ATLANTIC PAIN INTERVENTIONS & REHABILITATION Enjoy A Better Quality Of Life

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1 Sastry K. Topalli, MD Diplomate of the American Board of PM&R Board Certified in PM&R 676 Battlefield Blvd N, Suite B Chesapeake, VA Phone: Fax: Atlantic Pain Interventions & Rehabilitation Welcome to Atlantic Pain Interventions & Rehabilitation (APR), your path to enjoying a pain free life. We appreciate the opportunity to serve you with your healthcare needs. APR emphasizes the diagnosis and treatment of complex pain syndromes allowing patients to make a faster recovery and resume a more normal lifestyle. Our treatment protocols usually involves a combination of procedures, medications, physical therapy, bracing and modalities. We have a federal mandate to utilize a multimodal approach and not just prescribe controlled medications. As a result, we will, in all likelihood be utilizing at least one treatment modality in addition to medications. What to Expect from APR Dr. Topalli and/or an associate physician, will see you during your initial visit. Any interventional procedure will be performed in the ambulatory surgical center, which is conveniently located in each of our offices. You are required to comply with the treatment plan prescribed by our physicians. We look forward to serving you to relieve your pain and improve your quality of life.

2 Patient Registration Information Patient Last Name: First Name: Middle Inital: Address: City: State: Zip Code: Phone: Home: Work: ext: Cell: Date of Birth: Social Security Number: / / Sex: Marital Status: Emergency Contact: Relationship: Phone: Employer: Occupation: Employer Address: Phone: Primary or Referring Physician: Phone: How did you learn about us? Reason for Referral: Billing and Insurance Information If Not Completed You Will Be Billed Is your condition the result of a work related or motor vehicle accident? Date of Injury: Primary Insurance Carrier: Mailing Address: Phone: Subscriber Name: Date of Birth: Policy Number: Group Number: Subscriber Employer: Phone: Secondary Insurance Carrier: Mailing Address: Phone: Subscriber Name: Date of Birth: Policy Number: Group Number: Subscriber Employer: Phone: Subscriber Employer s Address: For A Work-Related Or Motor Vehicle Injury Please Complete This Section Have you filed a claim? Yes: No: Workers Compensation: Auto: Other: Date of injury/accident: Claim Number: Insurance Carrier: Billing Address: City: State: Zip Code: Phone: ext: Cell: Adjuster Name: Phone: Attorney Name: Phone: AUTHORIZATION TO RELEASE INFORMATION, ASSIGNMENT OF BENEFITS, FINANCIAL RESPONSIBILITY I authorize release of any information acquired in the course of my treatment to appropriate medical personnel or insurers. I assign insurance benefits to

3 New Patient Evaluation Referred by: Patient Name: Age: Date: / / Reason For Visit: Onset Of Problem: / / History Of Present Illness Briefly Describe The Cause Of Your Pain Back Pain: Neck Pain: Headache: (Circle All That Apply) Pain is: improving worsening stable constant intermittent Pain is Due To: car accident work injury sports injury old age disease other Is there a lawsuit or workers compensation claim? YES NO What worsens the pain? Standing Sitting Lying down Walking Twisting Leaning BackWard Driving Reaching Coughing Sneezeing Driving Leaning forward Change in Weather Other What reduces the pain? Standing Sitting Lying down Walking Twisting Leaning BackWard Driving Reaching Coughing Sneezeing Driving Leaning forward Change in Weather Other Is there new or different weakness (not pain related) Loss of feeling? bowel/bladder incontinence (accidents)? Reduced sleep? YES NO Do you feel depressed? YES NO Prior therapies, injections, treatments: (circle all that apply) Surgery Pain Meds Physical Therapy MRI CT Scan EMG Myelogram Bone Scan Xray Discogram Epidural Other Injection Current Physicains: PCP: Surgeon: Psychiatrist: Other: Prior Pain Physicians: Past Medical History Circle All That Apply Diabetes Heart Disease Blood Pressure Cancer Stroke Ulcers/GI Disease Liver disease Kidney Disease Depression Anxiety Asthma/Emphysema Other: PAST Surgical History Circle All That Apply Appendix Gall Bladder CABG/Angioplasty Hysterectomy Hernia Repair Tonsillectomy Neck or Back Surgery (and dates):

