PAIN CONSULTANTS OF THE ROCKIES, PC PAIN TREATMENT CENTER OF WYOMING, LLC Patient Demographics

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1 Patient Demographics Referring Physician: City/State: Phone Number: Legal Name: Date of Birth: / / Age: M F Social Security Number: Martial Status: M S W D Physical Address: City: State: Zip: Mailing Address: City: State: Zip: Home Phone #: Work Phone #: Cell Phone #: Employed?: Yes No Employer: Student?: No Full-Time Part-time Occupation: Spouse s Name: Date of Birth: / / Spouse s SSN: PERSON TO NOTIFY IN CASE OF EMERGENCY (Other than person listed above) Name: Relationship: Phone Number: INSURANCE INFORMATION: (Please fill out completely) If insurance information provided by the patient is not correct, the patient can be responsible for any balance on the account. We are only contracted with BlueCross BlueShield, WinHealth, BestLife, VA, Medicare, Wyoming Medicaid, and Wyoming Workers Compensation. Workers Compensation Auto Accident Other Accident (Home-owners, etc.) Company Name: Address: City: State: Zip: Adjuster s Name: Number: Fax: Have you notified your employer? Yes No Case Number: Date of Injury: State Injury Occurred: Area of Body Injured: Please provide your insurance cards to the receptionist to be copied at every appointment. Primary Insurance: Insurance Company: Policy #: Group #: Policy Holder Name: DOB: / / SSN: Effective Date: / / Phone Number: Address: City: State: Zip: Secondary Insurance: Insurance Company: Policy #: Group #: Policy Holder Name: DOB: / / SSN: Effective Date: / / Phone Number: Address: City: State: Zip: By signing below, I hereby authorize the release of pertinent medical information to the insurance carriers. I accept responsibility for all medical charges incurred on this account, regardless of whether I have insurance coverage or not. BCBS-Government Claims Only: By signing below, I hereby authorize my insurance benefits to be paid directly to Pain Consultants of the Rockies, LLC realizing I am responsible to pay for non-covered services. Today s method of payment (required): Check Credit Card Cash Patient s Signature: Date:

2 Please read the following as it has important information regarding your account with us. Our clinic participates with: Ø Blue Cross/Blue Shield Ø WinHealth/BestLife Ø UPREHS Ø Veterans Administration Ø Medicare Ø Wyoming Medicaid Only (Title 19) Ø Wyoming Workers Compensation Please note, our office is not a TRICARE or Colorado Medicaid participant. NOR DO WE ACCEPT ANY OUT OF STATE WORKERS COMPENSATION EXCEPT FROM ARIZONA, MONTANA, NEBRASKA & COLORADO If your insurance company is not listed above, please call us to make sure we accept payment from your insurance. The submission of claims is a courtesy to you. It is your responsibility to have your current insurance card with you at time of service. You are responsible for deductibles that are not yet met, co-payments, cost shares and/or denied benefits. If you do not have insurance, you are responsible for payment at time of service. There will be no exceptions. For your convenience we do accept money orders, cashiers checks, personal checks (these can not be post-dated), Visa, MasterCard, Discover, debit cards and, as always, cash. As with any insurance, there are usual and customary fees. This is the amount that your insurance allows for office visits, procedures, etc Please understand this is an agreement between your insurance and yourself when you enrolled with their company. In most cases, the doctor s fees are above the usual and customary rate which insurance companies choose to pay. Our office cannot and will not allow the insurance company to set the amount that we charge for services. Please be aware that you may receive a bill for physician fees and facility fees for any procedure done in Pain Treatment Center of Wyoming. If you have any questions, please feel free to contact one of our Billing Specialists. Patient Signature: Date:

