tri-state pain institute mailing address: tri-state pain ... · tri-state medical specialists, llc...
TRANSCRIPT
Tri-State Pain Institute Mailing Address: Tri-State Pain Institute 1510 Wagon Wheel Lane PO Box 10966 Fort Mohave, AZ 86426 Fort Mohave, AZ Phone: 928-788-3333 Fax: 928-788-3555 86427-0966
AUTHORIZATION TO RELEASE MEDICAL RECORDS
AsrequiredbytheHealthInformationPortabilityandAccountabilityActof1996andArizonalaw,youhavetherighttorequesttheopportunitytoinspectandcopyhealthinformationthepertainstoyou.Wewillevaluateyourrequestandwilleithergrantitorexplainthereasonwhytherequestwillnotbegranted.Yourrighttoaccessdoesnotextendtoinformationcompliedinreasonableparticipationof,orforuseinacivil,criminal,oradministrativeactionorproceeding,ortoinformationwereceivedinconfidencefromsomeoneotherthanahealthcareprovider.
Patient’sName:_____________________________________________________________________________________
DateofBirth:____________________SocialSecurityNumber:_____________________________________________
Irequestandauthorize________________________________________________________________toreleasehealth
careinformationofthepatientnamesaboveto:
TRI-STATE PAIN INSTITUTE
Thisrequestandauthorizationappliesto:
• Allhealthcareinformation.
• Other:_________________________________________________________________________________________________________________________________________________________________________________
• Healthcareinformationrelatingtothefollowingtreatment,condition,ordates:__________________________
___________________________________________________________________________________________
Iunderstandandherebyalsoconsenttothereleaseofanyandallalcoholand/ordrugabuseinformationrelatingtosexuallytransmitteddisease,acquiredimmunodeficiencysyndrome(AIDS),humanimmunodeficiencyvirus(HIV)orpsychiatrictreatmentrecordsunderthesameconditionoutlinedbelow.Iunderstandthatsuchinformationcannotbereleasedwithoutmyspecificconsent.
IunderstandthatIhavetherighttorevokethisauthorizationatanytime.IunderstandthatIhavetherighttorevokethisauthorization,Imustdosoinwritingandpresentmywrittenrevocationtothemedicalrecordsdepartment,andIunderstandthattherevocationwillnotapplytoinformationthathasalreadybeenreleasedinresponsetothisauthorization.Iunderstandthattherevocationwillnotapplytomyinsurancecompanywhenthelawprovidesmyinsurerwiththerightstoconsentaclaimundermypolicy.
PatientName:______________________________________________Date:_________________________________
PATIENT INTAKE WORKSHEET
Patient Name: _________________________________________________ DOB: _______________________________
Current Address: ___________________________________________________________________________________
City: ____________________________ State: ____________________ Zip: ____________________
Current Phone #s: Home: ____________________ Cell: __________________ Work: ___________________________
E-Mail Address: ____________________________________________________________________________________
Social Security Number (Patient): ______________________________________________________________________
Employer: _________________________________________________________________________________________
Insured (Policyholder) Name: _________________________________________________________________________
Social Security Number (Insured & Responsible Party): _____________________________________________________
Emergency Contact: ________________________________________ Relationship: _____________________________
Home #: ____________________ Cell #: ______________________ Work #: ____________________________
WORKER’S COMPENSATION INSURANCE
W/C Carrier: _______________________________________________________________________________________
Policy Number: ______________________ Group Number: _________________ Effective Date: ___________________
Insurance Name: ____________________________________________________________________________________
Date of Injury: __________________ Body Parts Injured: ___________________________________________________
Attorney: _______________________________________ Phone Number: _____________________________________
PERSONAL INJURY INFORMATION
Attorney: _______________________________________ Phone Number: _____________________________________
Office Contact: __________________________________ Date of Injury: ______________________________________
TRI-STATE MEDICAL SPECIALISTS, LLC 1510 E. Wheel Lane, SE. 110
FM Mohave, AZ 86426 PH: 928-788-3333 FAX: 928-788-3555
NOTICE OF PRIVACY POLICY FOR PROTECTED HEALTH INFORMATION (PHI)
The office of Tri-State Medical Specialists, LLC is dedicated to protect your “nonpublic personal health information”. This notice is to tell you how and why we collect that information, and who has access to that information.
HOW WE COLLECT YOUR INFORMATION Your personal demographic information such as name, address, birth date, social security number, and medical insurance information is obtained from you. This is why we ask you to fill out the patient information sheet and why we ask for a copy of your insurance card. This ensures that the information we collect is correct. If you came to our practice through a hospital encounter, we may obtain the information from the hospital. However, on your first visit to this office, we will ask you to fill out our information sheet to ensure that the information we received from the hospital was correct. We may also ask a doctor or other health care provider who referred you to this practice to give us health information that will enable us to better treat your medical condition. This benefits you in that we will have test results that have already been obtained by the referring entity. WHY WE COLLECT THIS INFORMATION We collect this information so that we can treat your medical condition and obtain payment from your health insurance. MAINTAINING ACCURATE AND TIMELY INFORMATION To ensure that the information we maintain is accurate, each time you visit the office you will be responsible to update your information. WHO HAS ACCESS TO THIS INFORMATION Any person or persons you designate in writing, people directly involved in your medical care, people creating and maintaining your medical record, and those entities that need your information to process health care claims and obtain payment for our services have access to you Protected Health Information. Entities such as Governmental Oversight agencies, Judicial and Administrative Proceedings, Law Enforcement Agencies, Coroners and Medical Examiners, and Organ Procurement Organizations may obtain copies of your Protected Health Information. These entities are mandated by law and this practice has no jurisdiction over such entities. HOW WE PROTECT YOUR INFORMATION We release your information only to those people who need your information. We maintain physical, electronic, and procedural safeguards so that no one but persons involved in your healthcare or entities that need this information for claims processing have access to your Protected Healthcare Information. YOUR RIGHTS You have the right to inspect your Personal Healthcare Information. You also have the right to amend any errors you may find in your records. If you leave this practice, your Protected Healthcare Information will continue to receive the protection outlined in this notice. COMPLAINT/COMMENTS If you have any complaints concerning our privacy practices, you may contact the Secretary of the Department of Health and Human Services, at 200 Independence Avenue SW, Room 509F, HHH Building, Washington D.C. 20201. You also may contact the Privacy Officer of this practice at P.O. Box 10966. Fort Mohave, AZ 86427-0966.
