GulfCoast Pain Institute

Transcription

1 GulfCoast Pain Institute 1850 Gause Blvd. East, Suite 201 Slidell, LA New Patient Registration (Please Print) Date: Patient Name: Street Address: City: State: Zip: Home Phone: ( ) Other: ( ) Birth Date: / / Social Security #: Sex: M F Marital Status: Single Married Widowed Separated Divorced Emergency Contact: Phone: ( ) How did you learn about our practice? Patient s Employer: Employer s Address: Occupation: Phone: ( ) Responsible Party (if not patient) Street Address: City: State: Zip: Relationship to Patient: Social Security #:

2 Primary Insurance Carrier: Street Address: City: State: Zip: Phone: Contract #: Group #: Subscriber Name: Relationship to Patient: Subscriber DOB: Subscriber SSN: Secondary Insurance Carrier: Street Address: City: State: Zip: Phone: ( ) Contract #: Group #: Subscriber Name: Relationship to Patient: Subscriber DOB: Subscriber SSN: IF THIS IS WORKMAN S COMPENSATION FILL IN THE FOLLOWING Adjuster s Name: Phone: ( ) Claim #: Date of Injury: IF THIS IS AN ATTORNEY CASE FILL IN THE FOLLOWING Attorney Name: Phone: ( )

3 AUTHORIZATION This undersigned patient or authorized individual acting on behalf of the patient, understands and agrees as follows: 1. GulfCoast Pain Institute may release information as follows: GulfCoast Pain Institute is granted permission to release to the insurance carrier, employer, their representatives or referring physicians any information in connection with any treatment rendered to patient, or on patient s behalf at any time such information is requested. 2. Patient or legal guardian is responsible for paying the part of the bill the insurance company does not pay, that is Patient shall pay GulfCoast Pain Institute such sums as are not or may become due for services rendered the patient, it being understood that in the event patient s insurance company, if any there by, does not make payment, or only a partial payment, this obligation to pay shall be binding personally upon patient. 3. Patient s insurance company shall make payments to GulfCoast Pain Institute: I hereby authorize my insurance company to pay directly to GulfCoast Pain Institute the surgical and/or medical benefits otherwise payable to me, for myself or any member of my family for services rendered. I understand that I am personally financially responsible for these charges, whether covered by insurance or otherwise. 4. Medicare Authorization: I request that payment of authorized Medicare benefits be made directly to GulfCoast Pain Institute for any services rendered. I authorized any holder of medical information about me to release to the Health Care Financing Administration and its agents of any information needed to determine these benefits or the benefits payable for related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If other health insurance is indicated in item 9 of the HCFA-1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, and non-covered services. Coinsurance and the deductible are based upon the charge determination of the Medicare carrier. 5. I consent to treatment necessary for the above named patient. 6. I allow fax transmittal of my medical records, if necessary. 7. I allow fax transmittal of financial records, if necessary. 8. I agree to pay all reasonable attorney fees and collection costs in the event of default of payment of charges. I assign benefits to GulfCoast Pain Institute. Date: Insured: Patient:

4 PAIN QUESTIONNAIRE-1 Patient Name: Date: Where is your pain? When did it start? How did it start? Work Accident Car Accident Fall Illness Other Injury Unknown Is the pain Constant? or Intermittent? How SEVERE is the pain? Mild Moderate Severe DESCRIBE your pain. (Check ALL that apply) Sharp Stabbing Dull Aching Burning Tender Throbbing Pressure What makes the pain worse? What makes the pain better? Associated Symptoms: Numbness? Yes No If yes, location: Intermittent Constant Weakness? Yes No If yes, location: Intermittent Constant Loss of bladder control? Yes No Loss of bowel control? Yes No Sexual dysfunction? Yes No Depression? Yes No Anxiety? Yes No Have you ever had surgery to treat this pain? Yes No What TESTS have you had for your pain? MRI Neck Back Other: CT Neck Back Other: X-ray Neck Back Other: EMG/nerve tests Other What TREATMENTS have you had for your pain? Physical Therapy With relief? Yes No Chiropractic With relief? Yes No Medications With relief? Yes No Nerve Blocks With relief? Yes No Epidural Injections With relief? Yes No Surgery With relief? Yes No Other What other doctors are treating you for pain? What does the pain prevent you from doing?

