New Patient Packet 102417 - Pain Doctor · Baclofen Methocarbamol (Robaxin) Carisoprodol (Soma) Cyclobenzaprine (Flexeril, Amrix) Metaxalone (Skelaxin) Tizanidine (Zanaflex) Other:_____

Phone: 512.416.7246 Fax: 512.275.2828 Toll Free: 888.299.9290

www.paindoctor.com/austin

Brannon R. Frank, M.D.

John W. Wages, M.D.

Christine M. Anderson, M.D.

Paul H. Le, M.D.

Martin V. Thai, M.D.

Mary Jo Hart, PA-C

Donna Teague, PA-C

Jessica Horwath, PA-C

C. Shawn Kyle, PA-C

Amy Gonzales, PA-C

Jessica Holley, PA-C

Sean Rockett, PA-C

Joshua Smith, PA-C

Emily Bowden, RN, FNP-C

Shannon O’Neill, RN, FNP-C

Tessa Gibbs, RN, FNP-C

Allison Turner, RN, DNP, FNP-C

Dear Patient,

Welcome to Pain Doctor! It is our goal and mission to help you improve your level of everyday function and reduce your level of pain. The most important part of your treatment plan is YOU! In order to develop an effective treatment plan, we need to obtain some detailed medical information about your health. To better serve you, please complete the information provided and utilize the checklist below to ensure you have everything ready for your initial appointment. Please note that your visit may be rescheduled if you have not completed all of the required information by your scheduled appointment time. We ask that the following items are sent to our office prior to your appointment date:

o Medical records from your referring and/or your primary care physician

o If required, referral or prior authorization from referring physician or insurance carrier You will need to bring the following required information to your initial appointment:

o New Patient Packet (Please allow 45 minutes to complete this packet)

o Medical insurance card(s) (primary and secondary- if applicable)

o State or government issued identification (example: driver’s license, passport)

o Payment for visit

If your insurance requires that you obtain a referral or prior authorization for office consultation, please contact your primary care physician or referring physician and have it faxed to 512.275.2828. If you have any further questions about referrals, authorizations, co-payments, deductibles, or coinsurance amounts, feel free to call our office and ask to speak to our Patient Account Representative or Preauthorization Department at 512.416.7246. Thank you for choosing Pain Doctor. We look forward to seeing you at your appointment on: Date: ____ / ____ / ____ Arrival Time: _____: ______ Appointment Time: _____: ______ Provider: _______________________________________ Office Location: ______________________________

South Austin Office: 2501 W. William Cannon Dr., Suite 401

Austin, TX 78745

North Austin Office: 2200 Park Bend Dr., Bldg. 1, Suite 201

Austin, TX 78758

Georgetown Office: 3201 S. Austin Ave., Suite 265

Georgetown, TX 78626

Cedar Park Office: 351 Cypress Creek Road, Suite 201,

Cedar Park, TX 78613

GENERAL INFORMATION

Your initial visit at Pain Doctor will be with one of our U.S. Anesthesia Partner’s (USAP) Board Certified pain management physicians and advanced practice providers. After visiting with the physician, you will receive a comprehensive treatment plan. We use a multidisciplinary approach to treat pain, so your plan may include diagnostic/therapeutic procedures, physical therapy, psychological evaluation/treatment, medication management, lab tests, and/or radiological examinations. For your convenience, we offer a majority of these treatments at many of our office locations. DIAGNOSTIC/THERAPEUTIC PROCEDURES Depending on your situation, your physician may prescribe an injection that may be used for diagnosis and/or treatment. The details of the injection will be explained by your medical provider and through educational materials. You can also learn more about these procedures by viewing our website. Click on the “Education” heading and select the “Pain Treatments” section to find information about the procedures. PHYSICAL THERAPY Through exercise, massage, and stretching, physical therapy can increase your strength, improve the movement of your joints, decrease your pain, and improve your function. PSYCHOLOGICAL EVALUATION/TREATMENT Behavioral Health therapists working with patients that suffer with chronic pain are not trying to decide whether a patient’s pain is real or imaginary. We understand that we cannot visualize pain and that it is real to the person that suffers with it every day. Pain can affect multiple parts of your life, including your ability to participate in your hobbies or job, interact with your family members, or even perform simple household chores. This can lead to significant frustration and possibly even depression. Behavioral Health therapists can help with these problems by using psychology-based treatment approaches that can reverse some of these effects of pain. Our goal is to help you regain the life you had before you started experiencing pain. MEDICATION MANAGEMENT All medications have the potential for side effects and may require multiple adjustments to find the best dosage that reduces your pain while minimizing side effects. These adjustments will typically take place during your office visits. NOTICE TO PATIENTS: Brannon R. Frank, M.D., John W. Wages, M.D., Christine M. Anderson, M.D., and Paul H. Le, M.D. directly or indirectly, hold ownership interests in one or more of the following companies and will receive, directly or indirectly, remuneration for services provided to patients by these companies: Stonegate Surgery Center, Cedar Park Surgery Center, Hays Surgery Center, and Arise Austin Medical Center.