This notice is effective as of November 1, 2014 Received and Read: _______________________________________________________ Date: _______________________________
MYPROVIDERS
Myprimarycareprovideris:____________________________________________________________
Ialsoseeorhaveseenasconsultants/specialists
Cardiologist:___________________________________Neurologist:____________________________
Neurosurgeon/SpineSurgeon:___________________________________________________________
OrthopedicSurgeon:_______________________PriorPainDoctor:______________________________
Pulmonologist:____________________________Rheumatologist:______________________________
Oncologist:_______________________________Podiatrist:___________________________________
Other:_______________________________________________________________________________
IhavehadRadiologyandImagingat:
______WARMC ______VVMC ______KRMC ______HRMC______CRMC
______Mt.West______LHCImaging______CoastMRIOTHER_______________________
Electrodiagnostics(“NerveTest”)?______NO______YESByWhom:_______________________
SleepStudy?______NO______YESByWhom:_________________________________________
RecentCardiacEvaluation?______NO______YESByWhom:_____________________________
When:____________WhatWasDone:______EKG_______Echo_______StressTest
ChiropracticorPhysicalTherapy:______NO______YESWhen:___________________________
Where:________________________________________________________________________
Whenwasthelasttimeyouwerehospitalized?________________Where:____________________
Reason:
PAINHISTORY
TRAUMA(Mostrecentfirst):
When?________________Whatwasinjured?_____________________________________
Treatment:_____________________________________________________________________
*AdditionalPriorTrauma(Pleaseexplainwhathappened,whatwasinjured,andhowyouweretreated):
WORKCOMPINJURY(Mostrecentfirst):
When?__________________Whatwasinjured?___________________________________
Treatment:_____________________________________________________________________
Settlement:____________________________________________________________________
*PriorW/CHistory(Pleaseexplainwhathappened,whatwasinjured,andhowyouweretreated):
PAINRELATEDINTERVENTIONS/OPERATIONS(CIRCLEPLEASE):
HEAD:TrigeminalInjection/SurgeryOccipitalNerveBlockTMJInjectionSuboccipitalStimulator
Other:_______________________________________________________________________
NECK:EpiduralFacetInjectionsTriggerPointInjectionsRadiofrequency(“NerveBurn”)
StimulatorSurgery:(Front/Back/Both)Other:_________________________________
THORACIC:EpiduralFacetinjectionsTriggerPointInjectionsRadiofrequency(“NerveBurn”)
StimulatorSurgery:(Front/Back/Both)Other:____________________________
BACK:EpiduralFacetinjectionsTriggerPointInjectionsRadiofrequency(“NerveBurn”)
StimulatorSurgery:(Front/Back/Both)DrugPumpOther:_____________________
JOINT:A=ArthroscopyR=Replacement
Injections:ShoulderElbowWrist/HandHipKneeSteroid/CollagenAnkle
Surgery:Shoulder(A/R)Elbow(A/R)Wrist/Hand(A/R)Hip(A/R)
Knee(A/R)Ankle(A/R)
OTHER:
PainDiagram
Pleasemarktheareaofinjuryordiscomfortonthechartbelowusingtheappropriatesymbols:
NumbnessPins&NeedlesBurningAchingStabbing-------------ᴼᴼᴼᴼᴼᴼᴼᴼ˄˄˄˄˄XXXXXX●●●●●------------ᴼᴼᴼᴼᴼᴼᴼᴼ˄˄˄˄˄XXXXXX●●●●●
Daily Pain Score
PLEASE RATE THE FOLLOWING ON A SCALE OF O - 10
0 = NO PAIN
1-4 = LOW AMOUNTS OF PAIN
5-7 = MODERATE PAIN 8-10 = SEVERE PAIN
Average______________
Best_____________
Worse_________________
Thingsthatmakemypainworse:
Thingsthatmakemypainbetter:
ICURRENTLYTAKETHEFOLLOWINGFORPAINANDRELATEDCOMPLAINTS(PleaseCircle):
Tylenol/CodeineMSContinSuboxoneNaprosynFlexerilGabapentinHydrocodoneDilaudidSubutrexMobicSomaCymbaltaZohydroMethadoneFentanylPatchCelebrexValiumLyrica
OxycodoneOpanaButransPatchDiclofenacZanaflexTegretol
OcyContinOpanaERTramadolIndomethacinXanaxDilantin
