Check One Williams Medical Plaza Building Consultants 2000 South Wheeling, Suite #600 (918) Tulsa, OK Muskogee Pain

Transcription

1 Dear Patient: Yu have an appintment t see n. We lk frward t wrking with yu, and evaluating and treating yur pain. Please arrive at least minutes early t prcess yur paperwrk. Als, please be prepared t present yur insurance card and make any applicable cpayment at that time. Yur initial visit will take place at the facility marked belw: Check One Tulsa Pain Williams Medical Plaza Building Cnsultants 2000 Suth Wheeling, Suite #600 (918) Tulsa, OK Muskgee Pain Hnr Heights Plaza Cnsultants 3204 W. Okmulgee (918) Muskgee, OK Bartlesville Pain Twne Center Cnsultants 2334 SE Washingtn (918) Bartlesville, OK Stillwater Pain Funtain Square Cnsultants 1417 S. Western Rad (405) Stillwater, OK Tulsa Spine and Specialty Olympia Medical Park Hspital 6901 S. Olympia Avenue (918) Tulsa, OK INSTRUCTIONS FOR PROCEDURE APPOINTMENTS ONLY! Nthing t eat 6 hurs prir t yur appintment. N liquids f any kind 4 hurs prir t yur appintment Take yur usual medicatin with a sip f water Bring a driver. If yu are taking any f the fllwing medicatin, please cntact a member f ur medical staff at (918) : Insulin, Glucphage, r any bld thinners (i.e. Cumadin, Plavix). FAILURE TO FOLLOW THESE INSTRUCTIONS MAY RESULT IN RESCHEDULING YOUR PROCEDURE! A cmplete histry f yur medical backgrund and pain issues are extremely imprtant. Attached yu will find yur New Patient Paperwrk, which yu need t read, cmpletely fill ut and sign. Failure t d s will delay yur appintment r pssibly cause yur appintment t be rescheduled. Please bring yur cmpleted paperwrk with yu t yur appintment. T prmte an envirnment in which prviders have ample time t adequately evaluate and treat all patients, we have established the fllwing plicies: 1) If yu are mre than 15 minutes late fr yur appintment, we may reschedule yu fr anther day r time. 2) If yu are late fr yur appintment n three (3) ccasins, we may dismiss yu frm ur practice. 3) If yu fail t shw fr an appintment n tw (2) ccasins withut having called us t cancel the appintment mre than 24 hurs ahead f time, we may dismiss yu frm ur practice. Thank yu fr allwing the physicians and staff f Tulsa Pain Cnsultants t be f service t yu. Shuld yu have any questins, please feel free t cntact us at (918) between the hurs f 8:00 am and 4:45 pm Mnday thrugh Friday (excluding hlidays). 1

2 PATIENT REGISTRATION AND INFORMATION Name: Nick name/ Alias Scial Security Number: Address: Hme Phne: Cell Phne: City, State & Zip Cde: address: Sex: M F Date f Birth: Marital Status: Emplyer: Business Address: Occupatin: Business Phne: Referring Dctr: Emergency Cntact: Telephne Number: SPOUSE INFORMATION Name f Spuse: Scial Security Number: Date f Birth: Spuse s Emplyer: Telephne Number: RESPONSIBLE PARTY Persn Respnsible fr Payment: Relatinship t Patient: Scial Security Number: Date f Birth: Address: (if different frm patient) Telephne Number: City, State & Zip: Respnsible Party Emplyer: Wrk phne number: Occupatin: INSURANCE INFORMATION Primary Insurance: Subscriber: Date f Birth: Billing Address: City, State & Zip: Emplyer / Address: Insurance ID# Grup#: Secndary Insurance: Subscriber: Date f Birth: Billing Address: City, State & Zip: Emplyer / Address: Insurance ID# Grup#: Is yur injury wrk related? Yes [ ] N [ ] Is yur visit persnal injury r MVA related? Yes [ ] N [ ] If yu answered yes t the abve questin and are represented by an attrney, list their name, address and telephne belw: ASSIGNMENT AND RELEASE I, the undersigned, certify that I (r my dependent) have the abve stated insurance cverage and assign directly t Tulsa Pain Cnsultants, Inc., P.C. all insurance benefits payable t me fr services rendered. I understand that I am financially respnsible fr all charges whether r nt paid by insurance. I hereby authrize Tulsa Pain Cnsultants, Inc., P.C. t release any infrmatin necessary t secure payment f benefits n all insurance submissins. Further, I authrize the release f my medical recrds frm the ffice t either myself, r any and all medical persnnel necessary fr my cntinued medical care. In prviding this cnsent, I am fully aware that the physicians f Tulsa Pain Cnsultants, Inc., P.C., the staff, and emplyees cannt be respnsible fr the cnfidentiality f the infrmatin disclsed after medical recrds have been released; and therefre, release the its physicians, staff, and emplyees frm any liability arising frm such disclsure. Patient Signature: Date: Respnsible Party Signature: Date: 2

