ATLANTIC PAIN INTERVENTIONS & REHABILITATION Sastry K. Topalli, MD Diplomate of the American Board of PM&R Board Certified in PM&R 300 Medical Parkway, Suite 306 Chesapeake, VA 23320 Phone: 757-410-4219 Fax: 757-410-4237 www.atlanticpaininterventions.com Atlantic Pain Interventions & Rehabilitation Welcome to Atlantic Pain Interventions & Rehabilitation (APR), your path to enjoying a pain free life. We appreciate the opportunity to serve you with your healthcare needs. APR emphasizes the diagnosis and treatment of complex pain syndromes allowing patients to make a faster recovery and resume a more normal lifestyle. Our treatment protocols usually involves a combination of procedures, medications, physical therapy, bracing and modalities. We have a federal mandate to utilize a multimodal approach and not just prescribe controlled medications. As a result, we will, in all likelihood be utilizing at least one treatment modality in addition to medications. What to Expect from APR • Dr. Topalli and/or an associate physician, will see you during your initial visit. • Any interventional procedure will be performed in the ambulatory surgical center, which is conveniently located in each of our offices. • You are required to comply with the treatment plan prescribed by our physicians. We look forward to serving you to relieve your pain and improve your quality of life. Enjoy A Pain Free Life
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ATLANTICPAIN INTERVENTIONS &REHABILITATION
Sastry K. Topalli, MDDiplomate of the American Board of PM&R
Board Certified in PM&R 300 Medical Parkway, Suite 306
AUTHORIZATION TO RELEASE INFORMATION, ASSIGNMENT OF BENEFITS, FINANCIAL RESPONSIBILITYI authorize release of any information acquired in the course of my treatment to appropriate medical personnel or insurers. I assign insurance benefits toAtlantic Pain Interventions & Rehabilitation (APR). I know that I am financially responsible if my insurer does not pay.
I ________________________________ (Print Name) hereby authorize benefits to be assigned to Atlantic Pain Interventions & Rehabilitation (APR) for healthcare
Services provided to me by Atlantic Pain Interventions & Rehabilitation. I hereby certify that the insurance information that I have provided Atlantic Pain
Interventions & Rehabilitation is true and accurate as of the date of service and that I am responsible for keeping it updated. I am fully aware that having
health insurance does not absolve me of my responsibility to ensure that my medical bill is paid in full. I also understand that my insurance company may not
pay 100% of the amount of the medical claim that I may be responsible for any and all amounts not payable by my insurance company including any portion
paid and not applied to in network benefits for any out of network services.
I hereby authorize Atlantic Pain Interventions & Rehabilitation to submit claims, on my behalf, to the insurance company listed on the copy of the current
insurance card I have provided to Atlantic Pain Interventions & Rehabilitation, in good faith. I fully agree and understand that the submission of a claim does
not absolve me of my responsibility to ensure the claim is paid in full.
I hereby irrevocably designate, authorize and appoint Atlantic Pain Interventions & Rehabilitation as my true and lawful attorney-in-fact. This power of attorney
Is hereby provided for the limited purpose of receiving all payments due under my policy/medical care plan on account of medical services and care
rendered or to be rendered. This power of attorney shall automatically terminate, without formal action being taken, as soon as Atlantic Pain Interventions &
Rehabilitation has received payment in full and remedies under applicable regulatory guidelines for all medical care services provided to patient. I hereby
confirm and ratify all actions taken by my attorney-in-fact pursuant to the authority granted herein.
I hereby authorize my insurer to assign and transfer any all applicable ERISA plan benefits and rights to Atlantic Pain Interventions & Rehabilitation and any
appointed business associates working with them for the sole purpose of making sure all protected rights and benefits under my plan are administered
accurately, including the right to receive any applicable plan document/remedies, disclosures, pursue appeals, administrative reviews and litigation on my
behalf. This authorization includes any and all other rights permissible under state and federal laws.