MorphineKadianMotrin(Ibu)Advil/AleveAtivanTopicalCream
Other:
MYMEDICALHISTORY
PLEASECIRCLEALLTHAT:
CVSHypertensionCholesterolMIAneurysmHeartFailurePADCarotidDisease
LEEdemaPacemakerOnBloodThinnersChestPainPalpitations
LUNGSCOPDAsthmaPneumoniaValleyFeverAsbestosBronchitisShortnessofBreath
GIGERD/PUDIrritableBowelCrohn’sDzGallbladderDiverticularDzConstipation
HemorrhoidsPancreatitisBowelObstructionLiverDz:(Hepatitis/Cirrhosis)
GU/Renal UTIKidneyStonesRenal:(Dialysis?YN)BladderDisease
Males:ProstrateHypertrophy(BPH)ErectileDysfunctionFemales:StressIncontinence
ENDO Diabetes:(Insulin/Meds)OsteoporosisThyroid:(Hypo/Hyper)LowT
NEUROStrokeSeizuresTremor(Essential/Parkinson’s)HA/MigraineMSDementia
Hydrocephalus(Shunt?)NeuropathyALSRSD/CRPSRestlessLegSyndrome
GYNPeriods:(Reg./Irreg.)Post-MenopauseMenopausePre-MenopauseHysterectomy
CANCER Skin(Melanoma)LungH/NStomach/Intestine/ColonBloodLymphomaBrain
ProstrateOvarianUterineBoneKidneyBladderThyroid
Other:_____________InTreatment_____InRemission_____MetastaticDisease_____
RHEUM Arthritis(Osteo/Rheum)LupusFibromyalgiaRaynaud’s
PSYCH DepressionAnxietyBipolarSchizophreniaPTSDDecreasedLibido
HEME AnemiaPlatelets(Low/High)“Bleeder”Hemochromatosis
INFEC +HIVMRSAChronicInfection(Where?____________)
SENSORYGlasses(ReadingOnly)CataractsGlaucomaHearingLossRinginginEarsLegallyBlind
DoubleVisionLossofSmell
OTHER:
MYMEDICATIONS,ALLERGIESANDFAMILYHISTORY
LISTALLNON-PAINRELATEDMEDICATIONS:______NONE_______SEEATTACHEDLIST
BLOODTHINNERS(circle):Aspirin(81mg325mg)PlavixCoumadinXeraltoOther:
OTHERMEDICATIONS(Name,Dose,andhowoftenyoutakethemedication):
IAMALLERGICTO: ________NONE
IODINERELATED(circle):ShellfishIVContrastContrastwithPainInjection
MEDICATIONALLERGIES(ListMedicationandReaction):
PLEASELISTALLDISEASESTHATRUNINYOURFAMILY: _________IAMADOPTED
MYSURGICALHISTORYPLEASE CIRCLE ALL THAT APPLY { If multiple, please write how many on the line } SPINE: Cervical - Front (ACDF) _____ Back (Laminectomy) _____ Both_____ Fusion Y N Thoracic - Laminectomy _____ Fusion _____ Scoliosis Surgery _____ Vertebroplasty _____ Lumbar - Laminectomy _____ ( Back / Front / Side ) Vertebroplasty _____ Stimulator ( Spinal / Peripheral ) Syrinx Drainage Drug Pump SI Fusion ORTHO: {A = Arthroscopy R = Replacement} Right Shoulder A _____ R _____ Elbow A _____ R _____ Wrist/Hand A _____ R _____ Hip A _____ R _____ Knee A _____ R _____ Ankle/Foot A _____ R _____ Carpal Tunnel ______ Ulnar Nerve Release _____ Fracture Surgery _____ Left
Shoulder A _____ R _____ Elbow A _____ R _____ Wrist/Hand A _____ R _____ Hip A _____ R _____ Knee A _____ R _____ Ankle/Foot A _____ R _____ Carpal Tunnel ______ Ulnar Nerve Release _____ Fracture Surgery _____
HEAD: Craniotomy ( Tumor / Aneurysm / Trauma ) Aneurysm Coiling Shunt ( VP / LP ) DBS Pituitary
EYES: Cataracts Glaucoma Surgery Detached Retina Lasik / Vision Surgery
ENT: Thyroid Sinus Surgery Head / Neck Tumor Ear Surgery Vocal Cord Surgery
LUNG: Bronchoscopy Lung Biopsy Lung Resection Drainage of Lung Fluid
CV: Heart Stent _____ Coronary Bypass Surgery _____ Cardiac Ablation _____ Pacemaker
Carotid ( Stent / Endarterectomy ) LE Stent Aortic Stent Renal Stent Femoral Stent
ABD: Appendectomy Gall Bladder Colon Resection Esophagus Stomach / PUD Trauma
Abdominal Surgery ( Trauma / Tumor / Infection / Adhesions ) Hemorrhoid Pancreas Surgery
Endoscopy ( Upper / Lower ) Liver ( Biopsy / Resection ) Drainage of Fluid Colostomy
GYN: Hysterectomy Tubal Ligation Endometriosis Adhesions C-Section D&C
CANCER: Skin Lung Stomach/ Intestine/ Colon Brain Breast ( Biopsy / Mastectomy ) Prostate Ovarian
Ovarian Uterine Bone Kidney Bladder Thyroid Head / Neck
GU: BPH Penile Prosthesis Bladder Suspension Uterine Suspension Renal
OTHER SURGERIES:
SOCIAL HISTORY
Circle and Answer All That Apply:
Are You A Snowbird? Y N If so, what is your permanent address?