3 PATIENT INFORMATION / HISTORY FORM Name: Last First MI Age: Sex: [ ] Male [ ] Female Weight: Height: Referring Physician: Primary Care Physician Please briefly describe yur main prblem: Indicate n the pictures belw the area(s) f yur pain. Use X fr pain and 0 fr numbness. When did yur pain start? (apprximate date) Hw did yur pain start? Is yur pain [ ] cnstant r [ ] cmes and ges? Present level f pain intensity (circle ne) N Pain Mild Mderate Severe Excruciating What wrds best describe yur pain? (Circle as many as apply) Sharp Burning Thrbbing Shting Aching Cramping Dull Crushing Stabbing Tingling Cldness Htness Electricity Other 3

4 Patient Name What brings n the pain r makes it wrse? (Circle as many as apply) Sitting Standing Walking Twisting Lifting Sneezing Cughing Using arms Bending frward Bending backward Other What eases r eliminates the pain? (Circle as many as apply) Lying dwn Standing Exercise Arthritis Medicine Pain Pills Muscle relaxants Nthing Other D yu have any lss f cntrl f yur bwels r bladder? [ ] Y [ ] N D yu have pain that shts dwn yur arms r legs? [ ] Y [ ] N D yu have any increasing weakness in yur arms r legs? [ ] Y [ ] N Please circle all the fllwing medical prblems that yu have had (circle as many as apply): Heart prblems Heart Attack High Bld Pressure Strke Bld clts Diabetes Asthma Kidney Failure Kidney Infectins Liver Prblems Thyrid Prblems COPD Lung Prblems Depressin Headaches Glaucma Seizures Ulcers Hepatitis A/B/C Immune Disrder Sleep Apnea (with CPAP) HIV Cancer Other Please list all past surgeries yu have had: Year: / Year: / Year: / Year: / Year: / Year: / Year: / Year: / Please list all current prescriptin medicatins and herbal supplements, vitamins, tpical creams and ver the cunter medicatins: Medicatin Dse Frequency Rute Oral, iv, (Example) Lrtab 10mg 3 times a day tpical D yu have any medicatin ALLERGIES? N: Yes, list Medicatins: 4

5 Patient Name Please list any pain medicatins yu have tried in the past: D yu take any f the fllwing medicatins: (please circle any that apply) Cumadin, Aspirin, Plavix, Lvenx, r Heparin? Please indicate which tests yu have had t evaluate yur present pain (with date): MRI CT Scan Myelgram Bne scan Discgram EMG Other: Please list any prcedures yu have received fr yur pain (with date and dctr) Please list any ther treatments yu have received fr pain(tens, chirpractic, physical therapy, bifeedback) Wrk histry: What is/was yur ccupatin? [ ] Wrk full time [ ] Wrk part-time [ ] Unemplyed [ ] Hmemaker [ ] Retired [ ] On Disability [ ] Other When did yu last wrk? If yur pain is wrk related, what was the date f yur injury? D yu currently have an attrney in regards t yur pain cnditin? [ ] Y [ ] N If yes, please prvide name and phne number. Scial histry: Are yu: [ ] Single [ ] Married [ ] Separated [ ] Divrced [ ] Widw D yu have children? Hw many? Wh lives in yur hme with yu? D yu smke? [ ] Y [ ] N If yes, hw many packs f cigarettes per day? Are yu a frmer smker? If yes, when did yu quit? D yu drink alchl? If yes, hw much in a week? D yu have a histry f alchl, street drugs, r prescriptin medicine abuse? [ ] Y Have yu ever been arrested r cnvicted n a drug related charge? [ ] Y [ ] N If yes, please explain and prvide dates Sleep and md: Hw many hurs a night d yu sleep? Have yu ever been diagnsed with depressin, psychsis, schizphrenia, r biplar disrder? If yes, which ne(s)? Are yu seeing a psychiatrist r psychlgist? [ ] Y [ ] N Fr what? D yu have any thughts f hurting yurself r thers? [ ] Y [ ] N If yes, please explain: PHQ 9 Ttal Scre: [ ] N 5

6 HEALTH QUESTIONNAIRE (PHQ-9) Name: Date: Over the last 2 weeks, hw ften have yu been bthered by any f the fllwing prblems? (Use t indicate yur answer) Mre than half the days Nt at all Several days 1. Little interest r pleasure in ding things Feeling dwn, depressed, r hpeless Truble falling r staying asleep, r sleeping t much Feeling tired r having little energy Pr appetite r vereating Feeling bad abut yurself- r that yu are a failure r have let yurself r yur family dwn Truble cncentrating n things, such as reading the newspaper r watching televisin Mving r speaking s slwly that ther peple culd have nticed. Or the ppsite- Being s fidgety r restless that yu have been mving arund a lt mre than usual Thughts that yu wuld be better ff dead, r f hurting yurself Nearly every day (healthcare prfessinal: Fr interpretatin f TOTAL, please refer t accmpanying scring card) Add clumns + + Ttal: 10. If yu checked ff any prblems, hw difficult Nt difficult at all Smewhat have these prblems made it fr yu t d difficult yur wrk, take care f things at hme, r get Very difficult alng with ther peple? Extremely difficult 6