4 Referred by: Patient History Patient Name: Age: Date: / / Medications: OTC medication: Aspirin Motrin Advil Aleve Goody s BC Powder Other: Allergies: Drug: Reaction: Drug: Drug: Drug: Reaction: Reaction: Reaction: Social History Status: Married Single Divorced Widowed Children: Alcohol use: None Social Daily (more than 2 drinks) Quit: Tobacco: None Packs Per Day: Number of Years: Quit: Street Drugs: Current Prior Education: Grade School High School GED Trade School College Post-grad Occupation: Last Worked: Disability: SSI Medicare Private Hobbies: Family History Genetic diseases Neurological disease Muscle disease Heart disease Stroke Alcoholism Illegal substance abuse REVIEW OF SYSTEMS: Weight loss Fever Dizziness Chest pain Shortness of breath Cough Wheezing Heartburn Nausea Vomiting Diarrhea Constipation Bloody stools Black stools Rash Fatigue IV drug abuse Headache Blood in the urine Easy bruising Suicidal ideations Sexual problems Decreased libido New onset seizures Recent memory loss Hot or cold temperature intolerance Recent change in vision or double vision

5 Physical Exam Vital Signs: Height: Weight: Temp: BP: HR: Where Is Your Pain Now? Mark the areas on your body where you feel the described sensations. Use the appropriate symbol Ache ^ Numbers o Pins & Needles Burning x Stabbing + Neck Pain: % Arm Pain: % Back Pain: % Leg Pain: % Total - 100% How Bad is Your Pain Now? NO PAIN INTERMEDIATE PAIN WORST PAIN

6 Assignment Of Benefits Form I (Print Name) hereby authorize benefits to be assigned to Atlantic Pain Interventions & Rehabilitation (APR) for healthcare Services provided to me by Atlantic Pain Interventions & Rehabilitation. I hereby certify that the insurance information that I have provided Atlantic Pain Interventions & Rehabilitation is true and accurate as of the date of service and that I am responsible for keeping it updated. I am fully aware that having health insurance does not absolve me of my responsibility to ensure that my medical bill is paid in full. I also understand that my insurance company may not pay 100% of the amount of the medical claim that I may be responsible for any and all amounts not payable by my insurance company including any portion paid and not applied to in network benefits for any out of network services. I hereby authorize Atlantic Pain Interventions & Rehabilitation to submit claims, on my behalf, to the insurance company listed on the copy of the current insurance card I have provided to Atlantic Pain Interventions & Rehabilitation, in good faith. I fully agree and understand that the submission of a claim does not absolve me of my responsibility to ensure the claim is paid in full. I hereby irrevocably designate, authorize and appoint Atlantic Pain Interventions & Rehabilitation as my true and lawful attorney-in-fact. This power of attorney Is hereby provided for the limited purpose of receiving all payments due under my policy/medical care plan on account of medical services and care rendered or to be rendered. This power of attorney shall automatically terminate, without formal action being taken, as soon as Atlantic Pain Interventions & Rehabilitation has received payment in full and remedies under applicable regulatory guidelines for all medical care services provided to patient. I hereby confirm and ratify all actions taken by my attorney-in-fact pursuant to the authority granted herein. I hereby authorize my insurer to assign and transfer any all applicable ERISA plan benefits and rights to Atlantic Pain Interventions & Rehabilitation and any appointed business associates working with them for the sole purpose of making sure all protected rights and benefits under my plan are administered accurately, including the right to receive any applicable plan document/remedies, disclosures, pursue appeals, administrative reviews and litigation on my behalf. This authorization includes any and all other rights permissible under state and federal laws. I hereby instruct and direct my Insurance Company to pay Atlantic Pain Interventions & Rehabilitation directly. I understand under applicable ERISA, state and/or federal regulatory guidelines that I have the right and authority to direct where payment for services rendered is sent. If my current policy prohibits direct payment to the provider of service, I under my rights per state and federal ERISA regulations here by instruct and direct my Insurance Company to provide SPD documentation stating such non-assign ability clause to myself and Atlantic Pain Interventions & Rehabilitation. Upon Proof of non-assign ability documentation I then instruct that the insurer make out the check to me and mail it directly to the Provider and address listed on the submitted claim for the professional or medical expense benefits, and otherwise payable to me under my current insurance policy as payment towards the total charges for the professional services rendered. I agree and understand that any funds I receive by my insurance company due for services rendered by Atlantic Pain Interventions & Rehabilitation will be immediately signed over and sent directly to Atlantic Pain Interventions & Rehabilitation. This is a direct assignment of my rights and benefits under this plan/policy. This payment will not exceed-my indebtedness to the above mentioned assignee, and I have agreed to pay, in a current manner, any balance of said professional service charges over and above this insurance payment. Upon receipt of said check, I authorize Atlantic Pain Interventions & Rehabilitation to receive any such checks, endorse them for deposit only, and to deposit and apply all the proceeds toward payment on my account. I authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in this case. I authorize Atlantic Pain Interventions & Rehabilitation or appointed business associates to be my personal representative, which allows Atlantic Pain Interventions & Rehabilitation, to: (1) submit any and all appeals when my insurance company denies me benefits to which I am entitled, (2) submit any and all requests for benefit information from my insurance company, and (3) initiate formal complaints to any State or Federal agency that has jurisdiction over my benefits. I fully understand and agree that I am responsible for full payment of the medical debt if my insurance company has refused to pay 100% of my stated plan benefits based on billed charges, within (90) days of any and all appeals or request for information. Should the account be referred to an attorney or outside agency for collection, the undersigned shall pay reasonable attorney s fees and collection expenses. All delinquent accounts bear interest at the legal rate. I also agree that any fines levied against my insurance company will be paid to Atlantic Pain Interventions & Rehabilitation for acting as my personal representative. I authorize Atlantic Pain Interventions & Rehabilitation and its associates to provide medical care reasonable by today s standards. A photocopy of this Assignment shall he considered as effective and valid as the original. Signature of Patient/Guarantor: Date: Signature of Policy Holder: Date: Witness:

7 Medicare And Medicaid Signature Authorization Medicare and Medicaid patient certification - patient certification authorization to release information and payment request. I certify that the information given by me in applying for payment under TITLE XVIII and/or TITLE XIX of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediary carriers, any information needed for this or a related Medicare or Medicaid claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for services. I request that this authorization apply to all claims, present and future. I understand that I am responsible for my health insurance deductible and coinsurance. Date: Print Patient s/beneficiary s Name: Patient s/beneficiary s Signature: Commercial Insurance, Managed Care Members And Secondary Payor Authorization I authorize the release of any medical information necessary to process my insurance c1aim(s). I request that the payment authorized be made on my behalf. I assign the benefits payable for physician services to APR. I request that this authorization apply to all insurance claims, present and future. I understand that I am responsible for payment of any balance not paid by my insurance company. Date: Print Patient s/insured s Name (Parent s Signature if child): Signature of Insured: Patient s/insured s Signature:

8 FINANCIAL POLICY, CONSENT FOR TREATMENT, AND RELEASE OF MEDICAL INFORMATION Thank you for choosing Atlantic Pain Interventions & Rehabilitation (APR) your pain management provider. Please understand that payment of your bill is considered part of your treatment. All Patients must complete the registration sheet and provide proper insurance information prior to seeing a physician. Full payment is expected as services are rendered. We accept cash, check, Visa, and Mastercard. Payment terms can be arranged with prior approval from our billing department. Co-payments are due at the time of service. If you have insurance, we will file your primary insurance form as a courtesy to you. We will wait no more than 45 days for them to pay. If your account has reached 45 days, you will receive a letter from our office. The letter requests that you contact your insurance company and check on the status of your claim and call our office with the results, within 10 days. We will also file your secondary insurance claim once the primary carrier has paid. Atlantic Pain Interventions & Rehabilitation is committed to providing the highest quality care for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of your insurance company s arbitrary determination of usual and customary rates. Your insurance policy is a contract between you and your insurance company. Any disagreement you have concerning the amount your insurance pays should be directed to your insurance company. We will follow the rules of the agreement for the insurance companies with whom we are contracted. Under no circumstance will co-insurance, co-payments, or deductibles be waived. If you have an HMO, PPO, or equivalent policy, it is your responsibility to inquire with the insurance company to see if we are a contracted provider. We try to become contracted providers for as many policies as we can. It is also the patients responsibility to keep track of referral and referral dates and number of visits. If your treatment is based on an accident or injury claim, our office will complete your paperwork at a minimum cost of $25 per form depending on the time required. Payment must be received, as the forms are prepared. Authorization: I hereby authorize Atlantic Pain Interventions & Rehabilitation to administer treatment and perform procedures as may be deemed necessary or advisable for my diagnosis. I further authorize the release of any medical information necessary to process my insurance claim and request payment of medical services to be assigned directly to Atlantic Pain Interventions & Rehabilitation In the event my insurance does not cover services rendered; I agree to be personally and fully responsible for payment. I have read the office policy and understand and agree to its terms. This authorization Is to remain In full force unless I revoke the same in writing. Signature: Printed Name: Date:

9 Appointment Cancellations We understand that circumstances occasionally arise changing your plans. You may cancel at no charge if, for office visits you call at least 24 hours before your appointment and 48 hours before your scheduled procedures. If you do not cancel or fail to show for your appointment a no show fee of $25.00 (office visits) and $50.00 (procedures) will be charged. I have read and understand these guidelines and agree to the terms therein. Print Name: Date of Birth: Signature: Date:

10 Controlled Substance Policy The Federal Government (Drug Enforcement Agency) frowns on the use of chronic opiates as a stand-alone means of treating chronic benign pain and is prosecuting physicians and patients at an increased rate over recent years. Their policy for prescribing chronic opiates to patients with chronic benign pain is modestly favorable as long as controls are in place, other more reasonable means have failed, and other diagnostic testing or treatment methods are being employed to help work towards reducing pain through non-medication means. Some of the non-medication means we utilize are: Controls o Random and scheduled urine or blood drug testing o Adherence to DEA rules and regulations Treatments o Spinal injections o Spinal implants o Trigger point injections, joint injections, etc. o Manipulation under anesthesia o Physical therapy o Psychotherapy o Massage therapy o Chiropractic Diagnostic Testing o MRI o EMG/NCS o Balance Testing If you have any questions regarding the above, please do not hesitate to contact one of our doctors. Signature: Date:

11 Informed Consent and Controlled Substances Agreement I understand and agree to follow the policies of Atlantic Pain Interventions & Rehabilitation (APR) as set forth below. I understand that APR is under no obligation to prescribe these medications for me. I also understand that there may be other, more reasonable treatment options available for my condition that my doctor may recommend instead of or in addition to the use of these medications. Definitions Of Opioids, Benzodiazapines, And Other Controlled Substances I understand the definitions of these medications to be: 1. Opioids - An opioid medication is a derivative of morphine or other related product and thus has strong pain relieving properties. 2. Benzodiazapine - A benzodiazapine is a drug that is related to Valium. Their primary role is for the treatment of anxiety. 3. Other related drugs - For the purposes of this agreement, other related drugs includes medications such as muscle relaxants (e.g., FlexeriI), membrane stabilizers (e.g., Neurontin), and non-narcotic analgesics (e.g., Ultram). These medications may cause sedation, altered mental status, occasionally dangerous withdrawal effects when stopped abruptly, and may have medication interactions similar to or different from opioids or benzodiazapines. 4. Controlled Substance - For the purposes of this agreement, a controlled substance will apply to opioids, benzodiazapines, or other related medications as described above. Risks Of Opioids, Benzodiazapines, And Other Related Medications ( Controlled Substances ) I understand that these medications have potential risks with the most significant being: 1. Physical Dependence - the abrupt discontinuation of controlled substances could lead to withdrawal symptoms such as abdominal cramping, diarrhea, anxiety, hypertensive crisis, cardiac arrest or other cardiac dysfunction, seizures, and death. 2. Psychological Dependence or Addiction - the use of these medicines may lead to behavior focused on the obtaining and misuse of the controlled substances. 3. Overdose - may lead to respiratory arrest and death. 4. Mental Changes - These classes of medications may cause confusion, sedation, drowsiness, problems with coordination, and changes in thinking ability. This may make it unsafe for you to drive a motor vehicle, operate hazardous equipment and machinery; or perform dangerous activities. Other side effects may include but are not limited to, the following: nausea, constipation, unsteadiness, decreased appetite, difficulty urinating, depression, and loss of sexual drive with testicular atrophy (in males). Conditions Of Agreement 1. I understand that Controlled Substances may be prescribed by my physician only if he/she determines that such treatment has a medically reasonable chance of improving my quality of life, ability to participate in work activities and social activities. (Initials) 2. I do not currently have problems with substance abuse (drugs and/or alcohol). (Initials) 3. I am not involved in the use, possession, diversion, or transport of illegally obtained controlled substances. (Initials) 4. I agree to use these medications only as prescribed to me and will not take more of these medications than instructed. I agree to not allow other individuals to take my medication nor will I take medication prescribed to another person. (Initials) 5. I understand the potential harm of controlled substances to unborn children and will notify APR if I am or become pregnant. (Initials) 6. I will obtain controlled substances only from APR and not from any other source unless a true medical emergency exists. i will notify APR in advance of any anticipated acute needs (dental work or surgery). (Initials)