Marital: Single Married Divorced Separated Co-Habitation Partner
Vocational: Work (F/T or P/T) Unemployed Retired Disabled Not Working by Choice
Children: Biological ____ Ages? Adopted / Stepchildren _____ Ages?
Disability: N/A Applying Receiving Benefits S/S W/C
Abuse: Spousal Physical Verbal Emotional PTS Syndrome
Transportation: Own Auto / Motorcycle Get a Ride Public Transportation /Taxi Other:
Tobacco: Cigarettes Age Started? _____ Age / Year Quit? _____ PPD? _____
Pipe Age Started? _____ Age / Year Quit? _____
Cigar Age Started? _____ Age / Year Quit? _____
Alcohol: Beer Wine Spirits How much and how often? ___________________________
Are you an alcoholic? Y N DUI? Y N
Drugs: Rx Meds MJ ( Certified? Y N ) Meth Cocaine Heroin Other? __________
Arrest Record for Drugs? Y N Attended Rehab? Y N
12 Step Program (AA or NA)? Currently _______ In The Past ________
ANYTHING ELSE YOU WOULD LIKE TO ADD?
TRISTATEPAININSTITUTE
Welcome to our clinic! We want to make your visit with us as efficient and productive as possible. To do so, it is important that we obtain as much informationbeforeyouseeoneofourproviders.Tohelpushelpyou,pleasedo the following:
• Please provide us your current drivers license or other photo ID, a copy of your insurance card, pharmacy card and any other related information.
• If you have x-ray films or a CD, please give them to the medical assistant when called back. If you have had any additional relevant x-rays or imaging within the last 2 years, please inform our staff to obtain reports. A consent form will need to be signed.
• If you were referred from a doctor's office, please inform our staff who that is.Wewouldliketotryandobtainacopyofyourmostrecentrecords.Aconsent form will need to be signed.
• If you have recently been seen in another pain clinic, please inform our staff who that was. We would like to try and obtain a copy of your most recent records and a discharge letter. A consent form will need to be signed.
• Please identify any consultant or specialist you have seen recently. We would like to try and obtain a copy of your most recent records. A consent form will need to be signed.
• Take your time and fill out this form completely. This will allow us to efficiently enter this information into our electronic medical record, and allow you to be seen sooner.
• You are entitled to a copy of today's consultation... just ask.
Any constructive feedback you provide us will be welcomed. Our staff and providers are committed to helping you back to the best health you can achieve.
The Staff and Providers of TriState Pain Institute
TriState Pain Institute
CONTROLLED SUBSTANCE CONTRACT
ThisagreementreflectsmyuseofcontrolledsubstancesforchronicpainprescribedbyTriStatePainInstitute.IhavebeeninformedandunderstandthepoliciesregardingtheuseofcontrolledsubstancesbyTriStatePainInstitute,it’sproviders,andstaff.IacknowledgethatIwillbeprovidedcontrolledsubstanceswhileparticipatingasapatientinthispracticeonlyifIadheretothefollowingconditions:
1. IwillusethesubstancesonlyasdirectedbytheTriStatePainInstitutestaff.2. IwillnotreceivereplacementmedicationsforanymedicationsofwhichIhavelostorhavebeenstolen.3. Iwillreceivecontrolledsubstancesonlyfromtheprovidersinthisoffice.4. Iwillnotexpecttoreceiveadditionalmedicationpriortothetimeofmynextscheduledrefill,evenifmy
prescriptionrunsout.5. Iwillnotconsumeexcessiveamountsofalcoholinconjunctionwithcontrolledsubstances.6. Iagreetoscheduleandkeepscheduledfollow-upappointmentsatrecommendedintervals.Iunderstandthat
failuretokeepappointmentsmayleadtodiscontinuationoftreatment.7. Ifitappearstothephysicianthattherearenosignificantbenefitstomydailyactivitiesoranyimprovement
inmyqualityoflifefromthecontrolledsubstance,Iwillgraduallyreducemymedicationasdirected.8. Iagreetopartakeinurineandbloodscreenstodetecttheuseofnon-prescribedmedications(including“streetdrugs”)atanytime.9. Irecognizethatmychronicpainrepresentsacomplexproblem,whichmaybenefitfromphysicaltherapy,
psychotherapyandbehavioralmedicinestrategies.Ialsorecognizethatmyactiveinvolvementinthemanagementofmypainisextremelyimportant.IagreetoactivelyparticipateinallaspectsofmyPainManagementProgramtomaximizefunctioningandimprovecopingwithmycondition.
10. IamresponsibleforkeepingtrackoftheamountofmedicationleftandtoplanaheadforarrangingtherefillofmyprescriptionsinatimelymannersoIwillnotrunoutofmedications.
11. Iagreetopartakeinapillcountatanytime,todocumenttheamountofmyremainingmedications.12. Iwillparticipateinthemonthlyprescriptionprogram.**13. IfIviolateanyoftheaboveconditions,myobtainingprescriptionsand/ortreatmentrecommendedand
agreedupon,Imaybeterminatedasapatientfromthispractice.14. Iftheviolationinvolvesobtainingcontrolledsubstancesoranyprescriptionformypainconditionfrom
anotherindividualorifIengageinanyillegalactivitysuchasalteringaprescription,Iunderstandthattheincidentmaybereportedbythisofficetootherphysicianscaringforme,localmedicalfacilities,pharmaciesandotherauthoritiessuchasthelocalpolicedepartment,DrugEnforcementAgency,etc.asdeemedappropriateforthesituation.