7 Patient Name: Family histry: (Circle as many as apply): Alchlism, Depressin, Substance abuse, Mental illness, Cancer, Heart prblems, Strke, Other Please prvide us with any additinal infrmatin that yu feel wuld assist us in treating yur pain Please circle if any f these apply t yu: Pregnant: [ ] Y [ ]N General: Fever, weight lss, weight gain, pr appetite, sexual prblems, insmnia Neurlgical: Headache, seizures, paralysis, cnfusin, disrientatin, numbness, tingling Eye, Ear, Nse, Thrat: Blurry visin, truble swallwing, lss f hearing, vice changes, Respiratry: Emphysema, brnchitis, asthma, tuberculsis, shrtness f breath Cardivascular: Chest pain, abnrmal heart beats, heart failure, heart murmurs Gastrintestinal: Nausea, vmiting, hepatitis, pancreatitis, bld in stl, cnstipatin GU: Bld in urine, recurrent urinary infectins, kidney stnes, truble urinating Musculskeletal: rheumatid arthritis, lupus erythematsis Skin: Rash, pen sres, recurrent infectins, tumrs, skin cancer Endcrine: Diabetes, thyrid prblems, adrenal dysfunctin, pituitary prblems Hematlgic: Leukemia, lymphma, anemia, bleeding gums Other: The dctrs and staff thank yu fr taking the time t cmplete this questinnaire. The infrmatin that yu have prvided us will be beneficial as we wrk t manage yur pain; and as always, all the infrmatin given is held in the strictest f cnfidence. Ntes: 7

8 MEDICATION POLICY We are here t prvide yu with the best quality treatment f yur pain. T d this, we have prepared the fllwing plicies t ensure yur safety, and ur cntinued ability t treat yu in the mst effective way pssible. Please read this carefully. These plicies are fr yur prtectin, and will be enfrced. Yu will be asked t sign a cntract stating that yu prmise t fllw these terms. 1. Medicatin must be taken nly as prescribed by ur physicians and yu must nt take pain medicatin given t yu by anther persn r physician. 2. Medicatin is prescribed t increase yur functin s that yu can wrk, participate in physical therapy, exercise prgrams, and weight lss prgrams. If yur activity level des nt imprve with medicatin, alternative methds f pain management may be substituted fr medicatin. 3. Any medicatin that is lst, misplaced, stlen, destryed, r finished early will nt be replaced fr any reasn. 4. Yu must nt share, sell, r therwise permit thers t have access t these medicatins. 5. All prescriptins shuld be btained at the same pharmacy, where pssible. Shuld the need arise t change pharmacies, ur ffice must be infrmed. 6. The prescribing physician and staff have permissin t discuss diagnstic and treatment details with dispensing pharmacists r ther prfessinals wh prvide yur healthcare fr the purpse f medicatin accuntability. We retain the right t discuss yur treatment with law enfrcement fficials during any fficial investigatin. 7. Refills will be given nly during ffice hurs: Mnday Friday 8:30 am t 4:30 pm. 8. We require at least 3 business days ntice t refill yur prescriptins. The telephne number(s) t ur prescriptin refill line at each site are as fllws: Tulsa Pain ( ), Muskgee Pain ( ), Bartlesville Pain ( ) and Stillwater Pain ( ).It is yur respnsibility t mnitr yur medicatins and request a refill in a timely fashin. Prescriptins called in n Friday cannt be refilled until the fllwing Tuesday. Any prescriptins that need t be mailed require 10 business days ntice. 9. Yu must keep yur scheduled appintments. If yu fail t appear fr an appintment, yur medicatin may nt be refilled and yu may be required t pay $25.00 n shw fee. If yu fail t appear fr mre than 2 appintments, yu may be dismissed frm ur practice 10. Yu must prvide us with 48 hurs ntice t cancel an appintment. If yu fail t prvide this ntice, yur appintment will be cnsidered as a failure t appear and may be subject t the fee and limitatin f refills described abve. 11. A randm urine drug screen will be requested. Presence f unauthrized substances r abnrmal results may result in discntinuatin f yur cntrlled medicatins including, but nt limited t piids. 12. Yu must sign a cntract indicating that yu acknwledge and understand the Medicatin Plicy f Tulsa Pain Cnsultants, Inc. 13. Yu must be seen in ur ffice every 3 mnths fr medicatin maintenance purpses. Yur health care pain management team is dedicated t yur safety and cntrl f yur pain, but we must have yur cperatin t achieve these gals. This Medicatin Plicy is designed t ensure yur safety and t help us and yu cmply with the standards f gd medical care, as well as state and federal narctics laws. 8