3 SELF-PAY Policy Please read and initial each item and sign below. I, understand that as a self-pay patient: I will pay at least $ for the new patient consultation and at least $80 for every appointment thereafter. New patient consultations start at $ and office visits start at $ You may be billed more depending on the amount of time the physician spends with you. I will pay the $80 once arriving to the clinic. If I do not pay, I will not receive any prescriptions from the provider. I may have to pay more for a follow-up appointment. If the provider spends more time with me than is allowed by the typical appointment, I will have to pay the difference at my next appointment. I will have to pay any fees to the clinic for a returned check. I will not be allowed to write another check to the clinic. I will have to pay by cash or money order for any appointments thereafter. I receive a discount of the provider s fees. I will be given a discounted price to receive a procedure, but that amount will be due before the procedure is performed. Once I have received health insurance, I must call and provide that information to the clinic. If I do not provide the clinic with the health insurance information, I CANNOT send the health insurance company any claims for reimbursement. I understand this is INSURANCE FRAUD. Once I provide the health insurance information to the clinic, I will be responsible for my deductible, copay, and coinsurance. I will not be considered self-pay and my health insurance will be billed for any and all claims from the effective date and all future appointments. Once I receive health insurance, I cannot choose to become self-pay again. I can only become self-pay when my health insurance terminates and I do not have any other form of health insurance. By signing below, I am indicating that I have read and understand the above policies with Pain Consultants of the Rockies, P.C. and Pain Treatment Center of Wyoming, LLC. Patient s Signature Date

4 NOTICE OF PRIVACY PRACTICES & ACKNOWLEDGEMENT This is a description of how your health information may be used and disclosed and how you can gain access to this information. PLEASE REVIEW THIS CAREFULLY. Each time you visit our office or treatment center, a record of this visit is made. This record is referred to as your medical record. Your medical record contains your health information including symptoms, examination findings, lab or x-ray results, diagnoses, treatment and plans for your care. Our facilities have policies in place requiring our staff to maintain the privacy of your health information. These policies may be changed, but our staff must stay abreast of these changes and continue to abide by them. USES AND DISCLOSURES Your health information will be disclosed: To healthcare professionals providing, coordinating and/or managing your health care or related services and To insurance agencies or third party payers for the purpose of reimbursement for services rendered. Disclosure of your health information may be made: When required by federal, state or local law and In matters of public health & safety. DISCLOSURE OF YOUR HEALTH INFORMATION FOR ANY OTHER PURPOSE WILL REQUIRE YOUR WRITTEN, SIGNED AUTHORIZATION. YOUR RIGHTS You have the right to: Request a restriction on some disclosures of your health information. However, if our facilities are unable to agree to said restriction, you will be notified of the reason. Inspect and obtain a copy of your medical record unless restricted by federal law. There may be a copying fee attached. Request amendment of your medical record. ACKNOWLEDGEMENT I hereby acknowledge receipt of my copy of this Notice of Privacy Practices from Pain Consultants of the Rockies, PC and/or the Pain Treatment Center of Wyoming, LLC. Patient s Signature Date

5 COMPLIANCE CONTRACT It is our goal at Pain Consultant of the Rockies to take a multidisciplinary approach when treating chronic pain. We aim to treat the mind and the body using multiple therapies and agencies. Therefore, we will likely be referring you to physical therapy and/or psychological services. Upon referral, we ask that you seek the first available appointment with these providers. Since these therapies play a very important role in your pain management program, attendance is monitored. Please note that appointments are at a premium with Pain Consultants of the Rockies and these outside providers. Therefore, we ask that you give 24 hours notice should you need to cancel any appointment. If you do not cancel your appointment you will be billed $50 for the missed appointment effective October 1, A total of 3 successive missed appointments with any provider will prompt a re-evaluation of your commitment to this program and could possibly result in dismissal from the practice. Exceptions may be made in extreme circumstances. You will be responsible for completing all new patient forms and paying a $50 refundable deposit prior to your appointment being scheduled. You will also be required to see Dr. Siiteri the Pain Psychologist at least once before seeing Dr. Ribnik. We aim to give our patients our undivided attention during their scheduled appointments. Therefore, we cannot accommodate patients without an appointment while we are in clinic. Walk-in appointments are not available. Should you have a question or concerns please feel free to call our office and leave a message. Your call will be returned as quickly as possible and in order of severity. Any messages received will be returned within a maximum of 3 business days. Please refrain from leaving multiple messages regarding the same issue. Our office requires 8-10 business days to complete forms that will be filled out by a qualified staff member. Please note that a fee is charged for each form to be completed. However, there will be no charge for Government Disability Forms. Please plan accordingly, as there are no exceptions. Lastly, we at Pain Consultants of the Rockies have adopted a Zero Tolerance policy with regard to abuse in the workplace. At no time will foul or abusive language or behavior directed toward our staff be tolerated. These actions are grounds for immediate dismissal from our practice. Your signature indicates you understand this contract and agree to abide by it. Patient s Signature Date