MEDICATIONREFILLINFORMATIONA. Advancenoticeof2-3businessdaysisrequiredforrefillsofnon-controlledprescriptions.B. RequestsforscheduledrefillsmustbetelephonedonlyduringregularofficehoursMonday-Friday
(9AM-5PM)).Refillswillnotbemadeatnight,onholidays,Fridaysoronweekends.C. Mostcontrolledsubstancescannot(ClassII)betelephonedintoapharmacy.Youmustmake
arrangementstopickupyourprescriptionduringregularbusinesshours.
**MONTHLYPRESCRIPTIONPROGRAMA. Iwillbegivenamonthlyprescriptionofallcontrolledsubstances(ClassII),unlessotherwisespecified.
Dependingonpharmacy,drugplanorpharmacycoverage,thisgenerallyrangesfrom28to30days.
2CONTROLLED SUBSTANCE CONTRACT (PT 2)
GLOBAL PAIN INTERVENTION AND MANAGEMENT CONTRACT
ThisagreementcoversmyparticipationinpainproceduresorotherinterventionsoutsideoftheTriStatePainInstitute.Iacknowledgethatagreethefollowing:(1)toonlyuseprescribedpainmedications(includingopioids)asoutlinedbythepaincontractasdocumentedabove;(2)tocompletealldiagnosticstudiesandothertestinginatimelymanneronceauthorized(financespermitting),inordertoarriveatadiagnosis;(3)tosubmitforurinedrugtoxicologywhenrequestedand(4)shouldyoubeadmittedtoanyemergencyroomhospital,andagreetobringalldischarge,lab,andx-rayorimagingreportstoyournextappointment.InadditionanynegativecommentsorallegationsagainsttheTriStatePainInstitute,itsprovidersand/orstaff,mustbeimmediatelyreported,especiallyifthesourceisanyhospitaladministrator,stafforprovider.EXCEPTIONSAREASFOLLOWS:
• Intramuscularsteroidinjectionsreceivedatyouprimaryprovider,specialist,orurgentcare/emergencyroom.
• Jointinjectionsperformedbyyourprimaryprovider,orthopedicorrheumatologyconsultant,orwithinthesettingofurgentcareoremergencyroom.
• Botoxorsteroidinjectionsforheadaches,performedbyaneurologist.• Anyimagedirectedprocedureperformedbyaradiologist,butonlyifyouareadmittedtothehospital.• AnyinjectionfollowingnotificationandpermissiongivenbyaTriStatePainInstituteprovider.
Itisimportantthatallspineinterventional(injection)management,beperformedattheTriStatePainInstituteorbyitsproviders.Weareresponsibleforyourtotalpainmanagement,andrarelyareweinformedwhentheseinjections/blocksarescheduledorreceiveanydocumentationofthis.FurthermoremanyoftheseinjectionsoutsideoftheTriStatePainInstituteareproperlyauthorized,andyoumaybefinanciallyresponsibletotheseotherproviders.
VALIDATION OF CORRECT MEDICATION MANAGEMENT
Wearerequiredbystatutetoregularlyandrandomlyasneeded,drugtestallpatients.Therearenoexceptions.Urinescreeningisthemostcommonsourceofspecimen,butalsobloodcanbeused.TheTriStatePainInstitutereservestherighttoobserveyouwhilethespecimenisobtained.Tampering,substitutingortamperingwiththespecimeninadeceptivemannerconstitutesgroundsfortermination.Shouldyoubeunabletoprovideaspecimenwhenrequested,youareresponsibletoreturnnolaterthat24-48hours(72hoursoveraweekend)todoso.
THISAGREEMENTWILLSUPERSEDEALLOTHERAGREEMENTS.
BYSIGNINGBELOW,IINDICATETHATIUNDERSTANDANDAGREETOALLTHETERMSOFTHEABOVECONTRACT.IHAVEALSORECEIVEDACOPYOFTHISFORMYRECORDS.
_______________________________________ ___________________________________ Patient Date______________________________________ ___________________________________ Witness Date
TriState Pain Institute INFORMEDCONSENT
TREATMENT FOR NON-CANCER / CANCER PAIN Thepurposeofthisagreementistogiveyouinformationaboutthemedicationsyouwillbetakingforpainmanagementandtoassurethatyouandyourphysician/healthcareprovidercomplieswithallstateandfederalregulationsconcerningtheprescribingofcontrolledsubstances.Atrialofopioidtherapycanbeconsideredformoderatetoseverepainwiththeintentofreducingpainandincreasingfunction.Thephysician’sgoalisforyoutohavethebestqualityoflifepossiblegiventherealityofyourclinicalcondition.Thesuccessoftreatmentdependsonmutualtrustandhonestyinthephysician–patientrelationshipandfullagreementandunderstandingoftherisksandbenefitsofusingopioidstotreatpain.