9 FINANCIAL POLICY FULL PAYMENT OF OFFICE COPAYS IS DUE AT TIME OF SERVICE. Yu are respnsible fr deductibles and cinsurance as directed by yur insurance plicy. We accept cash, checks, Visa/Mastercard, Discver and American Express. Insurance Yur ffice cpay is due at the time f yur visit. Fr yur cnvenience, we will file insurance claims with all insurance carriers. Yu will be respnsible fr any deductibles and cinsurance as explained in yur plicy. We cannt bill yur insurance cmpany unless yu prvide us with all insurance infrmatin, s please bring yur insurance cards t yur appintment. Yu are respnsible fr ntifying us f any changes in insurance cverage each visit. If n insurance card is presented at the time f service, yu will be treated as a cash patient and will need t pay fr services as they are rendered. Once the card is presented within ur insurance cntract guidelines fr billing claims, we will gladly file a claim and refund any mney due back t yu after claims have been prcessed and we receive payment frm insurance. Out-f-Netwrk r Nn-Cvered Services If patient is ut f netwrk due t ur dctr(s) nt yet cntracted but is in prcessing, we will cnsider patient as in net wrk and will use in netwrk rates t balance bill patients. Patients will nly be respnsible fr balance at in netwrk rate.charges nt cvered by yur carrier with signed ABN will be required t pay such amunts due when billed. Private Pay If yu d nt have insurance, payment is due at time f service. We accept cash and credit cards. Please be prepared t pay in full at the time f yur visit unless prir payment arrangements have been made. Wrker s Cmpensatin Only authrized referrals will be accepted. If ntificatin is nt received prir t the appintment, the patient will be respnsible fr charges incurred. Patient must ntify Tulsa Pain Cnsultants prir t their scheduled appintment with the fllwing infrmatin: attrney s name and phne number; emplyer name, cntact persn and phne number; wrk cmp carrier name, adjustrs name and phne number; the date f injury, and claim number. Any curt rder must be brught in at time f visit. Persnal Injuries/ MVA Payment is expected at time f service. We will file private insurance prvided yu have subrgated with yur insurance cmpany. The patient is respnsible fr all cpays and they are due at time f service. Deductible and/r cinsurance are the patient s respnsibility and are required t be paid when billed. We will accept Med-Pay if available prvided said Med- Pay will issue direct payment t Tulsa Pain Cnsultants.. Returned/Insufficient Checks If we receive yur check back frm the bank fr insufficient funds/accunt clsed, yu will receive a $25 charge t yur accunt and we will n lnger accepts any checks fr yur accunt. Yu may pay n yur accunt by cash, credit card r mney rder. 9

10 NOTICE OF PRIVACY PRACTICES Page 1 f 4 Effective date April 14, 2003 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. Tulsa Pain Cnsultants (including its family f clinics) is cmmitted t prtecting yur medical infrmatin. This Ntice describes yur rights and ur legal duties regarding yur prtected health infrmatin. We create and maintain, n a variety f media, including paper, cmputers and films, a recrd f the care and services yu receive. This infrmatin is available t all Office Practice emplyees, and physicians, wh need this infrmatin t prvide treatment t yu, t btain payment fr services rendered t yu r t supprt health care peratins necessary fr the peratinal aspects f yur care. We are required by law t: Have prper safeguards in place t discurage imprper use r access. Prtect the privacy and cnfidentiality f yur persnal and prtected health infrmatin and recrds. Describe yur rights and ur legal duties regarding yur prtected health infrmatin. WHAT DO THESE WORDS MEAN? Prtected Health Infrmatin (PHI) Yur persnal and prtected health infrmatin created and used by us t prvide care t yu and bill fr services prvided. Privacy Officer The persn respnsible fr the plicies and prcedures develped t prtect yur PHI and fr investigating yur cmplaints n hw yur PHI is used r disclsed. Business Assciate An independent business r individual wh cntracts with the Office Practice fr services prvided t yu r the Office Practice. Authrizatin A dcument signed by yu that gives us permissin t use r disclse yur prtected health infrmatin fr purpses ther than yur treatment, btaining payment fr yur treatment r ur health care peratins. WHAT WILL YOU DO WITH MY MEDICAL AND BILLING INFORMATION? The fllwing categries describe hw we may use and disclse yur prtected health infrmatin. Nt every use r disclsure in a categry will be listed. T ensure cmpliance with Oklahma law, we will btain yur cnsent fr the use and disclsure f yur prtected health infrmatin. INFORMATION USED AND DISCLOSED MAY INCLUDE RECORDS WHICH MAY INDICATE THE PRESENCE OF A COMMUNICABLE OR VENEREAL DISEASE AND MAY INCLUDE, BUT ARE NOT LIMITED TO, DISEASES SUCH AS HEPATITIS, SYPHILIS, GONORRHEA AND THE HUMAN IMMUNO-DEFICIENCY VIRUS ALSO KNOWN AS ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS). If yu d nt cnsent, we cannt prvide yu treatment except in emergency situatins r when we cannt cmmunicate with yu fr sme ther reasn. 1. Treatment: We may use yur prtected health infrmatin t prvide yu with medical treatment r services. We may disclse yur prtected health infrmatin t dctrs, nurses, technicians, medical students, r ther Office Practice persnnel wh are invlved in yur care. Example: The surgen treating yur brken leg may need t knw if yu have diabetes because diabetes may slw the healing prcess. The dctr treating yu fr high bld pressure may ask a nurse t take yur bld pressure and reprt this t the dctr. We als may disclse yur medicatin infrmatin t ther medical persnnel utside the ffice practice that will prvide medical treatment r services. Example: The treating dctr may send a sample f yur bld t be tested at a lab and infrm the lab f yur cnditin and a brief medical histry s the lab will knw what tests t run. 2. Payment: We may use and disclse yur prtected health infrmatin s that the treatment and services yu receive may be billed t and payment cllected frm yu, yur insurance cmpany r a third party. Examples: We may need t give yur health plan cpies f yur physician s chart ntes abut the treatment yu received in the ffice fr high bld pressure s yur health plan will pay us r reimburse yu fr the treatment. We may als tell yur health plan abut a bld pressure treatment yu are ging t receive t btain prir apprval r t determine whether yur plan will cver the treatment. 10