6 RELEASE OF INFORMATION Please sign and return this form only if you would like to designate any other person (i.e. spouse, mother, father, brother, family member, etc.) to inquire about the status of your care or your account. Thank you. Name: Social Security Number: I, give my permission for my, (Patient s Name) (Relationship), to give and receive information regarding my care or (Name) account. I give permission for Pain Consultants of the Rockies to speak to the above person on issues concerning my care or account. (Patient Signature) (Date) (Witness Signature) (Date) Voic Authorization I hereby authorize the staff members of Pain Consultants of the Rockies, PC and Pain Treatment Center of Wyoming, LLC to leave voic messages for me at my telephone number(s) of record or at any telephone number I may indicate in any message I leave. I understand messages left by staff members could contain information which may be confidential in nature. (Patient Signature) (Date) (Witness Signature) (Date)

7 Authorization to Disclose Protected Health Information I, the undersigned, authorize Pain Consultants of the Rockies, PC, and/or Pain Treatment Center of Wyoming, LLC, to release or receive my health information as noted below: Patient Information: Full Name: Other Names Used: Date of Birth: Address: City: State: Zip: Phone: Release Information: To From Section must be filled out completely for request to be processed Name/Facility: Pain Consultants of the Rockies Attention: Medical Records. Address: 4136 Laramie Street, Suite A Phone: (307) City: Cheyenne State: WY Zip: Fax: (307) Release Information: To From Section must be filled out completely for request to be processed Name/Facility: Attention: Address: City: State: Zip: Phone: Fax: Purpose of Request: Personal Treatment/Continued Care Legal Insurance Disability Transfer/Reason: Other: Please forward the Records by: Mail Fax (For Doctor s Office Only) Pick Up Please Note: Records will be mailed unless otherwise noted. Information to be Released: Please provide a year(s) abstract of my records (includes most recent notes, labs, and diagnostic testing) Please provide my entire record Other: Please Note: Copy Fee May Be Charged For Medical Records. Authorization to Release Protected Information: I acknowledge and hereby consent to such, that the released information may contain alcohol, drug abuse, psychiatric, HIV testing, HIV results, or AIDS information.* (Initials of Patient or Legal Representative) I understand that: 1. I may refuse to sign this authorization and that it is strictly voluntary. 2. My treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this authorization. 3. I may revoke this authorization at any time in writing, but if I do, it will not have any effect on any actions taken prior to receiving the revocation. Further details may be found in the Notice of Privacy Practices. 4. If the requestor or receiver is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations and may be disclosed. 5. I understand that I may see and obtain a copy of the information described on this form. 6. I can request a copy of this form after I sign and date it. * Please confirm that you have initialed the protected information category above, regardless if they are applicable or not. If form is incomplete, or if protected information is not released, we may be unable to fulfill this request. Patient s Signature Date: Signature of Legal Guardian: Date:

8 Patient Agreement/Informed Consent for Long-term controlled substances therapy for chronic pain. I,, have consulted with my provider at Pain Consultants of the Rockies, PC (Pain Consultants) and we have agreed to try long-term controlled substance therapy [pain medications (narcotics)] in the treatment of my chronic pain. I have been informed and clearly understand the following issues regarding the treatment of pain with these medications, as well as other analgesic (pain relieving) or sedative medications. I am aware that failure to abide by any of these conditions will be considered a breach of this contract and may result in the termination of the patient-provider relationship. I agree to or represent the following: Initial Here 1. Monthly appointments: are required for prescription refills. Prescriptions will only be written during regularly scheduled appointments. If I cancel an appointment or miss one without calling, I understand that my prescriptions will not be refilled until I am seen in the clinic. I further understand that medications to assist with the symptoms of withdrawal can be written at my provider s discretion. a. The symptoms of withdrawal may include: sweating, anxiety, tremors, muscle aches, hot & cold flashes, abdominal cramps and diarrhea, nausea and vomiting. b. You agree to keep all scheduled appointments, not just with your physician, but also with recommended therapists and psychological counselors. Three or more missed appointments or same day cancellations will lead to discharge from this clinic. 2. Sole Providers: The providers at Pain Consultants will be the only providers to write prescriptions for sedative medications and/or analgesics of any sort. I will not accept prescriptions for these medications from any provider outside of Pain Consultants. Nor will I take medications prescribed to someone else or allow someone else to take medications prescribed to me. 3. Safe-keeping: I understand that I am responsible for the safekeeping of my prescriptions and medications. If I lose them or they are stolen, I will not be given replacements and I could experience the symptoms of withdrawal. 4. Pharmacy: I agree to use only one pharmacy to fill my medications and to accept prescriptions for the generic form of my medications. 5. Medication dosages: I understand that my provider will prescribe my medications in dosages that he/she deems necessary. I will not adjust the amount of medication I take without first contacting Pain Consultants. If I should adjust the amount of medication I am to be taking and I run out early, I will not be given additional medications to get me through until my next appointment. I understand that increasing my dose without close supervision could lead to drug overdose, causing severe sedation, respiratory depression and death. 6. Side Effects: I am to notify my provider of any adverse side effects that I might experience while taking analgesic or sedative medications. a. Adverse side effects include: over-sedation, nausea, vomiting, constipation, confusion, euphoria (feeling high ), and dysphoria (feeling low ). Other side effects can include: dizziness, sweating, itching, skin rashes, swelling, difficulty with urination, dry mouth, insomnia, disorientation, decrease sex drive and potency, and quick, sudden jerky movements of the arms or legs. b. Motor vehicles: If my medications should cause me to feel drowsy, dizzy or disoriented, I agree to not operate a motor vehicle or other heavy machinery which could cause bodily injury to me or others. 7. Treatment Goal: I understand the treatment goal is to improve my ability to function and/or work. In consideration of that goal, and that I am being given potent medication to help me achieve that goal, I agree to help myself by following better health habits (i.e. exercise, weight control and the cessation of alcohol and tobacco use) and by complying with the recommendations of my provider in the use of adjunctive therapies (i.e. physical therapy, psychological counseling). I further understand that if the use of these medications does not assist me in reaching this goal or if I refuse to participate in any adjunctive therapies, I will be tapered off these medications and other methods of pain control will be explored. a. You agree to comply fully with all aspects of your treatment program including behavioral medicine (psychology/psychiatry) and physical therapy, if recommended. Failure to do so may lead to discontinuation of your medication and referral to an outside physician. 8. Physical Dependence: It is clearly understood that the use of these medications may result in physical dependence. This condition is common to many drugs such as blood pressure medications, anti-anxiety medications and anti-seizure medications, as well as long-term controlled substance therapy.