Patient Name________________________________________________________________________DOB:________________________ 1

NOTE: Please complete in BLACK ink, as other ink colors may not show when scanning into the computer system.

Date: ____/____/____ Name: _____________________________________________________________________ Last First Middle Sex: Male Female Date of Birth ____/____/____ Height: ______ Weight: _______ Marital Status: Single Married Significant Other’s Name: ____________________________

Emergency Contact: _________________ Relationship to Patient: _____________Contact number: ( ) ________

Preferred Language: English � Spanish French � German � Vietnamese � Italian � Mandarin Other

Race: � American Indian/ Alaska Native � Asian � Black/ African American

� Native Hawaiian/ Other Pacific Islander White

Ethnicity: Hispanic or Latino Non-Hispanic or Latino

Referring Physician: _____________________________________________________________

Treating/Primary Care Physician: ___________________________________________________

Other Physicians you have seen specifically for this pain problem: _________________________

______________________________________________________________________________

______________________________________________________________________________

Patient Name________________________________________________________________________DOB:________________________ 2

INSTRUCTIONS: Please fill out each section; if a section does not apply, please answer with ”N/A” for “not applicable”. PAIN DESCRIPTION

1. Where is your worst pain? __________________________________________________________

________________________________________________________________________________

2. When did your pain begin? __________________________________________________________

________________________________________________________________________________

3. My pain is the result of an (check one): �accident �illness �I do not know what caused my pain

a. Please describe illness or accident:______________________________________________

__________________________________________________________________________

b. If accident, is there litigation involved? �Yes �No Please explain:

__________________________________________________________________________

4. Please shade the locations of your pain in the diagrams below.

Patient Name________________________________________________________________________DOB:________________________ 3

5. Please check the word/words that best describe your pain. �Aching �Dull �Constant �Numbing �Coldness �Burning �Sharp �Stinging �Stabbing �Tingling �Cramping �Radiating

6. Please indicate if any of the following increases, decreases, or causes no change to your pain.

PAIN SCALES 7. Please rate your lowest pain level. (0 = No pain 10= Worst pain)

�0 �1 �2 �3 �4 �5 �6 �7 �8 �9 �10

8. Please rate your worst pain level. (0 = No pain 10= Worst pain) �0 �1 �2 �3 �4 �5 �6 �7 �8 �9 �10

9. Please rate your present pain level. (0 = No pain 10= Worst pain)

�0 �1 �2 �3 �4 �5 �6 �7 �8 �9 �10

FUNCTIONAL SCALES 10. Please rate your ability to cope with pain. (0 = Not able 10 = Very able)

�0 �1 �2 �3 �4 �5 �6 �7 �8 �9 �10

11. Please rate your ability to perform activities of daily living such as hygiene, household chores, transportation, etc. (0 = Not able 10 = Very able)

�0 �1 �2 �3 �4 �5 �6 �7 �8 �9 �10

12. Please rate your ability to function and interact well with family and friends. (0 = Not able 10 = Very able) �0 �1 �2 �3 �4 �5 �6 �7 �8 �9 �10

13. Please rate your ability to work in your usual occupation. (0 = Not able 10 = Very able)

�0 �1 �2 �3 �4 �5 �6 �7 �8 �9 �10

Stimulus/Treatment Increase Pain Decrease Pain No Change

Heat

Cold

Weather Changes

Lying Down

Sleep

Physical Activity

Sexual Intercourse

Sitting

Standing

Sneezing/Coughing

Physical Therapy

Massage Therapy

Urination

Bowel Movement

Tension

Fatigue

Patient Name________________________________________________________________________DOB:________________________ 4

PAIN TREATMENT HISTORY 14. Please check all medications that you have tried in the past.