Ihaveagreedtouseopioids(morphine-likedrugs)aspartofmytreatmentforchronicpain.Iunderstandthatthesedrugscanbeveryuseful,buthaveahighpotentialformisuseandarethereforecloselycontrolledbythelocal,state,andfederalgovernment.Becausemyphysician/healthcareproviderisprescribingsuchmedicationtohelpmanagemypain,Iagreetothefollowingconditions:
1. Iamresponsibleformypainmedications.Iagreetotakethemedicationonlyasprescribed.a. Iunderstandthatincreasingmydosewithouttheclosesupervisionofmyphysiciancouldleadtodrug
overdosecausingseveresedation,respiratorydepression,anddeath.b. Iunderstandthatdecreasingorstoppingmymedicationwithouttheclosesupervisionofmyphysician
canleadtowithdrawal.Withdrawalsymptomscanincludeyawning,sweating,wateryeyes,runnynose,anxiety,tremors,achingmuscles,hotandcoldflashes,“gooseflesh”,abdominalcramps,anddiarrhea.Thesesymptomscanoccur24-48hoursafterthelastdoseandcanlastupto3weeks.
2. IwillnotrequestoracceptcontrolledsubstancemedicationfromanyotherphysicianorindividualwhileIamreceivingsuchmedicationfrommyphysician/healthcareprovideratTriStatePainInstitute.
3. Therearesideeffectswithopioidtherapy,whichmayinclude,butnotexclusively;skinrash,constipation,
sexualdysfunction,sleepingabnormalities,sweating,edema,sedation,orthepossibilityofimpairedcognitive(mentalhealth)and/ormotorability.Overuseofopioidscancausedecreasedrespiration.
Itismyresponsibilitytonotifymyphysician/healthcareproviderofanysideeffectsthatcontinueoraresevere(i.e.,sedation,confusion).IamalsoresponsiblefornotifyingmypainphysicianimmediatelyifIneedtovisitanotherphysicianorneedtovisitanemergencyroomduetopain,orifIbecomepregnant.
4. Iunderstandthattheopioidmedicationisstrictlyformyownuse.Theopioidshouldneverbegivenorsoldtoothersbecauseitmayendangerthatperson’shealthandisagainstthelaw.
5. IshouldinformmyphysicianofallthemedicationsthatIamtaking,including,herbalremedies.MedicationslikeValiumorAtivan;sedativessuchasSoma,Xanax,Fiorinal;antihistamineslikeBenadryl.Aswellasalcoholandcoughsyrupcontainingalcoholandcodeinecaninteractwithopioidsandproduceserioussideeffects.
6. Iunderstandthatopioidprescriptionswillnotbemailed.IfIamunabletoobtainmyprescriptionsmonthly,I
willberesponsiblefordiscussingthiswithmypainphysicianinadvance.
7. Anyevidenceofdrughoarding,acquisitionofanyopioidmedicationoradjunctiveanalgesiafromotherphysicians(whichincludesemergencyrooms),uncontrolleddoseescalationorreduction,lossof
prescriptions,orfailuretofollowtheagreementmayresultinterminationofthedoctor/patientrelationship.
8. Iwillcommunicatefullywithmyphysiciantothebestofmyabilityattheinitialandallfollow-upvisits.This
includesmypainlevelandfunctionalactivityalongwithanysideeffectsofthemedications.Thisinformationallowsmyphysiciantoadjustmytreatmentplanaccordingly.
9. Youshouldnotuseanyillicitsubstances,suchascocaine,marijuana,ect.whiletakingthesemedications.
Thismayresultinachangetoyourtreatmentplan,includingsafediscontinuationofyouropioidmedicationswhenapplicableorcompleteterminationofthedoctor/patientrelationship.
10. Theuseofalcoholtogetherwithopioidmedicationsiscontraindicated.
11. Iamresponsibleformyopioidprescriptions.Iunderstandthat:
a. Refillprescriptionscanbewrittenforamaximumofone-monthsupply.b. ItismyresponsibilitytoscheduleappointmentsforthenextopioidrefillbeforeIleavetheclinicor
within3businessdaysofthelastclinicvisit.c. Iamresponsibleforkeepingmypainmedicationsinasafeandsecureplace,suchasalockedcabinetor
safe.Iamexpectedtoprotectmymedicationsfromlossortheft.Iamresponsiblefortakingthemedicationinthedoseprescribedandforkeepingtrackoftheamountremaining.
d. Ifmymedicationisstolen,Iwillreportthistomylocalpolicedepartmentandobtainastolenitemreport.Iwillthenreportthestolenmedicationtomyphysician.Ifanymedicationsarelost,misplaced,orstolen,myphysicianmaychoosenottoreplacethemedicationsortotaperanddiscontinuethemedications.
e. Refillswillnotbemadeasan“emergency”,suchasonFridayafternoonbecauseIsuddenlyrealizedIwill“runouttomorrow”.
f. Prescriptionsforpainmedicineoranyotherprescriptionswillbedoneonlyduringanofficevisitorduringregularofficehours.Norefillsofanymedicationswillbedoneduringtheeveningoronweekends.
g. Youmustbringallopioidmedicationsandadjunctivemedicationsprescribedbyyourphysicianorhealthcareproviderintheoriginalcontainers/bottlesateveryvisit.
h. Prescriptionswillnotbewritteninadvanceduetovacations,meetings,orothercommitments.i. Ifanappointmentforaprescriptionrefillismissed,anotherappointmentwillbemadeassoonas
possible.Immediateoremergencyappointmentswillnotbeautomaticallygranted.j. Generally,no“walk-in”appointmentsforopioidrefillswillbegranted,howeverexceptionscanbemade
dependingoncircumstances.
