat and monitor common acute and chronic diseases as well as provide you with health maintenance care. Supervision does not require the constant physical presence of a physician, but rather overseeing the activities of and accepting responsibility for the medical services provided. I hereby consent to the services of a physician assistant and/or nurse practitioner for my health care needs. I understand that I can refuse to see a physician assistant and/or nurse practitioner and request to see a physician at any time. I understand that this may require my appointment to be rescheduled or require a longer wait time for an appointment.

RELEASE OF INFORMATION I give permission to Pain Doctor/USAP and its affiliated health care providers to release any information about me, my health, the health services provided to me, or payment for my health services, that may be necessary: (1) for my treatment (to health care providers or facilities that need the information for my continued care); (2) for any purposes related to payment by me or a third party for services (to determine eligibility, to process an insurance claim, for utilization and quality review, or for billing or collection purposes, as necessary to obtain payment); (3) for the health care operations of Pain Doctor/USAP or another health care provider that has had a relationship with me (quality assessment, training programs, planning, and fundraising); or (4) as otherwise described in the Notice of Privacy Practices and as permitted by law.

BY SIGNING BELOW, I AM AGREEING TO THE CONSENTS AND RELEASES DESCRIBED ON THIS FORM. I HAVE READ THIS CONSENT AND HAVE BEEN ABLE TO ASK QUESTIONS.

___________________________________________ _______________________________________ Printed Name of Patient or Representative Signature of Patient or Representative

_ ________ ________________

Relationship to Patient Date

General Consent and Authorization for Treatment, Evaluation, and Information Release

Patient Financial Agreement

Rev. 10.2.17 Page 1 of 3

Thank you for choosing Pain Doctor. Our goal is to provide you with the highest quality care possible. We find

that communication regarding our financial agreement assists us in providing the best service to you.

Therefore, we take this opportunity to explain your financial responsibilities for the clinical services provided

to you by US Anesthesia Partners of Texas, PA (“USAP”) at Pain Doctor (hereafter referred to as the

“Practice”). Please carefully review this Patient Financial Agreement, initial each section and sign the

agreement to indicate your acceptance of its terms.

AP P O I N T M E N T S

1. Copayments and Deductibles. Copayments and deductibles for clinic visits are due at the time of

service, in accordance with your insurance carrier’s plan. If you are unable to make your copayment at

the time of service, the Practice reserves the right to reschedule your appointment until you are able

to pay your estimated responsibility. Initial: _____

2. Procedure Prepayment. The Practice wi l l collect your payment for a procedure at the time the

procedure is scheduled or prior to your appointment. Your prepayment is based on an estimate of your

expected financial responsibility. We reserve the right to reschedule your procedure until prepayment

arrangements have been made. You are responsible for any unpaid balance after your insurance

carrier has processed your claim. Should your insurance carrier pay more than was expected resulting

in a credit on your account, we will apply the credit to any unpaid balances that may exist and then

refund any amounts due you. Initial: _____

3. Self-Pay. If you do not have health insurance, or if your health insurance will not pay for services

rendered by the Practice, or if you notify us not to contact or bill your insurance company, you are

considered a self-pay patient. Your charges will be based on our current self-pay fee schedule. Payment

is due in full at the time of service. Initial: _____

4. Missed Appointments and Late Arrivals. Patient cancellations that occur within 24 hours of

appointment time, late arrivals (more than 15 minutes) and no-show events are subject to a

fee of $50.00 for office visits and $150.00 for procedures. Patients who consistently fail to

show up for their scheduled appointments without providing 24 hour advanced notice may be

terminated from the practice. Initial: _____

I N S U R A N C E PAYMEN TS

5. Financial Responsibility. Your insurance policy is a contract between you and your insurance carrier.

You are ultimately responsible for payment-in-full for all medical services provided to you. Any charges

not paid by your insurance carrier will be your responsibility, except as limited by the Practice’s specific

network agreement with your insurance carrier, if such an agreement is in place. Initial: ____

6. Coverage Changes and Timely Submission. If there are any changes in your insurance, it is your

responsibility to inform us and provide the detailed changes of your insurance. We request that you

inform us at least 24 hours prior to your appointment. Your insurance carrier places a t ime limit within

which the Practice can submit a claim on your behalf. If the Practice is unable to process your claim

within this period due to your providing incorrect insurance information or not responding to insurance

carrier inquiries, you will be responsible for all charges. Initial: ______

B E N E F I T S AN D A UT H O R I Z A T I O N

7. Insurance Plan Participation. The Practice has specific network agreements with many insurance

carriers, but not all insurance carriers. It is your responsibility to contact your insurance carrier to

verify that your assigned provider participates in your plan. Be aware, our participation can change

at any time and you are responsible to contact your insurance carrier to ensure we are contracted