Opioids

� Fentanyl (Actiq, Fentora,

Duragesic)

� Demerol � Hydrocodone (Lortab, Norco,

Vicodin, Vicoprofen)

� Tramadol (Ultram ER

Ultram)

� Morphine (Avinza, kadian,

Embeda, MS Contin)

� Oxymorphone (Opana,

Opana ER)

� Methadone � Other: ____________

� Oxycodone (Oxycontin,

Percocet)

� Hydromorphone (Dilaudid,

Exalgo)

� Tapentadol (Nucynta) __________________

� Propoxyphene (Darvocet,

Darvon)

� Buprenorphine (Suboxone,

Subutex, Butrans Patch)

� Codeine

Anti-inflammatories & Tylenol

� Diclofencac (Arthrotec,

Voltaren, Voltaren Gel) � Oxaprozin (Daypro) � Meloxicam (Mobic) � Nabumetone (Relafen)

� Aspirin � Indomethacin (Indocin) � Ibuprofen (Motrin, Advil) � Acetaminophen (Tylenol)

� Celecoxib (Celebrex) � Etodolac (Lodine) � Naproxen (Naprosyn) � Flector patch

� Other:_____________________________________________________________________

Muscle Relaxants

� Baclofen � Methocarbamol (Robaxin) � Carisoprodol (Soma)

� Cyclobenzaprine (Flexeril, Amrix) � Metaxalone (Skelaxin) � Tizanidine (Zanaflex)

� Other:___________________________________________________________________

Antidepressants

� Cymbalta � Nortriptyline (Pamelor) � Remeron � Wellbutrin

� Effexor � Paxil � Serzone � Zoloft

� Amitriptyline (Elavil) � Pristiq � Imipramine (Tofranil)

� Lexapro � Fluoxetine (Prozac) � Trazodone

� Other:___________________________________________________________________

Sleep Aids

� Zolpidem (Ambien, Ambien CR) � Lunesta � Rozerem

� Xyrem � Restoril � Sonata

� Other:___________________________________________________________________

Other

� Axert � Hydroxyzine � Lyrica � Tegretol � Zonegran

� Buspar � Imitrex � Maxalt � Topamax

� Frova � Keppra � Gabapentin (Neurontin) � Vistaril

� Gabitril � Lidoderm Patch � Relpax � Zomig

� Other:______________________________________________________________________

Patient Name________________________________________________________________________DOB:________________________ 5

15. Please list the diagnostic tests you have received. Include the approximate date and location in which the testing was performed.

Diagnostic Test Area of Body Date Location X-Ray MRI Scan CT Scan EMG Myelogram

16. Have you had any of the following treatments for your pain?

Treatment Yes No If yes, last date

Surgery � � Traction � � Spinal Injection � � Joint Injection � � Muscle Injection � � Ketamine Infusion � � Nerve Block � � Physical Therapy � � Chiropractic Care � � Psychotherapy � � Acupuncture � � TENS Unit � �

TREATMENT GOALS 17. We are dedicated to helping you improve your function in everyday life. Please list goals (i.e. running,

gardening, riding a bike, etc…that you would like to achieve. ___________________________________

_____________________________________________________________________________________

_________________________________________________________________________________

SLEEP BEHAVIOR 18. Have you been evaluated for sleep apnea with a sleep study? � Yes � No

If yes, were you diagnosed with sleep apnea? � Yes � No

19. If you were diagnosed with sleep apnea, are you currently using a CPAP or

BiPAP machine? � Yes � No

Patient Name________________________________________________________________________DOB:________________________ 6

REVIEW OF SYSTEMS 20. Are you currently experiencing any of the following?