12. Whilephysicaldependenceistobeexpectedafterlong-termuseofopioids,signsofaddiction,abuse,or
misuseshallprompttheneedforsubstancedependencetreatmentsaswellasweaninganddetoxificationfromtheopioids.a. Physicaldependenceiscommontomanydrugssuchasbloodpressuremedications,anti-seizure
medications,andopioids.Itresultsinbiochemicalchangessuchthatabruptlystoppingthesedrugswillcauseawithdrawalresponse.Itshouldbenotedthatphysicaldependencedoesnotequaladdiction.Onecanbedependentoninsulintotreatdiabetesordependentonprednisone(steroids)totreatasthma,butoneisnotaddictedtotheinsulinorprednisone.
b. Addictionisaprimary,chronicneurobiologicdiseasewithgenetic,psychosocialandenvironmentalfactorsinfluencingitsdevelopmentandmanifestation.Itischaracterizedbybehaviorthatincludesoneormoreofthefollowing:impairedcontroloverdruguse,compulsiveuse,continuedusedespiteharm,
andcravings.Thismeansthedrugdecreasesone’squalityoflife.Ifthepatientexhibitssuchbehavior,thedrugwillbetaperedandsuchapatientisnotacandidateforanopioidtrial.He/shewillbereferredtoanaddictionmedicinespecialist.
c. Tolerancemeansastateofadaptationinwhichexposuretothedruginduceschangesthatresultinalesseningofoneormoreofthedrug’seffectsovertime.Thedoseoftheopioidmayhavetobetitratedupordowntoadosethatproducesmaximumfunctionandarealisticdecreaseofthepatient’spain.
13. Ifitappearstothephysician/healthcareproviderthatthereisnoimprovementinmydailyfunctionor
qualityoflifefromthecontrolledsubstance,myopioidsmaybediscontinued.Iwillgraduallytapermymedicationasprescribedbythephysician.
14. IfIhaveahistoryofalcoholordrugmisuse/addictionImustnotifythephysicianofsuchhistorysincethe
treatmentwithopioidsforpainmayincreasethepossibilityofrelapse.Ahistoryofaddictiondoesnot,inmostinstances,disqualifyoneforopioidtreatmentofpain,butstartingorcontinuingaprogramforrecoveryisanecessity.
15. Iwillbeseenonaregularbasisandgivenprescriptionsforenoughmedicationtolastfromappointmentto
appointment,andsometimestwotothreedaysextraiftheprescriptionendsonaweekendonholiday.Thisextramedicationisnottobeusedwithouttheexplicitpermissionoftheprescribingphysicianunlessanemergencyrequiresyourappointmenttobedeferredoneortwodays.
16. Iagreeandunderstandthatmyphysicianreservestherighttoperformrandomorunannouncedurinedrug
testing.Ifrequestedtoprovideaurinesample,Iagreetocooperate.IfIdecidenottoprovideaurinesample,Iunderstandthatmydoctormaychangemytreatmentplan,includingsafediscontinuationofmyopioidmedicationswhenapplicableorcompleteterminationofthedoctor/patientrelationship.Urinedrugtestingisnotforensictesting,butisdoneformybenefitasadiagnostictoolandinaccordancewithcertainlegalandregulatorymaterialsontheuseofcontrolledsubstancestotreatpain.
17. Iagreetoallowmyphysician/healthcareprovidertocontactanyhealthcareprofessional,pharmacy,legal
authority,orregulatoryagencytoobtainorprovideinformationaboutyourcareoractionsifthephysicianfeelsitisnecessary.
18. Iagreetoafamilyconferenceoraconferencewithaclosefriendorsignificantotherifthephysicianfeelsit
isnecessary.
19. Iunderstandthatnon-compliancewiththeaboveconditionsmayresultinare-evaluationofmytreatmentplananddiscontinuationofopioidtherapy.Imaybegraduallytakenoffthesemedications,orevendischargedfromtheclinic.
Ihavereadtheaboveinformationorithasbeenreadtomeandallmyquestionsregardingthetreatmentofpainwithopioidshavebeenansweredtomysatisfaction.Iherebygivemyconsenttoparticipateintheopioidmedicationtherapyandacknowledgereceiptofthisdocument.
Patient’sSignature_________________________________ Date______________________________
Witness’sSignature________________________________ Date______________________________
Tri-State Pain Institute 1510 E. Wagon Wheel Lane, Ste. 110 Fort Mohave, AZ 86426 PH: 928-788-3333 Fax: 928-788-3555
AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION
I have been presented with a copy of the Notice of Privacy Practices, detailing how my health information may be used and disclosed as permitted under federal and state law, and outlining my rights regarding my health information. Print Patient Name: ___________________________________ Date: _____________________ Relationship (if not signed by patient): ______________________________________________ Please name all of your family/friends we can contact and/or discuss your medical information with:
Name: ______________________ Relationship: _________________ Phone: ______________
Name: ______________________ Relationship: _________________ Phone: ______________
Name: ______________________ Relationship: _________________ Phone: ______________
Name: ______________________ Relationship: _________________ Phone: ______________
I wish to place the following restrictions on disclosure of my health information: ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Signature: ________________________________________________ Date: _______________
CONSENTTOTREATandAuthorizationtoReleaseInformationIconsenttoandauthorizetheadministrationofalldiagnosticandtherapeutictreatmentsthatmaybeconsideredadvisableornecessaryinthejudgmentoftheattendingphysician.IauthorizeTriStateMedicalSpecialists,LLCtofurnishmyInsurancecarriersinformationregardinghistory,physicalfindingsandtreatmentrenderedasallowedbyHIPAA.IfurtherauthorizeanyholderofmedicalorotherInformationaboutmetoreleasesuchinformationtotheSocialSecurityAdministrationandHealthCareFinancingAdministrationoritsintermediariesorcarriersanyinformationneededforthisorarelatedMedicare/otherinsurancecompanyclaim.Ipermitacopyofthisauthorizationtobeusedinplaceoftheoriginal,andrequestpaymentormedicalinsurancebenefitstothepartywhoacceptsassignment.