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with your insurance plan. Your insurance carrier’s plan may have out-of-network charges that have

higher deductibles and copayments, which you will be responsible for. Initial: _____

8. Referrals. Referral and prior authorization requirements vary among insurance carriers and plans. If

your insurance carrier requires a referral for you to be seen by the Practice, it is your responsibility to

obtain this referral prior to your appointment. Pursuant to HIPAA, your referring health care provider,

and the Practice, are expressly permitted to disclose your Protected Health Information (PHI) to each

other and other healthcare providers and facilities for your treatment.

As a matter of course, the practice will inform your referring physician of your patient care plan and

progress either by using any secure electronic transmission machine or by an employee of the Practice.

Initial: _____

9. Prior Authorization and Non-Covered Services. The Practice may provide services that your insurance

carrier’s plan excludes or requires prior authorization. The Practice as a courtesy to our patients, will

make a good-faith effort to determine if services we provide are covered by your insurance carrier’s

plan, and, if so, determine if prior authorization for treatment is required. If determined that a prior

authorization is required, we will attempt to obtain such authorization on your behalf. If we are unable

to obtain prior authorization, we will either reschedule the procedure or offer a self-pay option.

Ultimately, it is your responsibility to ensure that services provided to you are covered benefits and

authorized by your insurance carrier. Initial: _____

10. Out-of-Network Payments and Direct Insurer Payments. You are personally responsible for all

charges. If the Practice is not part of your insurance carrier’s network (out-of-network) or your

insurance carrier pays you directly, you are obligated to forward the payment or payment proceeds to

the Practice immediately. Initial: _____

A CCOUNT B A LA N CE S AND PAY M E N T S

11. Reassignment of Balances. If your insurance carrier does not pay for serv ices within a reasonable

time, according to the provisions of our agreement with your insurance carrier, we may transfer the

balance to your sole responsibility. Please follow up with your insurance carrier to resolve non-

payment issues. Balances are due within 30 days of receiving an initial statement. Initial: _____

12. Collection of Unpaid Accounts. If you have an outstanding balance over 120 days old and have

failed to make payment arrangements (or become delinquent on an existing payment plan), we may

turn your balance over to a collection agency and/or an attorney for collection. This may result in

adverse reporting to credit bureaus and additional legal action. In addition, any fees charged by the

collection agency or attorney will be added to your account balance as your responsibility. The Practice

reserves the right to refuse treatment to patients with outstanding balances over 120 days old. You

agree, in order for us to service our account or to collect any amounts you may owe, we may contact

you at any telephone number associated with your account, including cellular numbers, which could

result in charges to you. We may also contact you by text message or e-mail, using any e-mail address

you provide. Methods of contact may include using pre-recorded/artificial voice messages and/or use of

an automatic dialing device. Initial: _____

13. Returned Checks. You will be charged $30 per incident for returned checks (including any Bank Fees).

Initial: _____

14. Refunds. Refunds for overpayment are processed only after full insurance reimbursement of all

medical services has been received. Please allow up to 4 weeks for your refund to be processed. You

may also email questions you have about your refund to [email protected] for

Austin and San Antonio patients, or [email protected] for Dallas and

Houston patients. Initial: _____

15. Statements. Charges shown by statement are agreed to be correct and reasonable unless protested

in writing within 30 days of the receipt. Depending on services rendered, your account balance may be

split between multiple statements. Initial: _____

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A DDITION AL F EES

16. Medical Records Requests. The HIPAA Privacy Rule and state law allows you to receive a copy of your

personal medical and billing records, and allows the Practice to require individuals to complete and sign

an Authorization for Disclosure and Release of Medical Records Form. There is no charge to transfer a

copy of your medical records to a new Provider. Initial: _____

17. Other Forms. During your visit, the Provider will determine a response to requests for the completion of

certain medical forms (FMLA, Short Term Disability & Temporary Disability Parking Permit) according to

the medical discretion of your Provider. Depending upon the circumstances, we charge a fee for

completing certain forms. Initial: _____

18. Acknowledgment of Notice of Privacy Practice. By initialing this section, I acknowledge that I have

received and reviewed a copy of the Practice’s Notice of Privacy Practice. Initial: _____

19. Public Fee Schedule. By initialing this section, I acknowledge that I have received a copy of the Practice’s

Public Fee Schedule. Initial: _____

USAP and its affiliates has adopted this Public Fee Schedule in order to comply with the Health Insurance

Portability and Accountability Act of 1996 (“HIPAA”) and applicable state law.