MEDICAL HISTORY

21. Have you ever been diagnosed with the following? (check all that apply)

�AIDS �Epilepsy �High Blood Pressure �Peripheral Vascular Disease

�Asthma �Fibromyalgia �Kidney Disease �Shingles

�Cancer �HIV Positive �Lupus �Sleep Apnea

�Diabetes �Heart Disease �Migraines �Stroke

�Emphysema �Hepatitis (A, B, C, D) �Osteoarthritis

�Other: ________________________________________________________________________

22. Are you currently pregnant? � Yes � No

23. Do you currently have an Advanced Directive? � Yes � No

24. Have you had a pneumonia vaccination in the past? � Yes � No

25. Please list all medications including pain medications, over the counter medications and supplements.

Medication Strength Directions Prescribing Doctor

General Gastrointestinal PsychYes No Yes No Yes No

�� Chills �� Constipation �� Hallucinations

�� Night sweats �� Nausea Muscular

�� Fever �� Vomiting Yes No

Eyes Genitourinary �� SwellingYes No Yes No �� Stiffness

�� Visual changes �� Pain with urination �� Joint pain

Cardiovascular �� Difficulty controlling urine �� Bone pain

Yes No �� Erectile dysfunction Neurological

�� Abnormal heart beat Skin Yes No

�� Chest pains Yes No �� Memory changes

Respiratory �� Sores �� HeadachesYes No �� Rashes �� Numbness

�� Shortness of breath �� Loss of body hair Endocrine

�� Persistent cough Hematologic Yes No

Yes No �� Decreased sex drive

�� Bleeding Disorders �� Absence of menstrual cycle

Patient Name________________________________________________________________________DOB:________________________ 7

26. Do your pain medications provide relief? � Yes � No � I do not take pain medications

If yes, how much relief do you receive?

� 10% � 20% � 30% � 40% � 50% � 60% � 70% � 80% � 90% � 100%

27. Do your pain medications improve your function? � Yes � No � I do not take pain medications

If yes, how much improvement in function do you receive?

�10% �20% �30% �40% �50% �60% �70% �80% �90% �100%

28. Do you experience any side effects or adverse effects? � Yes � No

We would like to access your pharmacy records and drug formulary information through a third party database. This service provides us with accurate prescription information from other prescribing physicians and will allow our system to check which medications are on your drug formulary. I authorize Pain Doctor to access my prescription history through my pharmacy, pharmacy benefits

manager and or Surescripts. _____________________________________ (Patient Signature)

ALLERGIES AND OR SIDE EFFECTS 29. If you are allergic to any medications, please list the medication name and reaction below.

Medication Reaction

SURGICAL HISTORY 30. Do you currently have an implanted ICD, pacemaker, or defibrillator? � Yes � No

31. Please list prior surgeries or procedures in the table below.

Date Surgery/Procedure Physician

Patient Name________________________________________________________________________DOB:________________________ 8

FAMILY MEDICAL HISTORY Do any of your family members have a history of or are currently suffering from any of the following medical and/or psychiatric conditions:

32. Father

� Addiction/substance abuse � Cancer � Hypertension

� Alcoholism � Chronic pain � Multiple personality disorder

� Alzheimer’s � Dementia � Schizophrenia

� Anxiety � Depression � Stroke

� Arthritis � Diabetes � Other __________________

� Bipolar disorder � Heart disease

33. Mother







34. Brother







35. Sister







36. Other relative (please specify): _____________________________________________







Patient Name________________________________________________________________________DOB:________________________ 9

LIFESTYLE 37. What is your current work status?

� Employed � Retired � Disabled � Unemployed 38. If you are unemployed, employed part-time or have work restrictions, is this due to your present pain

condition? � Yes � No

39. What are your current work restrictions, if any? ___________________________________________

______________________________________________________________________________

40. Do you smoke? � Yes, currently � Yes, in the past � No, never

a. If currently, how many packs do you smoke per day? � 0-1/2 � 1/2-1 � 1-2 � More than 2

b. How long have you smoked? Years:________

41. Do you use alcohol? � Yes � No

If currently, how many drinks do you consume? (Answer 1 of the options below)

a. I consume _____ drinks every day.

b. I consume _____ drinks every week.

c. I consume _____ drinks every month.