11 NOTICE OF PRIVACY PRACTICES Page 2 f 4 Effective date April 14, Health Care Operatins: We may use r disclse yur prtected health infrmatin fr Office Practice peratins. These uses and disclsures are needed t run the Office Practice and make sure that all ur patients receive quality care. Examples: We may use yur bld pressure measurements t review ur treatment and services and evaluate the perfrmance f ur staff in caring fr yu. We may als cmbine medical infrmatin abut many ffice patients t decide what additinal services the ffice shuld ffer, what services are nt needed, and whether certain new treatments are effective. We may als cmbine medical infrmatin we have with medical infrmatin frm ther ffices t cmpare hw we are ding and see where we can make imprvements in the care and services we ffer. 4. Business Assciates: We may disclse yur prtected health infrmatin t Business Assciates independent f the Office Practice and with whm we cntract t prvide services n ur behalf. We will nly make these disclsures after receiving satisfactry assurances that the Business Assciate will prperly safeguard yur privacy and the cnfidentiality f yur prtected health infrmatin. Examples: We may cntract with a cmpany utside f the Office Practice t prvide medical transcriptin services fr the Office Practice r t prvide cllectin services fr past due accunts. 5. Appintment Reminders: We may use and disclse yur prtected health infrmatin t cntact yu as a reminder that yu have an appintment fr treatment r medical care. This may be dne thrugh an autmated system r by ne f ur staff members t yur landline r wireless cell phne. If yu are nt at hme, we may leave this infrmatin n yur answering machine, vice mail r in a message left with the persn answering the telephne. 6. Health Related Benefits and Services: We may use and disclse yur prtected health infrmatin t tell yu abut health-related benefits r services t recmmend pssible treatment ptins r alternatives that may be f interest t yu. 7. Marketing: We may disclse certain prtected health infrmatin t a third party t prvide marketing materials and infrmatin t yu. 8. Facility Directry: We may release yur name and general cnditin t peple wh ask fr yu by name s yur family and friends can knw generally hw yu are ding. If yu d nt want t be included in this directry, ntify Office Practice persnnel during registratin. 9. Individuals Invlved in Yur Care r Payment fr Yur Care: We may release prtected health infrmatin t a friend r family member wh is invlved in yur medical care. We may als give prtected health infrmatin t smene wh helps pay fr yur care. We may disclse prtected health infrmatin abut yu t an entity assisting in a disaster relief effrt s that yur family can be ntified abut yur cnditin, status and lcatin. 10. Research: Under certain circumstances, we may use and disclse yur prtected health infrmatin fr research purpses r, t determine whether yu might benefit frm, r be willing t be invlved in certain research. Examples: A research prject may invlve cmparing the health and recvery f all patients with high bld pressure wh received ne bld pressure medicatin t thse wh received anther type f bld pressure medicatin t determine which type is mst effective. We may disclse yur prtected health infrmatin t peple preparing t cnduct a research prject s lng as the prtected health infrmatin they review des nt leave the ffice. Mst research nly uses medical infrmatin withut using yur name, address r ther infrmatin that reveals wh yu are. We will almst always ask fr yur specific permissin if the researcher will have access t yur name, address r ther infrmatin that reveals wh yu are r if yur medical infrmatin will leave the ffice. CAN YOU EVER USE OR DISCLOSE MY PROTECTED HEALTH INFORMATION WITHOUT MY CONSENT? Yes. The fllwing categries describe ways we may use r disclse yur prtected health infrmatin withut yur cnsent. Nt every use r disclsure in a categry will be listed. 1. Required by Law: We will disclse yur prtected halth infrmatin when required t d s by federal, state r lcal law. Example: Oklahma law requires us t reprt all cmmunicable r venereal diseases which are identified r diagnsed in ur ffice t the Oklahma State Department f Health. 2. T Avert a Serius Threat t Health r Safety: We may use and disclse yur prtected health infrmatin when necessary t prevent a serius threat t yur health and safety r the health and safety f the public r anther persn. This disclsure wuld nly be made t smene able t help prevent the threat. 3. Organ and Tissue Dnatins: If yu are an rgan dnr, we may release yur prtected health infrmatin t rganizatins that handle rgan prcurement fr rgan, eye r tissue transplantatin r t an rgan dnatin bank, as necessary t facilitate rgan r tissue dnatin and transplantatin. 11