I hereby instruct and direct my Insurance Company to pay Atlantic Pain Interventions & Rehabilitation directly. I understand under applicable ERISA, state
and/or federal regulatory guidelines that I have the right and authority to direct where payment for services rendered is sent. If my current policy prohibits
direct payment to the provider of service, I under my rights per state and federal ERISA regulations here by instruct and direct my Insurance Company to
provide SPD documentation stating such non-assign ability clause to myself and Atlantic Pain Interventions & Rehabilitation. Upon Proof of non-assign ability
documentation I then instruct that the insurer make out the check to me and mail it directly to the Provider and address listed on the submitted claim for
the professional or medical expense benefits, and otherwise payable to me under my current insurance policy as payment towards the total charges for
the professional services rendered. I agree and understand that any funds I receive by my insurance company due for services rendered by Atlantic Pain
Interventions & Rehabilitation will be immediately signed over and sent directly to Atlantic Pain Interventions & Rehabilitation.
This is a direct assignment of my rights and benefits under this plan/policy. This payment will not exceed-my indebtedness to the above mentioned assignee,
and I have agreed to pay, in a current manner, any balance of said professional service charges over and above this insurance payment. Upon receipt of
said check, I authorize Atlantic Pain Interventions & Rehabilitation to receive any such checks, endorse them for deposit only, and to deposit and apply all
the proceeds toward payment on my account.
I authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in this case. I authorize Atlantic Pain
Interventions & Rehabilitation or appointed business associates to be my personal representative, which allows Atlantic Pain Interventions & Rehabilitation, to:
(1) submit any and all appeals when my insurance company denies me benefits to which I am entitled, (2) submit any and all requests for benefit information
from my insurance company, and (3) initiate formal complaints to any State or Federal agency that has jurisdiction over my benefits. I fully understand and
agree that I am responsible for full payment of the medical debt if my insurance company has refused to pay 100% of my stated plan benefits based on billed
charges, within (90) days of any and all appeals or request for information. Should the account be referred to an attorney or outside agency for collection,
the undersigned shall pay reasonable attorney’s fees and collection expenses. All delinquent accounts bear interest at the legal rate. I also agree that any
fines levied against my insurance company will be paid to Atlantic Pain Interventions & Rehabilitation for acting as my personal representative.
I authorize Atlantic Pain Interventions & Rehabilitation and its associates to provide medical care reasonable by today’s standards.
A photocopy of this Assignment shall he considered as effective and valid as the original.
Signature of Patient/Guarantor: __________________________________________________________________ Date: ____________________
Signature of Policy Holder: _______________________________________________________________________ Date: ____________________
Appointment CancellationsWe understand that circumstances occasionally arise changing your plans. You may cancel at no charge if, for office visits you call at
least 24 hours before your appointment and 48 hours before your scheduled procedures. If you do not cancel or fail to show for your
appointment a “no show” fee of $25.00 (office visits) and $50.00 (procedures) will be charged.
I have read and understand these guidelines and agree to the terms therein.
Print Name: ___________________________________________________________________ Date of Birth: ______________________________________
Controlled Substance PolicyThe Federal Government (Drug Enforcement Agency) frowns on the use of chronic opiates as a stand-alone means of treating chronic
benign pain and is prosecuting physicians and patients at an increased rate over recent years. Their policy for prescribing chronic opiates
to patients with chronic benign pain is modestly favorable as long as controls are in place, other more reasonable means have failed, and
other diagnostic testing or treatment methods are being employed to help work towards reducing pain through non-medication means.
Some of the non-medication means we utilize are:
•Controls
o Random and scheduled urine or blood drug testing
o Adherence to DEA rules and regulations
•Treatments
o Spinal injections
o Spinal implants
o Trigger point injections, joint injections, etc.
o Manipulation under anesthesia
o Physical therapy
o Psychotherapy
o Massage therapy
oChiropractic
•DiagnosticTesting
o MRI
oEMG/NCS
o Balance Testing
If you have any questions regarding the above, please do not hesitate to contact one of our doctors.
Informed Consent and Controlled Substances Agreement
I _______________________________________ understand and agree to follow the policies of Atlantic Pain Interventions & Rehabilitation (APR) as set forth below.
I understand that APR is under no obligation to prescribe these medications for me. I also understand that there may be other, more reasonable treatment
options available for my condition that my doctor may recommend instead of or in addition to the use of these medications.
Definitions Of Opioids, Benzodiazapines, And Other Controlled Substances
I understand the definitions of these medications to be:
1. Opioids - An opioid medication is a derivative of morphine or other related product and thus has strong pain relieving properties.
