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1 P a g e 1 Today s Appt : Time: Physician: Patient s Name of Birth: Age: Address: Home Phone: Business Phone Cell Phone Sex Social Security: Marital Status License Number: Occupation: Who is your Primary Physician: Phone#: - - Responsible Party Information Primary Insurance Relationship Party Policy Holders Name of Birth Address: Group# ID# Secondary Insurance Relationship Party Policy Holders Name of Birth Address: Group # ID# In case of Emergency, please contact: Name Relationship Address: Home Phone Alternate Phone Release of Information: I give permission to Associated Pain Specialists Spine, LLC to release information contained in my medical record to my insurance company, attorney, assignees and/or beneficiaries. Information without patient identifiers may be used for quality assurance purposes. Signed: : Assignment of Benefits: I hereby assign all medical and/or surgical benefits to include major medical benefits to which I am entitled, including Medicare, private insurance, and any other health plans to: Associated Pain Specialists Spine, LLC. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release all information necessary to ensure payment. I am responsible for following my insurance policy protocol and will accept any penalties incurred. Signed: :

2 P a g e 2 FINANCIAL RESPONSIBILITY FORM Unfortunately most insurance companies do not pay for all services render by physicians for patients. All insurance companies follow Medicare Guidelines. Medicare only pays for services that are deemed to be reasonable and necessary under section 1862 (a)(1) of Medicare law. If your insurance company determines that a particular service, although it would otherwise be covered, is not reasonable and necessary under Medicare program standards, your insurance will deny payment for that service. If your insurance company does deny payment for these services, we will bill you, the patient for these services. This payment in full is due immediately as your insurance sends you a denial. If you disagree with your insurance company s determination, it is your responsibility to appeal the process. I have fully read and understand the above waiver and agree to pay the physician any costs not covered by my insurance plan. Out of Network Benefits Notice Our Group currently does not participate with your Insurance Company. However we will accept payment from your insurance company once you have met your annual in network deductible responsibility. Because we are out of network providers, your insurance company may issue the payment of our claim to you directly. In the event you receive a check from your insurance company please contact our billing office immediately and remit check (countersigned) along with a copy of the explanation of benefits which will accompany the payment. I have read and agree to comply with the above. Signature of Patient Printed Name of Patient Witness, Associated Pain Specialists, LLC

3 P a g e 3 The patient understands that: Protected health information may be disclosed or used for treatment, payment or health care operations. The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review that Notice. The practice reserves the right to change the Notice of Privacy Practices. The patient reserves the right to restrict the uses of their information by the Practice does not have to agree to those restrictions. The patient may revoke this consent in writing at any time and all future disclosures will then cease. The Practice may condition receipt of treatment upon the execution of this consent. This Acknowledgement by: Please Print- patient name Signature/Guarantor Witness IF YOU CHOOSE NOT TO HAVE INFORMATION RELEASED TO A PARTICULAR INDIVIDUAL- PLEASE INDICATE BELOW For Treatment and Payment We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, insurance companies, attorneys, courts, or any other personnel who are involved in taking care of you as well as friends or family members. IF YOU CHOOSE NOT TO HAVE INFORMATION RELEASED TO A PARTICULAR INDIVIDUAL, PLEASE INDICATE THE NAME OF THE PERSON BELOW ALONG WITH YOUR SIGNATURE. Name of person(s) that you do not want information released to Signature

4 P a g e 4 INFORMATION RELEASE : I,, hereby authorize Associated Pain Specialists, LLC. And its professional staff to release any information contained within my file including the diagnosis and records of any treatment or examination rendered to me while I have been under your care. Patient Name: Patient Address: Patient Signature: Witness Signature: Witness Printed Name: AUTHORIZATION FOR RELEASE OF INFORMATION TO FAMILY DATE: Please be aware that the indicated parties on this document are hereby authorized to receive medical information about me or on my behalf: Patient Name: Patients Signature: Witness Name: Witness Signature:

5 P a g e 5 NARCOTIC AGREEMENT This is an agreement between,ss# (me, the patient) and Associated Pain Specialists (APS, my providers). It explains how I receive my mediations (pain medications, narcotics, muscle relaxers, sedatives, sleeping medications or other controlled drugs prescribed by APS). It lists my responsibilities. I agree to take my medications responsibly and to follow all orders. 1. I agree to use the following pharmacy only:, in (city) at (telephone). 2. I will attend all of my office visits. I will come in immediately if asked. 3. I will not go to the ER or to other providers for these or similar medications. 4. I will bring my medication bottles to my appointment if instructed to do so. 5. I am personally responsible for my medications. I understand that they will not be replaced if lost, stolen or destroyed. 6. I will not give my medication(s) to anyone else or take anyone else s medication(s). 7. I will not request early refills or take more than the prescribed amount. 8. For safety reasons, refill requests will only be honored at the time of my appointments, during office hours, currently 9AM-5PM Mon-Thru and Fri 9AM-2PM. No prescription refills will be provided on the weekends. 9. I will inform my doctor of any new medications or medical conditions. 10. I agree to allow APS to perform any urine or blood tests needed to make sure I use my medications correctly. 11. I will not operate a car or other equipment when I use my medications. 12. It is my responsibility to comply with applicable laws while taking these medications. 13. I will not use alcohol or illegal drugs when using these medications. 14. My providers may discuss my medications with other appropriate individuals or entities to insure safely. 15. I understand that there can be side effects from these medicines, including sedation, itching, nausea, vomiting, difficulty urinating, constipation and other problems. 16. I understand that I may become addicted to these medications. 17. I understand that suddenly stopping these medications may be dangerous. 18. If I violate these conditions, my providers may not refill the medications and may require that I obtain help to decrease my use of these medications. 19. I know that violating these conditions may result in my dismissal from the practice with no more than 30 days notice. 20. I further agree that my pain medication or other prescription may be stopped or decreased at any time, for any reason, by my providers. Finally, I understand that the above in not a complete list. I will be careful and will exercise caution and common sense. I will be completely honest, open and accurate about my use of these and other medications. I will ask questions if I do not understand something or if I feel that I may be having trouble with the medications. Patient Name: Patient Signature: Witness Name: Witness Signature: :

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