12 NOTICE OF PRIVACY PRACTICES Page 3 f 4 Effective date April 14, Military: If yu are a member f the Armed Frces, we may release yur prtected health infrmatin as required by military cmmand authrities. We may als release prtected health infrmatin abut freign military persnnel t the apprpriate freign military authrity. 5. Wrkers Cmpensatin: We may release yur prtected health infrmatin fr wrkers cmpensatin r similar prgrams as authrized by State laws. The prgrams prvide benefits fr wrk related injuries r illness. 6. Public Health Reprting: We may disclse yur prtected heath infrmatin fr public health activities. Examples: Preventin r cntrl f disease, injury r disability.eprting f birth defect r infant eye infectin. Reprting f cancer diagnses and tumrs. Reprting f reactins t medicatin r prblems with prducts. Ntificatin f peple using prducts that are recalled. Ntificatin f the Oklahma State Department f Health abut peple wh may have been expsed t a disease r at risk fr cntracting r spreading a disease r cnditin such as HIV, Syphilis r ther sexually transmitted diseases. Reprting f abuse, neglect r vilence as required by law, including children wh are brn with alchl r ther substances in their bdy. Reprting f births and deaths. 7. Health Oversight Agencies: We may disclse prtected health infrmatin t a health versight agency fr activities necessary fr the gvernment t mnitr the health care system, gvernment prgrams, and cmpliance with applicable laws. These versight activities include, fr example, audits, investigatins, inspectins, medical device reprting and licensure. 8. Lawsuits and Disputes: If yu are invlved in a lawsuit r dispute, we may disclse yur prtected health infrmatin in respnse t a curt r administrative rder. We may als disclse yur prtected health infrmatin in respnse t a subpena, discvery request, r ther lawful prcess by smene else invlved in the dispute, but nly if effrts have been made t tell yu abut the request r t btain an rder prtecting the infrmatin requested. 9. Law Enfrcement: We may release prtected health infrmatin if asked t d s by a law enfrcement fficial. Examples: In respnse t a curt rder, subpena, warrant summns r similar prcess. T identify r lcate a suspect, fugitive, material witness r missing persn. Abut a crime victim if, under certain circumstances, we cannt btain yur agreement. Abut a death we believe may be the result f criminal cnduct. In emergency circumstances t reprt a crime, the lcatin f the crime r victims, r the identity, descriptin r lcatin f the persn wh cmmitted the crime. 10. Crners, Medical Examiners and Funeral Directrs: We may disclse prtected health infrmatin t a crner, medical examiner r funeral directr. Examples: T identify a deceased persn r determine the cause f death. T assist the funeral directr in cmpleting the death certificate. 11. Natinal Security and Intelligence Activities: We may disclse yur prtected health infrmatin t authrized federal fficials fr intelligence, cunterintelligence and ther natinal security activities authrized by law. 12. Prtective services fr the President and Others: We may disclse yur prtected health infrmatin t authrized federal fficials s they may prvide prtectin t the President, ther authrized persns r freign heads f state r cnduct special investigatins. 13. Inmates: If yu are an inmate f a crrectinal institutin r in the custdy f a law enfrcement fficial, we may disclse yur prtected health infrmatin t the crrectinal facility r law enfrcement fficial. This may be necessary (1) fr the crrectinal institutin t prvide yu with health care r (2) t prtect the health and safety f yurself, thers r the crrectinal institutin. WHAT ARE MY RIGHTS REGARDING MY PROTECTED HEALTH INFORMATION? Yu have the fllwing rights regarding yur prtected health infrmatin that we maintain abut yu. Yu are required t submit a written request t exercise any f these rights fr recrds we create and maintain. 1. Right t Inspect and Cpy: Yu have the right t inspect and request a cpy f yur prtected health infrmatin, except as prhibited by law. If yu request a cpy f yur prtected health infrmatin, we may charge 25 cents per page. We may deny yur request t inspect and cpy in certain circumstances, such as a request fr mental health recrds. If yu are denied access t certain prtected health infrmatin, yu may request that the denial be reviewed. A licensed health care prfessinal chsen by us will review yur request and the denial. The persn cnducting the review will nt be the persn wh denied yur request. We will cmply with the utcme f the review. 12