5 PAIN QUESTIONNAIRE-2 Patient Name: Date: Medical History (Check any of the following conditions you have now or in the past) Heart Disease Diabetes Mellitus (Type 1 or Type 2) Lung Disease Osteoporosis Kidney Disease Cancer Hepatitis HIV Bleeding Abnormalities Anemia Seizures Neuropathy Depression Anxiety Thyroid Problems (Hypo or Hyper) High Blood Pressure Reflux (GERD) Ulcers List other medical problems (use back of the form if needed): Surgical History (Check any of the following operations you have had) Cervical spine surgery Lumbar spine surgery Heart surgery Other operations Please list all your current medications and doses (use back of form if needed): Please list any medication allergies or intolerance and type of reaction (use back of form if needed): What is your marital status? Single Married Divorced Widowed What is your work status? Full-time Part-time Unemployed Disabled Student Homemaker Retired If working, what is your occupation? Do you smoke? Yes No If yes, how much? ½ pack 1 pack 2 or more packs Do you drink alcohol? Yes No If yes, how much? Do you use marijuana, cocaine or similar substances? Yes No What medical conditions run in your family? Check any of the following symptoms you have now or have had recently: Depression Anxiety Insomnia Chest pain Shortness of breath Suicidal thoughts Balance Problems (falls) Weakness in arm or legs Headaches Loss of appetite Loss of bladder or bowel control Pregnancy Constipation Weight gain or Weight loss Abnormal menstrual periods

6 GULFCOAST PAIN INSTITUTE- OPIOD POLICY RULES AND INFORMED CONSENT 1. Narcotics will be used to treat pains that improve with medication. They will not be used for pains that do not respond to the medication. 2. Narcotics will not be used to treat insomnia, anxiety or depression. If these symptoms are present, they will be treated by others means. 3. Careful records of narcotic use will be made. These include time, dose of medication, symptoms the medication is being taken for, and response, including pain relief and side effects. 4. Pain medication prescriptions will be obtained only from this clinic. This includes muscle relaxants. If prescriptions are obtained from any other physician or clinic, this clinic must be notified within three working days. Unless special arrangements are made, all sedatives and anti-anxiety medications will be obtained only from this clinic. They will be obtained only at the time of visits to the clinic. Prescriptions cannot be obtained after hours. 5. Failure to follow these rules can result in life-threatening conditions. If these rules are not followed, then we will not continue prescribing narcotics. 6. The purpose of using narcotics for chronic non-cancer pain is to improve function. Your level of function will be assessed periodically to verify that the medication is helping. 7. Psychological evaluation will be performed prior to initiating chronic narcotic therapy and will be repeated at intervals. This is to make sure that a) no psychological problems are developing from the narcotic therapy, b) there is no undiagnosed anxiety problem that would be better managed with a different treatment, c) there is no undiagnosed anxiety problem that would be better managed with a different medication, and d) to verify that the narcotic medication is improving the level of functioning. 8. Lost or stolen prescriptions and/or medications will not be replaced. 9. The medication must not be given to anyone except the person for whom it is prescribed. 10. Narcotic induced drowsiness and/or impairment of judgment, reflexes, etc. can make driving an automobile, operating heavy machinery or performance of other tasks dangerous both to the individual as well as the other member of the community. These activities must be avoided while on narcotic therapy. 11. The rationale and the more common side effects of narcotic therapy are on the first page of this document. It is recognized that even with careful use of narcotics, side effects can occur. These side effects include medical, psychological and social problems. The potential risks of narcotic therapy must be understood in order to make an informed decision to participate in this type of treatment. If alternate forms of treatment become available, these should be investigated for appropriateness. 12. The physician has the full permission of the patient to obtain any information concerning the use of the prescribed drug, any other prescription drug or any non-prescription drug. The physician may obtain any information concerning any behavioral aspect relevant to the use of the opiate drug. This information may be obtained from persons including but not limited to: the dispensing pharmacist, other pharmacists, law enforcement officials, family members, immediate supervisor at work and any other important source of information. 13. The physician has the full permission of the patient to perform or authorize performance of random drug level testing. I, (patient name) have read and understand the rationale and rules as listed above. I agree to follow the rules for the use of narcotics in the management of my painful condition. _ Patient s Signature _ Today s Date Witness Signature Physician Signature