If you have abused alcohol in the past, have you abused alcohol within the last year? � Yes � No

42. Have you ever had a problem with prescription medications (misuse, abuse, addiction, etc)?

� Yes, currently � Yes, in the past � No, never

If in the past, was it within the last year? � Yes � No

43. Have you ever used any drugs that are illegal in Texas? (cocaine, marijuana, intravenous drugs, etc.)?

� Yes, currently � Yes, in the past � No, never

If in the past, was it within the last year? � Yes �No

44. Have you ever been treated for addiction or alcoholism? � Yes � No

If yes, please explain: ____________________________________________________________

______________________________________________________________________________

Patient Name________________________________________________________________________DOB:________________________ 10

PSYCHOLOGICAL TREATMENT 45. Have you ever been diagnosed with or received psychiatric, psychological, or social work

treatments/evaluations for any of the following diagnosis/problems? (check all that apply)

� Alzheimer’s � Anxiety � Bipolar Disorder

� Dementia � Depression � Multiple Personality Disorder

� Schizophrenia � Other: _______________________________________________

a. If yes, have you ever been treated for any of the above diagnoses?

� Yes, currently � Yes, in the past � No

If yes, when were you treated? _____________________________________________

Therapist’s name: _______________________________________________________

46. Have you considered suicide? � Yes � No

47. Have you ever planned suicide? � Yes � No

48. Have you ever attempted suicide? � Yes � No Date: __________

I acknowledge that I have provided you with the most accurate and complete information about my medical history to the best of my ability. __________________________________________________________________________ Patient/Guardian Signature Date

Patient Name________________________________________________________________________DOB:________________________ 11

SOAPP-R The following are some questions given to patients who are on or being considered for medication for their pain. Please answer each question as honestly as possible. There are no right or wrong answers.

Never Seldom Sometimes Often Very Often

1 How often do you have mood swings? 0 1 2 3 4

2 How often have you felt a need for higher doses of medication to treat your pain?

0 1 2 3 4

3 How often have you felt impatient with your doctors? 0 1 2 3 4

4 How often have you felt that things are just too overwhelming that you can't handle them?

0 1 2 3 4

5 How often is there tension in the home? 0 1 2 3 4

6 How often have you counted pain pills to see how many are remaining?

0 1 2 3 4

7 How often have you been concerned that people will judge you for taking pain medication?

0 1 2 3 4

8 How often do you feel bored? 0 1 2 3 4

9 How often have you taken more pain medication than you were supposed to?

0 1 2 3 4

10 How often have you worried about being left alone? 0 1 2 3 4

11 How often have you felt a craving for medication? 0 1 2 3 4

12 How often have others expressed concern over your use of medication?

0 1 2 3 4

13 How often have any of your close friends had a problem with alcohol or drugs?

0 1 2 3 4

14 How often have others told you that you had a bad temper? 0 1 2 3 4

15 How often have you felt consumed by the need to get pain medication?

0 1 2 3 4

16 How often have you run out of pain medication early? 0 1 2 3 4

17 How often have others kept you from getting what you deserve?

0 1 2 3 4

18 How often, in your lifetime, have you had legal problems or been arrested?

0 1 2 3 4

19 How often have you attended an AA or NA meeting? 0 1 2 3 4

20 How often have you been in an argument that was so out of control that someone got hurt?

0 1 2 3 4

21 How often have you been sexually abused? 0 1 2 3 4

22 How often have others suggested that you have a drug or alcohol problem?

0 1 2 3 4

23 How often have you had to borrow pain medications from your family or friends?

0 1 2 3 4

24 How often have you been treated for an alcohol or drug problem?

0 1 2 3 4

I acknowledge that I have provided you with the most accurate and complete information about my medical history to the best of my ability. __________________________________________________________________________ Patient/Guardian Signature Date

Patient Name________________________________________________________________________DOB:________________________ 12

Informed Consent

TO THE PATIENT: As a patient, you have the right to be informed about your condition and the recommended medical or diagnostic procedures or medication therapies to be used, so that you may make the informed decision whether or not to undergo the procedures, or take the medications, after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you, but rather it is an effort to make you better informed so that you may give or withhold your consent/permission to use the medications or undergo the treatments recommended to you by your physician. For the purpose of this agreement the use of the word “physician” is defined to include not only your physician but also your physician’s authorized associates, technical assistants, nurses, staff, and other health care providers as might be necessary or advisable to treat your condition.