13 NOTICE OF PRIVACY PRACTICES Page 4 f 4 Effective date April 14, Right t Amend: If yu feel that the prtected health infrmatin created by us is incmplete r incrrect, yu may request an amendment fr as lng as we maintain the infrmatin. Yu must prvide a reasn that supprts yur amendment request. If yur request is nt in writing r des nt include a reasn t supprt yur request fr amendment, we may deny yur request fr amendment. We may als deny yur request if yu ask us t amend infrmatin that: We did nt create, unless the persn r entity that created the infrmatin is n lnger available t make the amendment. Is nt part f the prtected health infrmatin maintained by us. Is nt part f the infrmatin that yu wuld be permitted t inspect r cpy. Is accurate and cmplete. 3. Right t an Accunting f Disclsure: Yu have the right t request ne free accunting f disclsures every 12 mnths. This accunting des nt include disclsures made fr treatment, payment r healthcare peratins. Yur request must state a time perid which may nt be lnger than 6 years r include dates befre April 14, Fr additinal accuntings, we may charge yu fr the csts f prviding the accunting. We will ntify yu f the cst invlved and yu may chse t withdraw r mdify yur request at that time befre any charges are incurred. 4. Right t Request Restrictins: Yu have the right t request a restrictin r limitatin n the prtected health infrmatin we use r disclse abut yu fr treatment, payment r healthcare peratins. Yu als have the right t request r limit the prtected health infrmatin we disclse abut yu t a family member r friend. Example: Yu ask us nt t use r disclse infrmatin abut yur surgery. We are nt required t agree with yur request. If we d nt agree, we will cmply with yur request unless the infrmatin is needed t prvide yu with emergency treatment r the use r disclsure is required by law. Yur request must include: What infrmatin yu want restricted. The type f restrictin yu want, and T whm yu want the restrictin t apply. 5. Right t Request Cnfidential Cmmunicatins: Yu have the right t request that we cmmunicate with yu abut yur prtected health infrmatin in a certain way r certain lcatin. Examples: Yu request we nly cntact yu via mail r at yur wrk phne number. We will nt ask yu the reasn fr the request. We will accmmdate all reasnable requests. Yur request must specify hw r where yu wish t be cntacted. 6. Right t a Paper Cpy f this Ntice: Yu have the right t a paper cpy f this ntice. Yu may ask us t give yu a cpy f this ntice at any time. Even if yu have agreed t receive this ntice electrnically, yu are still entitled t a paper cpy f this ntice. T btain a paper cpy, cntact ur Privacy Officer. CAN YOU CHANGE THIS NOTICE? We reserve the right t change this ntice. We reserve the right t make the revised r changed ntice effective fr yur prtected health infrmatin we already have abut yu as well as fr any prtected health infrmatin we receive in the future. Each ntice will have an effective date. Cpies f the current ntice will be psted. Additinally, at each visit fr treatment r health care services, we will make available t yu a cpy f the current ntice. WHAT IF YOU WANT TO USE OR DISCLOSE MY PROTECTED HEALTH INFORMATION FOR A PURPOSE NOT DESCRIBED IN THIS NOTICE? Other uses and disclsures nt cvered by this ntice r the laws that apply t us will nly be made with yur written authrizatin. In ther wrds, the cnsent yu already prvided us will nt be enugh t use r disclse yur prtected health infrmatin fr any purpse nt described in this ntice. If yu prvide us authrizatin t use r disclse yur prtected health infrmatin, yu may revke that authrizatin, we will n lnger use r disclse yur prtected health infrmatin fr the reasns cvered by yur authrizatin. Yu understand that we are unable t take back any uses r disclsures we have already made with yur authrizatin. WHAT IF I HAVE QUESTIONS OR NEED TO REPORT A PROBLEM? If yu believe yur privacy rights have been vilated, yu may file a written cmplaint with us r the Secretary f the Department f Health and Human Services. Yu will nt be penalized fr filing a cmplaint. T file a cmplaint with us, cntact ur Privacy Officer at: Tulsa Pain Cnsultants, 2000 S. Wheeling Avenue, Ste 600, Tulsa, Oklahma

14 INFORMED CONSENT AND CONTRACT FOR THE USE OF NARCOTIC MEDICATIONS AND OTHER PAIN MEDICATIONS Our gal is t prvide the best pain care pssible. T accmplish this gal, we have prepared this cnsent and cntract t explain hw certain medicatins are used, t describe pssible side effects, and t set frth yur respnsibilities with regard t these medicatins. Please read all this infrmatin carefully. Ask the physicians r clinical staff any questins yu may have. Once yu understand all f this infrmatin fully, please sign and date belw, indicating yur cnsent t treatment and agreement t fllw the terms f this frm. I am vluntarily requesting the physicians and staff at Tulsa Pain Cnsultants t treat my cnditin f chrnic pain with apprpriate medicatins and ther interventins. I understand that sme medicatins can be addictive and/ r dangerus if misused, and that the fllwing infrmatin is prvided t ensure my safety. I have received and agree t the terms f the Medicatin Plicy f Tulsa Pain Cnsultants (including their affiliates). I understand that the physicians and staff at Tulsa Pain have relied n the infrmatin I have prvided in writing and verbally t select apprpriate medicatins, and I prmise that this infrmatin is cmplete and accurate. I understand that intentinally prviding misleading infrmatin will be grunds fr discharge frm the practice. I understand the cntinued use, reduced use, r discntinuatin f any pain medicatin is at the discretin f the physicians at Tulsa Pain Cnsultants and their affiliates. PAIN MEDICATION CAN BE ADDICTIVE. This includes piid analgesics (narctic medicines) as well as ther types f pain medicatin. This means my bdy may begin t depend n the medicatin, and I may experience WITHDRAWAL (unpleasant sensatins) such as nausea, shakes, sweating, rapid heart rate, diarrhea, high bld pressure, pain r severe nervusness if I suddenly stp taking the medicatin. I understand that it is my respnsibility t request refills f medicatins n a timely basis, and I understand that narctic medicatin will nt be refilled early under any circumstance. T ensure my safety, I agree t take pain medicatins nly as prescribed by the Tulsa Pain physicians, including their affiliates, and agree that I will nt take pain medicatins given by any ther physicians. I understand that taking mre medicatin than prescribed, r taking pain medicatin frm anther surce may lead t verdse, and this culd result in slwed r stpped breathing, brain injury frm lack f xygen, cma r death. (Please cntinue n t next page) 14