2. Benzodiazapine - A benzodiazapine is a drug that is related to Valium. Their primary role is for the treatment of anxiety.
3. Other related drugs - For the purposes of this agreement, “other related drugs” includes medications such as muscle relaxants (e.g., FlexeriI), membrane
stabilizers (e.g., Neurontin), and non-narcotic analgesics (e.g., Ultram). These medications may cause sedation, altered mental status, occasionally
dangerous withdrawal effects when stopped abruptly, and may have medication interactions similar to or different from opioids or benzodiazapines.
4. Controlled Substance - For the purposes of this agreement, a controlled substance will apply to opioids, benzodiazapines, or other related medications as
described above.
Risks Of Opioids, Benzodiazapines, And Other Related Medications (“Controlled Substances”)
I understand that these medications have potential risks with the most significant being:
1. Physical Dependence - the abrupt discontinuation of controlled substances could lead to withdrawal symptoms such as abdominal cramping, diarrhea,
anxiety, hypertensive crisis, cardiac arrest or other cardiac dysfunction, seizures, and death.
2. Psychological Dependence or Addiction - the use of these medicines may lead to behavior focused on the obtaining and misuse of the controlled
substances.
3. Overdose - may lead to respiratory arrest and death.
4. Mental Changes - These classes of medications may cause confusion, sedation, drowsiness, problems with coordination, and changes in thinking ability.
This may make it unsafe for you to drive a motor vehicle, operate hazardous equipment and machinery; or perform dangerous activities. Other side effects
may include but are not limited to, the following: nausea, constipation, unsteadiness, decreased appetite, difficulty urinating, depression, and loss of sexual
drive with testicular atrophy (in males).
Conditions Of Agreement
1. I understand that Controlled Substances may be prescribed by my physician only if he/she determines that such treatment has a medically reasonable
chance of improving my quality of life, ability to participate in work activities and social activities. _____________________ (Initials)
2. I do not currently have problems with substance abuse (drugs and/or alcohol). _____________________ (Initials)
3. I am not involved in the use, possession, diversion, or transport of illegally obtained controlled substances. _____________________ (Initials)
4. I agree to use these medications only as prescribed to me and will not take more of these medications than instructed. I agree to not allow other individuals
to take my medication nor will I take medication prescribed to another person. _____________________ (Initials)
5. I understand the potential harm of controlled substances to unborn children and will notify APR if I am or become pregnant. _____________________ (Initials)
6. I will obtain controlled substances only from APR and not from any other source unless a true medical emergency exists. i will notify APR in advance of any
anticipated acute needs (dental work or surgery). _____________________ (Initials)
Enjoy A Pain Free Life
ATLANTICPAIN INTERVENTIONS &REHABILITATION
CONDITIONS OF AGREEMENT (Cont.)
7. I agree to accept generic brands of my controlled substances if available. _____________________ (Initials)
8. If it appears to my physician that the use of controlled substances are not providing a demonstrable therapeutic benefit such as improvement in daily
function or improved ability to participate in the treatment program, if the controlled substances being prescribed are expected to be the mainstay
of pain treatment when other medical options exist and are practical or that addiction, rapid loss of effect, or significant side effects are developing, I
agree to gradually taper my medication as directed. If a substance abuse problem is suspected, I understand that I may be referred for evaluation and
management of the problem. _____________________ (Initials)
9. I agree to come to my scheduled appointments prepared to provide a urine sample to assess compliance with my treatment plan. Failure to provide a
sample may result in immediate termination of treatment with controlled substances and possibly discharge from APR. _____________________ (Initials)
10. I agree to bring my medications to the office for random pill counts to assess compliance with treatments. Failure to provide medication for inspection
may result in immediate termination of opioid treatment. _____________________ (Initials)
11. I agree to comply with my physicians’ request for additional imaging studies, lab tests, diagnostic procedures (with separate informed consent), and
referrals to additional sub specialists as recommended by my physician. _____________________ (Initials)
12. I understand that APR is a specialty consulting practice. The APR staff will communicate with my Primary Care Provider, Specialists, pharmacists, Therapists,
and Family to assist in determining the best course for continued treatment for chronic pain. My care may be transferred back to my Primary Care Provider
for continued prescriptions of controlled substances once my medical regimen has been optimized. _____________________ (Initials)
13. All of my controlled substance prescriptions will be filled at the same pharmacy. Should I choose to change pharmacies, I will notify APR immediately.