CONSENT TO TREATMENT AND/OR DRUG THERAPY: I voluntarily request my Pain Doctor physician to treat my conditions which have been explained to me as contributing to my chronic pain. I hereby authorize and give my voluntary consent for my physician to administer or write prescription(s) for dangerous and/or controlled drugs (medications) as an element in the treatment of my chronic pain. It has been explained to me that these medications may include opioid/narcotic drugs, which can be harmful if taken without medical supervision. I further understand that these medications may lead to physical dependence and/or addiction and may, like other drugs used in the practice of medicine, produce adverse side effects or results. The alternative methods of treatment, the possible risks involved, and the possibilities of complications have been explained to me as listed below. I understand that this listing is not complete, and that it only describes the most common side effects or reactions, and that death is also a possibility as a result from taking these medications. THE SPECIFIC MEDICATION(S) THAT MY PHYSICIAN PLANS TO PRESCRIBE WILL BE DESCRIBED AND DOCUMENTED SEPARATE FROM THIS AGREEMENT. THIS INCLUDES THE USE OF MEDICATIONS FOR PURPOSES DIFFERENT THAN WHAT HAVE BEEN APPROVED BY THE DRUG COMPANY AND THE GOVERNMENT (THIS IS SOMETIMES REFERRED TO AS “OFF-LABEL” PRESCRIBING). MY DOCTOR WILL EXPLAIN HIS/HER TREATMENT PLAN(S) FOR ME AND DOCUMENT IT IN MY MEDICAL CHART. I HAVE BEEN INFORMED and understand that I will undergo medical tests and examinations before and during my treatment. Those tests include random unannounced checks for drugs and psychological evaluations if and when it is deemed necessary, and I hereby give permission to perform the tests or my refusal may lead to termination of treatment. The presence of unauthorized substances may result in my being discharged from Pain Doctor’s care. I understand that no warranty or guarantee has been made to me as to the results of any medication therapy, procedures, or other pain management treatments or cure of any condition. The long-term use of medications to treat chronic pain is controversial because of the uncertainty regarding the extent to which they provide long-term benefit. I have been given the opportunity to ask questions about my condition and treatment, risks of non-treatment and the drug therapy, medical treatment or diagnostic procedure(s) to be used to treat my condition, and the risks and hazards of such drug therapy, treatment and procedure(s), and I believe that I have sufficient information to give this informed consent. For female patients as applicable:

• To the best of my knowledge I am NOT pregnant.

• If I am not pregnant, I will use appropriate contraception/birth control during my course of treatment. I accept that it is MY responsibility to inform my physician immediately if I become pregnant.

• If I am pregnant or am uncertain, I WILL NOTIFY MY PHYSICIAN IMMEDIATELY. All of the above possible effects of medication(s) have been fully explained to me and I understand that, at present, there have not been enough studies conducted on the long-term use of many medication(s) i.e. opioids/narcotics to assure complete safety to my unborn child(ren). With full knowledge of this, I consent to its use and hold my physician harmless for injuries to the embryo/ fetus / baby.

__________________________________________________________________________ Patient/Guardian Signature Date

Patient Name________________________________________________________________________DOB:________________________ 13

Assignment of Insurance Benefits

I hereby authorize US Anesthesia Partners to file claims with my insurance company and to receive payment for my medical care and /or procedures. I also understand that I am financially responsible for all charges not covered by my insurance for services rendered on my behalf or my benefits. I further authorize payment directly to US Anesthesia Partners of all insurance benefits related to my care. US Anesthesia Partners has my permission to release any information required to secure payment of benefits. I authorize the use of this signature on all insurance submissions. I understand that I am responsible for any co-payments, deductibles, or co-insurance due at the time of any and all office visit(s) and/or procedures. __________________________________________________________________________ Patient/Guardian Signature Date __________________________________________________________________________ Witness Signature Date

Medicare Authorization

I request that payment of my Medicare benefits be made to US Anesthesia Partners on my behalf for any services furnished by US Anesthesia Partners or under their direction. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. In Medicare assigned cases, the physician agrees to accept the charge determination of the Medicare carrier as the full charge and the patient is responsible only for the charge determination of the Medicare carrier.