12 CONDITIONS OF AGREEMENT (Cont.) 7. I agree to accept generic brands of my controlled substances if available. (Initials) 8. If it appears to my physician that the use of controlled substances are not providing a demonstrable therapeutic benefit such as improvement in daily function or improved ability to participate in the treatment program, if the controlled substances being prescribed are expected to be the mainstay of pain treatment when other medical options exist and are practical or that addiction, rapid loss of effect, or significant side effects are developing, I agree to gradually taper my medication as directed. If a substance abuse problem is suspected, I understand that I may be referred for evaluation and management of the problem. (Initials) 9. I agree to come to my scheduled appointments prepared to provide a urine sample to assess compliance with my treatment plan. Failure to provide a sample may result in immediate termination of treatment with controlled substances and possibly discharge from APR. (Initials) 10. I agree to bring my medications to the office for random pill counts to assess compliance with treatments. Failure to provide medication for inspection may result in immediate termination of opioid treatment. (Initials) 11. I agree to comply with my physicians request for additional imaging studies, lab tests, diagnostic procedures (with separate informed consent), and referrals to additional sub specialists as recommended by my physician. (Initials) 12. I understand that APR is a specialty consulting practice. The APR staff will communicate with my Primary Care Provider, Specialists, pharmacists, Therapists, and Family to assist in determining the best course for continued treatment for chronic pain. My care may be transferred back to my Primary Care Provider for continued prescriptions of controlled substances once my medical regimen has been optimized. (Initials) 13. All of my controlled substance prescriptions will be filled at the same pharmacy. Should I choose to change pharmacies, I will notify APR immediately. (Initials) 14. Early refills are not provided. Renewals are at the discretion of your treating physician and will be prescribed at office appointments only. APR will not prescribe any medication after hours or on weekends. APR is under no obligation to prescribe replacement medications should they become misplaced, stolen, damaged, or destroyed. (Initials) 15. I am seeking treatment for pain. APR is under no obligation to treat or prescribe medication for any other medical or mental condition to include: high blood pressure, bronchitis, pneumonia, anxiety, depression, or any chronic-medical condition. If I am referred to a Primary Care Provider or other specialist for a medical or mental condition, I will make and keep that appointment in a timely manner. (Initials) I understand that any violation of this agreement may pose a health risk to myself and others and may result in a discontinuation of treatment with controlled substances if deemed medically prudent. Violation of this agreement may result in dismissal from the care of APR as well as reporting any illegal activities to appropriate law enforcement agencies. I have read this document, understand it, have had all questions regarding risks and conditions of the agreement answered satisfactorily, and I agree to all of its elements. Patient Signature: Date:

13 Consent To Release Medical, Psychiatric, AIDS/ARC/HIV Testing, Alcohol Or Drug Abuse Patient Records 1. I hereby authorize my physician at Atlantic Pain Interventions & Rehabilitation: q To RELEASE copies of my medical records to: q To RECEIVE copies of my medical records from: 2. I understand that my records may contain information pertaining to my diagnosis or treatment of my medical, psychiatric, AIDS/ARC/HIV testing, alcohol or drug abuse condition. I also understand that any topic discussed during my medical treatment was documented, and therefore, will be released: Signature: Date: 3. Information to be released/requested: (please circle) OFFICE NOTES LAB X-RAYS EKG HOLTER ECHO D/C SUMMARY OP NOTE H&P DX ALL BILLING INFO Date of service(s) 4. I understand that this release can be revoked at any time, except to the extent that disclosure made in good faith has already occurred in reliance on this consent. To revoke this consent, written notice must be given. 5. This consent expires in 90 days. 6. Atlantic Pain Interventions & Rehabilitation is released from any legal responsibility of liability; for the release of the above information to the extent indicated and authorized herein. Signature: Date: Print Patient Name: Witness: Patient SS#: Date of Birth: Patient Address: Print name of person signing for the patient and their relationship to the patient: Name: Date: Please send requested information to: Phone #: Fax #:

14 Medication Agreement And Refill Policy As part of your treatment, our medical staff may prescribe medications for you. Many of these medications can have serious side effects if they are not managed properly. Your health and safety are very important to us, and we need your help to make sure your treatment follows our guidelines. If APR has any questions regarding your healthcare, including medications, we reserve the right to contact your other treating physicians and pharmacies. 1. I agree to follow the dosing schedule prescribed to me by my doctor or PA. 2. I agree to never share my medications with others, nor will I sell or exchange my medications for any reason. 3. I agree to always keep my medications safeguarded and within my control. 4. I agree to notify APR if I experience any adverse effects or dosage problems with my prescribed medications. I will not discard any unused medication. Before any new medication can be prescribed, I must bring the unused medication to APR for disposal. 5. I agree that if I receive narcotic prescriptions from APR, I am not allowed to receive the same type of medications from another physician without the express consent or consultation with APR. 6. I agree to use only one pharmacy for my pain-related medications unless extenuating circumstances prevent this from being possible. In this event, I will notify APR of all pertinent information pertaining to additional pharmacies, mail-order, or other sources. 7. I understand that medication refill prescriptions involving narcotic pain medicine require a scheduled office visit when my doctor is on duty in the office. Narcotic pain medication refills will not be called into a pharmacy, nor will they be increased over the telephone. 8. I agree to keep all scheduled appointments. I understand that no medications will be given for canceled or no-show appointments. I agree also to be prompt to my appointments and understand that If I am more than 15 minutes late, I will have to reschedule. 9. I understand that medication refills cannot be made after hours or on the weekend. APR s refill hours are 9:00 am to 4:00 pm, Monday through Friday. 10. I agree to bring my medications from any other doctor s office to APR for my office appointments. 11. I understand that I should not drive or operate heavy machinery while I am taking medications that may cause drowsiness or impaired cognitive function. 12. I understand that I am solely responsible for the safekeeping of my medications and I must treat my medications as I would my money or valuable possession. APR, will under no circumstances replace LOST OR STOLEN prescriptions or medications. 13. I understand that my therapy at APR may legally require a monthly office visit so my doctor can properly evaluate my progress, and/or adjust appropriate narcotic pain medications every thirty (30) days. 14. I understand that abusive behavior or harassment toward any APR staff member will not be tolerated. Harassment includes, but is not limited to, more than two (2) phone calls to the office in one business day. 15. I will not show up at the APR office unannounced seeking medication refills. 16. I understand that a forged or falsified prescription will result in the immediate dismissal from APR. 17. I understand that if I do not follow this medication agreement, I may be dismissed from APR at their discretion. By signing this agreement, you affirm that you have the full right and power to be bound by this agreement and that you have read, understood, and accepted these terms. No narcotic or otherwise habit-forming medications will be prescribed without the acceptance of this agreement. PHARMACY NAME: PHARMACY PHONE NUMBER: PATIENTS NAME: TODAY S DATE:

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