7 GULFCOAST PAIN INSTITUTE NARCOTIC USE GUIDELINES CHRONIC NARCOTICS FOR PAIN NOT DUE TO CANCER. RATIONALE: The use of narcotics for chronic pain not due to cancer is controversial. This is because narcotics are often not effective for long-term pain management. Also, problems can arise from chronic narcotic use. These problems can be medical, psychological, or social. Because of the dangers of chronic narcotic use, these medications should be used only under special circumstances. Strict guidelines must be followed to minimize the risks. WHAT NARCOTICS ARE USED FOR: Narcotics are used to reduce pain. They work in the brain and in the spinal cord. There are some pains that are not relieved by narcotics. There is no reason to take larger doses of narcotics for types of pain that do not improve with narcotics. NARCOTIC SIDE EFFECTS: Narcotics can cause annoying side effects such as itching, nausea, and constipation. More dangerous side effects include drowsiness (as severe as coma), depression of breathing (as severe as respiratory arrest), and mental changes (confusion, euphoria, or psychosis). There is a well-known potential for narcotic medications to be abused. There is a potential for the development of TOLERANCE, in which a constant dose of narcotic starts producing less and less effect. There is a potential for the development of DEPENDENCE, in which symptoms such as nausea, sweating, cramps, anxiety, pain and other disagreeable sensations occur when the narcotic medication is not taken. When used properly, narcotics are excellent pain relieving medications. When used improperly, there is a significant danger. WHAT NARCOTICS ARE NOT USED FOR: a. Insomnia Although narcotics can cause drowsiness, especially in higher doses, they are NOT good sleeping aids. This is because they alter the sleeping cycles and may actually worsen sleeping difficulties. If you are having difficulty sleeping, a medication specifically designed to help you will be prescribed. The only time it is appropriate to take narcotics near bedtime is if the medication is being taken for pain relief. b. Anxiety The mental effects of narcotics may blunt the awareness of symptoms of anxiety. However, this is a side effect of the narcotic. If you are having feelings of restlessness, anxiousness, or nervousness, then these symptoms should be evaluated, because this may be a sign of something else going on. There are much better treatments for anxiety than narcotics. These include other medications, as well as the use of counseling and relaxation techniques. c. Depression The mental effects of narcotics may blunt the feeling of depression. Narcotics do not make depression better. The effects of narcotics on sleep cycles may actually worsen the depression. If you are having feelings of sadness, loss of motivation, loss of interest in usual activities, loss of appetite, or feeling of hopelessness, then these symptoms should be evaluated. There are much better treatments for depression than narcotics. These include medications specifically designed to help depression, as well as the use of counseling, relaxation, and other psychological techniques. WHY THE DIFFERENCE IS IMPORTANT: If narcotics are used appropriately, then they are excellent pain relieving medications. If they are used for conditions other than those for which they are designed, then they are not good medications. For many reasons, inappropriate use of narcotics must be avoided. They may not be effective and can actually be harmful. It is very important to understand which symptoms are being treated with narcotics and which symptoms should be treated with other medications.

8 HELIOS OUTPATIENT CENTER NOTICE AND ACKNOWLEDGEMENT On or after April 14, 2003, regulations promulgated under the Health Insurance Portability and Accountability Act of 1996 ( HIPPA ) will require Helios Outpatient Center to comply with certain privacy requirements associated with the transfer, use or disclosure of protected health information ( PHI ). By signature, I acknowledge that I have been provided a copy of the Helios Outpatient Center s Notice of Privacy Practices ( the Notice ) that provides a more complete description of information uses and disclosures. I also confirm that I had the right to review the Notice prior to signing this Acknowledgement. Patient s Name Signature Print Name Date Authorized Representative (If Applicable) Signature Print Name Date acknowledgement

9 GULFCOAST PAIN INSTITUTE NOTICE AND ACKNOWLEDGEMENT On or after April 14, 2003, regulations promulgated under the Health Insurance Portability and Accountability Act of 1996 ( HIPPA ) will require GulfCoast Pain Institute to comply with certain privacy requirements associated with the transfer, use or disclosure of protected health information ( PHI ). By signature, I acknowledge that I have been provided a copy of the GulfCoast Pain Institute s Notice of Privacy Practices ( the Notice ) that provides a more complete description of information uses and disclosures. I also confirm that I had the right to review the Notice prior to signing this Acknowledgement. Patient s Name Signature Print Name Date Authorized Representative (If Applicable) Signature Print Name Date acknowledgement

10 Dear Sir or Madam: Under the advice of your physician, you may be recommended to receive a procedure. Your procedure will be performed in our Ambulatory Surgical Center- Helios Outpatient Center by your physician. Be advised that this office will be billing your insurance company and/or responsible payer two (2) bills. One bill will be for the physician charges, GulfCoast Pain Institute and one bill will be for Helios Outpatient Center. Also note that you are responsible for any co-pays and deductibles associated with this procedure. All conditions of your insurance will be followed. I have read and understand my obligations as to payment for GulfCoast Pain Institute and Helios Outpatient Center. Patient Signature Date