_____________________ (Initials)
14. Early refills are not provided. Renewals are at the discretion of your treating physician and will be prescribed at office appointments only. APR will not
prescribe any medication after hours or on weekends. APR is under no obligation to prescribe replacement medications should they become misplaced,
stolen, damaged, or destroyed. _____________________ (Initials)
15. I am seeking treatment for pain. APR is under no obligation to treat or prescribe medication for any other medical or mental condition to include: high
blood pressure, bronchitis, pneumonia, anxiety, depression, or any chronic-medical condition. If I am referred to a Primary Care Provider or other specialist
for a medical or mental condition, I will make and keep that appointment in a timely manner. _____________________ (Initials)
I understand that any violation of this agreement may pose a health risk to myself and others and may result in a discontinuation of
treatment with controlled substances if deemed medically prudent. Violation of this agreement may result in dismissal from the care of
APR as well as reporting any illegal activities to appropriate law enforcement agencies.
I have read this document, understand it, have had all questions regarding risks and conditions of the agreement answered
satisfactorily, and I agree to all of its elements.
As part of your treatment, our medical staff may prescribe medications for you. Many of these medications can have serious side effects if they are not
managed properly. Your health and safety are very important to us, and we need your help to make sure your treatment follows our guidelines. If APR has any
questions regarding your healthcare, including medications, we reserve the right to contact your other treating physicians and pharmacies.
1. I agree to follow the dosing schedule prescribed to me by my doctor or PA.
2. I agree to never share my medications with others, nor will I sell or exchange my medications for any reason.
3. I agree to always keep my medications safeguarded and within my control.
4. I agree to notify APR if I experience any adverse effects or dosage problems with my prescribed medications. I will not discard any unused medication.
Before any new medication can be prescribed, I must bring the unused medication to APR for disposal.
5. I agree that if I receive narcotic prescriptions from APR, I am not allowed to receive the same type of medications from another physician without the
express consent or consultation with APR.
6. I agree to use only one pharmacy for my pain-related medications unless extenuating circumstances prevent this from being possible. In this event, I will
notify APR of all pertinent information pertaining to additional pharmacies, mail-order, or other sources.
7. I understand that medication refill prescriptions involving narcotic pain medicine require a scheduled office visit when my doctor is on duty in the office.
Narcotic pain medication refills will not be called into a pharmacy, nor will they be increased over the telephone.
8. I agree to keep all scheduled appointments. I understand that no medications will be given for canceled or no-show appointments. I agree also to be
prompt to my appointments and understand that If I am more than 15 minutes late, I will have to reschedule.
9. I understand that medication refills cannot be made after hours or on the weekend. APR’s refill hours are 9:00 am to 4:00 pm, Monday through Friday.
10. I agree to bring my medications from any other doctor’s office to APR for my office appointments.
11. I understand that I should not drive or operate heavy machinery while I am taking medications that may cause drowsiness or impaired cognitive
function.
12. I understand that I am solely responsible for the safekeeping of my medications and I must treat my medications as I would my money or valuable
possession. APR, will under no circumstances replace LOST OR STOLEN prescriptions or medications.
13. I understand that my therapy at APR may legally require a monthly office visit so my doctor can properly evaluate my progress, and/or adjust appropriate
narcotic pain medications every thirty (30) days.
14. I understand that abusive behavior or harassment toward any APR staff member will not be tolerated. Harassment includes, but is not limited to, more
than two (2) phone calls to the office in one business day.
15. I will not show up at the APR office unannounced seeking medication refills.
16. I understand that a forged or falsified prescription will result in the immediate dismissal from APR.
17. I understand that if I do not follow this medication agreement, I may be dismissed from APR at their discretion.
By signing this agreement, you affirm that you have the full right and power to be bound by this agreement and that you have read, understood, and
accepted these terms. No narcotic or otherwise habit-forming medications will be prescribed without the acceptance of this agreement.