9 9. Psychological Addiction: I understand that psychological addiction is a possible risk associated with long-term controlled substance therapy. If I exhibit such behavior, I will be tapered off my medications and will no longer be considered a candidate for long-term controlled substance therapy. a. Psychological addiction can be recognized by: abuse of the drug(s) to obtain mental numbness or euphoria, drug craving behavior, doctor shopping, escalating drug usage without correlation with pain relief, and manipulative behavior toward the medical provider in order to obtain prescriptions. 10. Other Drugs: I may not take other drugs such as tranquilizers, sedatives or antihistamines without first contacting Pain Consultants. I may not use alcoholic beverages or illegal drugs. The combination of these drugs/beverages and those medications prescribed by my provider could produce profound sedation, respiratory depression, severe drop in blood pressure and possibly death. I agree to submit to regular samples for drug/alcohol testing at the discretion of my provider. 11. Pregnancy: If I am female, I agree to advise the clinic if there is even the slightest possibility that I am or may become pregnant. I understand that infants born to mothers on long-term controlled substance therapy will likely be physically dependent at birth and could possibly have birth defects as a result of the medications. 12. Release of Information: I agree to allow Pain Consultants to have contact with other providers, Emergency Departments, pharmacies and urgent care facilities regarding the agreement. I further allow these outside entities to disclose to Pain Consultants any information required to ensure my adherence to this agreement. 13. Severability: I understand that if any provision of this agreement is determined to be invalid or unenforceable, the remainder of the agreement will remain in force. 14. Termination: I understand that this agreement may be terminated by either party upon 30 days written notice to the other. Delivery of such notice by US Postal Service Certified mail to my address of record shall be deemed sufficient notice. It is my responsibility to ensure that Pain Consultants has my current valid address. I may notify Pain Consultants of my intent to terminate our relationship in a similar fashion. I must send my notice to Pain Consultants main address. Long-term controlled substance may cause drowsiness, which can be worsened with alcohol, benzodiazepines, and other sedating medications. Use care when driving or operating machinery. An overdose can cause severe side effects, even death. Other common, usually temporary, side effects include nausea, itching, and sweating. Psychological depression and lowered testosterone levels (in men) may also occur. Sleep apnea, if present, may be worsened by long-term controlled substance. Constipation commonly occurs, and often does not improve with time. It is impossible to predict long-term controlled substance side effects in any individual patient. Having side effects on one long-term controlled substance does not necessarily mean there will be side effects on another long-term controlled substance. You must take long-term controlled substance only as directed. Federal law prohibits giving this medication to anyone else. Physical dependence will develop with regular use, but does not by itself indicate addiction. A withdrawal syndrome will develop if you stop your medication abruptly. Tolerance may develop to the pain relief effects of long-term controlled substance, but in chronic pain states usually occurs slowly, if at all. Not all pain conditions respond to long-term controlled substance therapy. Some pain may only be partially responsive to long-term controlled substance therapy. Total elimination of pain is an unrealistic goal. Escalating dosages may indicate that long-term controlled substances are not effective or that there is an underlying problem with addiction or psychological dependence. Discontinuation of long-term controlled substance medications may need to be done under these circumstances. I have read the above information (or it has been read to me), have received a copy of the agreement and all of my questions regarding my treatment with long-term controlled substance therapy have been answered to my satisfaction. I hereby give my consent to participate in long-term controlled substance therapy. Patient s Printed Name Patient s Signature Physician s Signature Date Signed Pharmacy Name & Phone Number:

10 MEMORANDUM FOR ALL PATIENTS RECEIVING NARCOTIC OR SEDATING MEDICINES Please be aware that any patients who take prescribed medications such as narcotics, sedatives, sleeping pills, or other drugs which may impair your alertness or cause you to be sleepy or drowsy should not operate any motor vehicle while taking these medications. Even though you have gotten these medications by prescription, you are still responsible for safely operation your vehicle. The State laws do not excuse you from these requirements simply because you have a prescription. Please Drive Safely!! Our children are depending on you to stay alert. By my signature below, I acknowledge receiving a copy of this notice and I agree to avoid driving when I am taking my medications. Patient s Printed Name Patient s Signature Witness Signature Date Signed

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