ITEM FEE CHARGED

Failure to Cancel your Appointment $50.00 per Clinic Incident

within 24 hours of the schedule time $150.00 per Procedure, EMG or MRI incident

No Show for your appointment $50.00 per Clinic Incident

$150.00 per Procedure, EMG or MRI incident

Late Arrivals. If you arrive 15 minutes $50.00 per Clinic Incident

past your arrival time, and we must $150.00 per Procedure, EMG or MRI incident

reschedule your appointment

Completion of Disability Forms Costs below are per each occurrence:

FMLA - $50.00

Short Term Disability - $30.00

Life Insurance - $30.00

Other forms requested by third party/patient -

$30.00

I have read and understand the Financial Policy of the Practice and I agree to abide by its terms. I hereby assign

all of my medical and surgical insurance benefits and authorize my insurance carrier(s) to issue payment directly

to USAP for services provided by the Practice. I understand that I am financially responsible for all services I

receive from the Practice. This financial agreement is binding upon me and my estate, executors and/or

administrators, if applicable.

Printed Name: _________________________________________

Signed: _______________________________________________

Date: _____________________

Public Fee Schedule

Agreement and Assignment of Benefits

Practice Code of Conduct

Rev. 7.27.17 Page 1 of 1

We are pleased to serve you and glad that you chose the Practice as your new pain management provider. We

will always strive to provide exceptional care for you.

Reasons that we may ask you to seek health care services elsewhere might include, but are not limited to the

following:

• Disruptive, rude, uncooperative or violent behavior to staff via in-person or telephone - this also

applies to your family members and/or friends

• Repeated no shows, cancellations, or continual late arrivals for office visits or procedures

• Refusal to adhere to the plan of care as outlined by your Provider

• Violation of controlled substance agreement

• Failure to pay for services rendered

• The patient terminates the relationship with their provider

Our goal is to help you by providing you with the highest quality care possible. Therefore, we ask that you

schedule and keep all follow up appointments, participate in all treatments and diagnostic testing.

Printed Name: ______________________________________________

Signed: ____________________________________________________

Date: _____________________________

Pain Doctor, Inc. Original: 11/17/2016 Revised: 02/21/2018

CONFIDENTIAL ‐ For internal use only. Any unauthorized

reproduction or distribution without the written consentof Pain Doctor, Inc. is strictly prohibited.

Page 1 of 5

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.

To appropriately treat you and receive payment for the services we provide, we need to obtain information from you including your full name and address, insurance company, family medical history, current medical history, and current medical condition. We will use and disclose this information and other information we collect in the ways described below. To help you understand how we will use and disclose your information we have put the different uses and disclosures into categories and give examples of each. All of the ways we use or disclose your information will fit into one of the categories listed below, but we cannot list all of the uses and discloses in each category.

We may use and disclose your health information, without your consent or authorization, for treatment, payment, and health care operations, and for the following other reasons.

Treatment. We may use and disclose your information to provide you with medical treatment and services. Your information may be disclosed to individuals and facilities providing care to you. These individuals and facilities need your information to provide care, and to coordinate and provide services (such as prescriptions, lab tests, meals, and x-rays).

Payment. We may use and disclose your information to receive payment for the services and treatment provided to you. We use your information to create a bill and disclose your information when we send the bill to your insurance company, you, or a third party. The individual or entity paying the bill may request more information to determine whether the bill is covered by your insurance. We may tell your health plan about a treatment you are going to receive to get approval for payment or to determine whether your health plan will cover the treatment.

Health Care Operations. We may use and disclose your information for health care operation purposes. Health care operations includes review of the care you receive for quality assessment, educational, business planning, and compliance plan purposes.

Business Associates. From time to time, we enter into agreements with Business Associates who perform services on our behalf. These Business Associates are required to keep your information confidential according to the terms of the agreement and the requirements of the Health Insurance Portability and Accountability Act (HIPAA) privacy rules. In general, Business Associates are required to keep your information confidential to the same extent as we are.