15 (Page 2 f INFORMED CONSENT AND CONTRACT FOR THE USE OF NARCOTIC MEDICATIONS AND OTHER PAIN MEDICATIONS) I understand that the use f pain medicatins may als be assciated with additinal risks such as: decreased effectiveness, physical dependence, cnfusin, itching, difficulty urinating, allergic reactins, decreased sex drive, drwsiness, nausea, vmiting, addictin, cnstipatin, truble driving r perating machinery, and interactin with ther medicines. I understand that I may be subject t a urine drug screen and criminal backgrund check if deemed necessary by my treating physician. I understand that I shuld never cmbine alchl, illicit drugs such as marijuana, ccaine, herin, methamphetamine r ther illegal drugs with prescriptin medicatins, as these cmbinatins are highly dangerus. I understand that if these substances are fund in my urine r bld tests that my physician may n lnger prescribe medicatins t me. It has been explained t me that sme cmmn txic effects are: Central nervus system depressin, which can range frm drwsiness (at its mildest) t cma (at its mst severe), Respiratry depressin, which can lead t a persn t stp breathing, Cardiac effects, such as changes in heart rhythm that can lead t the heart stpping, Decreased seizure threshld, meaning that the brain can have a seizure mre easily,and/r Psychiatric effects, such as psychsis After carefully reading and understanding the abve terms (including thse n subsequent and preceding pages), I request treatment by the physicians f Tulsa Pain Cnsultants and their affiliates (t include narctic medicatins if apprpriate), and prmise t fllw the terms f this cntract and the Medicatin Plicy f Tulsa Pain Cnsultants. Pharmacy Telephne Number Patient Name (please print) Patient Signature Date Witness Signature Relatinship t Patient Date 15

16 AUTHORIZATION AND CONSENT FOR RELEASE OF MEDICAL RECORDS (In rder fr Tulsa Pain Cnsultants, Inc., P.C. t prvide yu with the best pssible care, we may require cpies f yur medical recrds. Fr us t btain this infrmatin, we will need yur written permissin. Please review the Authrizatin and Cnsent fr Release f Medical Recrds belw. Yur signature n this frm will allw us t btain the necessary infrmatin.) Being cmpetent, eighteen (18) years f age r lder and duly authrized; d willfully and vluntarily authrize the release f all medical recrds and infrmatin t Tulsa Pain Cnsultants and their affiliates. I further understand and acknwledge the infrmatin authrized fr release may include infrmatin which may be cnsidered a cmmunicable r venereal disease which may r may nt include, but are nt limited t, diseases such as Hepatitis, Syphilis, Gnrrhea, and Human Immundeficiency Virus (HIV), als knwn as Acquired Immune Deficiency Syndrme r AIDS. Full Name f Patient (please print) Scial Security Number Date f Birth Authrized Signature Tday s Date Fr medical recrds use nly, please DO NOT cmplete this sectin. Recrd Hlder: Fax Number: Tulsa Pain Cnsultants requests the fllwing infrmatin at this time: All dictated reprts All anesthesia reprts All radilgy reprts All therapy recrds Other: Please fax this infrmatin t the Tulsa Pain Cnsultants, Inc at (918) If yu are unable t fax the chart due t its size, please cntact ur ffice s that ther arrangements can be made. 16

17 Acknwledgment f Financial Plicy I acknwledge receipt and understanding f Tulsa Pain Cnsultant s Financial Plicy. Patient s Signature Date Patient s Name (please print) Date f Birth Acknwledgment f Ntice f Privacy Practices I acknwledge receipt f Tulsa Pain Cnsultant s Ntice f Privacy Practices. Patient s Signature Date Patient s Name (please print) Date f Birth 17

18 HIPAA RELEASE OF PROTECTED HEALTH INFORMATION Patient r Patient s Legal Representative Signature Date Please prvide us with a list f names f whm yu wuld allw ur ffice t release medical infrmatin. Infrmatin may be released t the fllwing individual(s): Name Name Name Name Name Name Relatinship t patient Relatinship t patient Relatinship t patient Relatinship t patient Relatinship t patient Relatinship t patient 18

19 HIPAA RELEASE OF PROTECTED HEALTH INFORMATION ****FOR PRESCRIPTION PICK-UPS ONLY**** PATIENT OR PATIENT S LEGAL REPRESENTATIVE SIGNATURE DATE Please prvide us with a list f names f whm yu shuld allw ur ffice t release yur prescriptins t. Name (Please print) Name (Please print) Name (Please print) Name (Please print) Name (Please print) Relatinship t Patient Relatinship t Patient Relatinship t Patient Relatinship t Patient Relatinship t Patient 19