AuthorizationtoPayBenefitstoProviderIrequestandauthorizethatpaymentsforauthorizedMedicare/otherinsurancecompanybenefitsbemadedirectlytoTriStateMedicalinstitute,LLConmybehalfforanyservicesfurnishedtomebyTriStateMedicalSpecialists,LLC,whoacceptsassignment.RegulationspertainingtoMedicareassignmentofbenefitsapply.Ialsounderstandthatitismandatorytonotifythehealthcareproviderofanyotherpartywhomayberesponsibleforpayingformytreatment(Section11288oftheSocialSecurityActand31USC.3801-3812providespenaltiesforwithholdingthisInformation).
PatientResponsibilityIagreethatIamresponsibleforallchargesincurredinthisoffice,ifmyinsurancecoveragedoesnotprovidefullbenefits.Iwillpayanypatientresponsibilitybalanceduewithin30daysunlessIhavemadeotherarrangementswithTriStateMedicalSpecialists,LLC.Further,IagreethatthisvisitisnotrelatedtoalitigationmatterasitismyunderstandingthatTriStateMedicalSpecialists,LLCdoesnotseethistypeofcaseforevaluationsandtreatments.Ifcancellationofmyappointmentbecomesnecessary,IwillcontactTri-StateMedicalInstitute,LLCnolaterthantwenty-four(24)hourspriortomyscheduledappointmenttime.Iunderstandthatfailuretofollowthecancellationofappointmentpolicy,Imaybesubjecttoachargeoffiftydollars($50.00)andsuchchargeisnotpayablethroughmyinsurance.IhavereadtheTriStateMedicalSpecialists,LLCOfficePolicyStatementandallmyfinancialquestionswereanswered.
AncillaryServicesAsaconveniencetoourpatients,TriStateMedicalSpecialists,LLCoffersdirectdispensingofmedications,topicalcreams,durablemedicalequipment,aswellasonsitediagnostictestingasrecommended.IunderstandIamundernoobligationtoobtainthesepharmaceuticals,orthotics,orservicesthroughTriStateMedicalSpecialists,LLC,andatanytimecanrequestareferraltoanindependentpharmacy,medicalsupplyoutlet,imagingcenter,hospitaloranotherprovider.
AssignmentofInsuranceBenefitsIherebyauthorizedirectpaymentofallmedical/surgicalbenefitstoTriStateMedicalSpecialists,LLC(dbaTriStateMedicalInstitute),forservicesrenderedtotheminpersonorundertheirsupervision.IunderstandthatIamfinanciallyresponsibleforanybalancenotcoveredbymyinsurance.IalsoauthorizemydoctortoinitiateacomplainttotheInsuranceCommissionerforanyreasononmybehalf.
AuthorizationtoReleaseInformationIherebyauthorizeTriStateMedicalSpecialists,LLC(dbaTriStateMedicalinstitute)toreleaseanymedicalorincidentalinformationthatmaybenecessaryforeithermedicalcareorinprocessingapplicationsforfinancialbenefits.
PatientName:_______________________________Parent/Guardian:_______________________
Signature:______________________________________Date:_____________________________
TRISTATE PAIN INSTITUTE Policy for Financial Responsibility
Dear Valued Patient,
Your providers at the TriState Pain Institute often recommend services, orthotics, non-opioid pain medications, and/or topical cream agents or interventions as part of your overall plan of care. Our goal is to provide effective pain management (and overall good health), while minimizing the risk of medication side effects and addiction. While you are under no obligation to accept any or all of our suggestions, we hope they are at least considered.
A struggling economy has placed all of us under considerable fiscal pressure. Furthermore, specific plan coverage and formulary benefits (the part of your insurance responsible for your medications) often vary from patient to patient. We believe, however, your healthcare transcends the ups and downs of both our local and national financial conditions. In light of this, we will attempt to determine what is covered by your insurance plan and formulary, in addition to any monetary responsibility you may have. You are however under no obligation to follow these recommendations. Furthermore, you are free to choose to obtain any or all services, through local pharmacies or mail order drug services, DME retailers, hospitals, or other providers.
Ideally monetary or transportation challenges should not limit treatment. If it is more convenient to obtain medications or other clinical services at our clinic (if possible), we will attempt to coordinate your office visits with additional care.
Thank you for choosing the TriState Pain Institute as one of your healthcare providers. As with all of our services, please bring all questions or concerns to our attention immediately. As always, we strive each day to earn your confidence as your partner for good health. Thank you for your consideration,
ProvidersandStaffTriState Pain Institute
I have read and understand all of the above.
____________________________________________________________________________
PATIENT DATE