Appointment Reminders. We may provide appointment reminders to you. You may request in writing that we send reminders to a confidential or alternative address.

Treatment Alternatives. We may provide you with information about treatment alternatives and other health related benefits and services.




Page 2 of 5

We may also disclose your health information to outside entities, without your consent or authorization, in the following circumstances:

Required by Law. We disclose information as required by law. For example, we are required to report gunshot wounds to the police.

Public Health Purposes. We disclose information to health agencies as required by law for preventing or controlling disease. Examples are reporting of sexually transmitted, communicable, and infectious diseases

to Prevent a Serious Threat to Health or Safety. We may disclose information about you to law enforcement or an identified victim to prevent a serious threat to your health or safety or the health or safety of another individual or the public.

Research. Your information may be used by or disclosed to researchers for research approved by a privacy board or an institutional review board.

Health Oversight Activities. Your health information may be disclosed to governmental agencies and boards for investigations, audits, licensing, and compliance purposes.

Judicial and Administrative Proceedings. We may be required to disclose your health information to a court or for an administrative proceeding.

Law Enforcement Activities. We may be required to disclose your information as required by law, pursuant to a court order, warrant, subpoena, or summons.

In Emergency Circumstances.

Deceased Individual. We may disclose information for the identification of the body or to determine the cause of death.

Military and Veterans. If you are a member of the armed forces we may release information about you as required by military command authorities. We may also release information about foreign military personnel to the appropriate foreign military authority.

Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official. This release must be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety or security of the correctional institution.

Protective Services for the President and Others.

Organ and Tissue Donation. If you are an organ donor, we may release your medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ bank, as necessary to facilitate organ or tissue donation

Workers’ Compensation. We may release medical information about you for workers’ compensation or similar programs.

National Security and Intelligence Activities. We may release information about you to authorized Federal officials for intelligence, counterintelligence, and other national security activities authorized by law.




Page 3 of 5

We will give you the opportunity to object to the following uses and disclosure of your information:

Notification. We may tell your friends, relatives and other caretakers information which is relevant to their involvement in your care.

Disaster Relief. We may disclose information about you to public or private agencies for disaster relief purposes.

Except as provided above, we will obtain your written authorization prior to disclosure of your information for any other purpose. Specifically, written authorization is required prior to the disclosure of your information:

Psychotherapy Notes. We will not use or disclose your psychotherapy notes without a written authorization except as specifically permitted by law.

Marketing. We will not use or disclose your information for marketing purposes, other than face-to-face communications with you or promotional gifts of nominal value, without your written authorization.

Sale of Information. We will not sell your PHI without your written authorization, including notification of the payment we will receive.

Where a disclosure is made under your written authorization, you have the right to revoke the authorization at any time. Revocation of an authorization must be in writing. The revocation is effective as of the date you provide it to USAP and does not affect any prior disclosures made under the authorization. If a state or federal law provides additional restrictions or protections to your information, we will comply with the most stringent requirement.

Your Rights

You, or a person with legal authority to act on your behalf, have the right to:

Request a restriction on how information about you is used and disclosed. If you want to request a restriction of a use or disclosure of your information, contact our Privacy Officer at the number or e-mail listed at the end of this form. We are required to agree to a request for a restriction related to disclosure of information to your health plan for payment or healthcare operations where you pay for the service in full. We are not otherwise required to agree to any restriction on the use or disclosure of your information.

Request communications with you be made at an alternative address or phone number. We will honor any reasonable request. To request that communication be made at a different address or phone number contact our Privacy Officer at the number or e-mail listed at the end of this form to obtain the form to make your request.




Page 4 of 5

Inspect and copy your PHI maintained in the designated record set. To inspect and copy your record a request must be made in writing on the form provided by us. There are limited situations in which we may deny this request. To obtain a form contact your clinic. We have also included a form in this packet.

Request an amendment to your medical record if you believe the information we have about you is incorrect or incomplete. Your request must be made in writing on a form provided by the Practice. To request a form contact your clinic.

You have the right to receive an accounting of disclosures, a list of individuals and entities that received your health information for reasons other than treatment, payment, or healthcare operations and other certain disclosures. You may receive one (1) free accounting during a twelve (12) month period. If you request more than one (1) accounting in a twelve (12) month period, you may be charged a fee. An accounting is not provided for disclosures prior to April 14, 2003.

You have the right to request a paper copy of this Notice. Our Duties

We are required by law to maintain the privacy of PHI and to provide individuals with this Notice of our legal duties and privacy practice regarding health information.

We are required to notify you if there is a breach of your unsecured PHI.

We are required to follow the terms of the current Notice.

We may change the terms of this Notice and the revised Notice will apply to all health information in our possession. If we revise this Notice, a copy of the revised Notice will be posted and a copy may be requested from our Privacy Officer at the number or e-mail listed at the end of this form.

Organized Health Care Arrangement If you are an inpatient or outpatient of a hospital or other health care facility where our health care professionals perform services, our practice is part of an organized health care arrangement (OCHA) with the hospital or other health care facility and the Notice of Privacy Practices of the hospital or other health care facility controls the use and disclosure of your information. The participants in the OCHA will share your information as necessary to carry out treatment, payment, and healthcare operations, and as permitted by law. Use of Electronic Records We may use an electronic health record. Your records may be disclosed in electronic form for treatment, payment, and healthcare operations, and as permitted by law. Questions

If you have questions about this notice or want more information, please contact the USAP Privacy Officer at 972-663-8531 or [email protected].




Page 5 of 5

Complaints

If you believe your privacy rights have been violated or you disagree with a decision made about your health information, you may contact the USAP Privacy Officer at 972-663-8531 or [email protected] or you may contact the U.S. Department of Health and Human Services Office for Civil Rights. Under no circumstances will we ever ask you to waive your rights under this notice or retaliate against you in any manner for filing a complaint. Effective Date

The effective date of this notice is June 5, 2015.

Pain Doctor, Inc. Original: 11/17/2016

Revised: 02/21/2018 Page 1 of 2

CONFIDENTIAL - For internal use only. Any unauthorized reproduction or distribution without the written consent

of Pain Doctor, Inc. is strictly prohibited.

AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION and MEDICAL RECORD RELEASE

1. I, , (patient’s name or authorized representative)

hereby authorize (medical provider) to

release:

The following information from the medical/financial record of:

Patient Name: Date of Birth:

Dates of Treatment: Social Security #:

The information is to be released to:

(entity)

(Street Address)

(City, State, Zip)

Telephone: Fax:

Information to be released:

□ All Medical and Billing Records

□ A copy of my Medical Records from to .

□ A copy of my Medical Records pertaining to .

□ Claim/Billing Information from to .

□ Other (specify) .

The information specified above is to be released for the following purpose(s):

Treatment/Consultation Patient Request Billing or Claims

Attorney Social Security

Other (specify):

Pain Doctor, Inc. Original: 11/17/2016 Revised: 02/21/2018 Page 2 of 2

CONFIDENTIAL - For internal use only. Any unauthorized reproduction or distribution without the written consent

of Pain Doctor, Inc. is strictly prohibited.

AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION and MEDICAL RECORD RELEASE – CONTINUED

2. Drug and/or Alcohol Information Records Release

I understand that if my medical or billing records contain information in reference to drug and/or alcohol use or treatment, I specifically agree to its release. Check one & Initial: Yes No Initial

3. HIV/AIDS Information Records Release

I understand that if my medical or billing records contain information in reference to HIV/AIDS (Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome) testing and/or treatment, I agree to its release. Check one & Initial: Yes No Initials

4. Psychiatric or Mental Health Information Records Release I understand that if my medical or billing records contain information in reference to psychiatric or mental health testing or treatment, I agree to its release. Check one & Initial: Yes No Initials

5. Right to Revoke Authorization I understand that, without exception, I have the right to revoke this authorization in writing. I further understand the consequence of any such revocation.

6. Re-disclosure

I understand the information disclosed by this authorization may be subject to re-disclosure by the recipient and will no longer be protected by the Health Information Portability and Accountability Act of 1996. The facility, its employees, officers and physicians are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.

7. Copy Provided

I understand that I may request and receive a copy of this authorization after signing it.

8. Expiration This authorization will automatically expire one (1) year from the date of my signature or unless revoked prior to that time or unless otherwise specified as follows: .

9. Signature of Patient or Personal Representative I understand that the signing of this authorization is not a condition for continued treatment, payment, enrollment, or eligibility for health plan benefits.

Signature of Patient/Representative Name of Patient/Representative

Date Description of Representative’s Authority

Patient’s Date of Birth

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