__________________________________________________________________________ Patient/Guardian Signature Date __________________________________________________________________________ Witness Signature Date

Patient Name________________________________________________________________________DOB:________________________ 14

REVIEW OF NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

A Notice of Privacy Practices is available to me at any time. I have the opportunity to obtain a copy by going to Pain Doctor Austin’s website, www.paindoctor.com/austin or accessing it from the patient resources when logged in to the patient portal or within any of their office locations.

I also acknowledge that I have been afforded the opportunity to read the Notice of Privacy Practices and ask questions prior to signing this notice. __________________________________________________________________________ Patient/Guardian Signature Date _____________________________________ ________________________ Name of Patient or Personal Representative Relationship to Patient CONTACT PERMISSION In the event that Pain Doctor needs to contact you about your medical care but is unable to reach you directly, we would like to know if you would like us to attempt any of the following commonly requested alternatives. Before you check one or more of the options below, please take into consideration that these messages could include information about your medication(s), test results, insurance coverage, appointment details, payment collection, or other personal information regarding your care at Pain Doctor. If unable to contact me directly, I authorize Pain Doctor to (please check the applicable boxes):

□ Leave a voice mail message at this phone number ( ) -

□ Speak to my spouse or significant other whose name is__________________________

□ Speak to or leave a message with the family members/friends listed below.

Name: __________________ Relationship to Patient: __________________Contact number: ( ) -

Name: __________________ Relationship to Patient: __________________Contact number: ( ) -

I understand should I no longer want to authorize Pain Doctor to share information regarding my care with any of the individuals listed above or leave a voicemail at the phone number listed above it will be my responsibility to notify Pain Doctor of such in writing. __________________________________________________________________________ Patient/Guardian Signature Date

DISCLOSURE OF HEALTH INFORMATION Pain Doctor will not disclose any of your health information to family (including your spouse), friends or third parties that fall outside of the Notice of Privacy Practice guidelines, unless you authorize us to do so in writing. If there are any persons and/or facilities that you do not authorize to have access to your personal health information please ask to complete a request for restriction form.

Patient Financial Agreement

Rev. 10.2.17 Page 1 of 3

Thank you for choosing Pain Doctor. Our goal is to provide you with the highest quality care possible. We find

that communication regarding our financial agreement assists us in providing the best service to you.

Therefore, we take this opportunity to explain your financial responsibilities for the clinical services provided

to you by US Anesthesia Partners of Texas, PA (“USAP”) at Pain Doctor (hereafter referred to as the

“Practice”). Please carefully review this Patient Financial Agreement, initial each section and sign the

agreement to indicate your acceptance of its terms.

AP P O I N T M E N T S

1. Copayments and Deductibles. Copayments and deductibles for clinic visits are due at the time of

service, in accordance with your insurance carrier’s plan. If you are unable to make your copayment at

the time of service, the Practice reserves the right to reschedule your appointment until you are able

to pay your estimated responsibility. Initial: _____

2. Procedure Prepayment. The Practice wi l l collect your payment for a procedure at the time the

procedure is scheduled or prior to your appointment. Your prepayment is based on an estimate of your

expected financial responsibility. We reserve the right to reschedule your procedure until prepayment

arrangements have been made. You are responsible for any unpaid balance after your insurance

carrier has processed your claim. Should your insurance carrier pay more than was expected resulting

in a credit on your account, we will apply the credit to any unpaid balances that may exist and then

refund any amounts due you. Initial: _____

3. Self-Pay. If you do not have health insurance, or if your health insurance will not pay for services

rendered by the Practice, or if you notify us not to contact or bill your insurance company, you are

considered a self-pay patient. Your charges will be based on our current self-pay fee schedule. Payment

is due in full at the time of service. Initial: _____

4. Missed Appointments and Late Arrivals. Patient cancellations that occur within 24 hours of

appointment time, late arrivals (more than 15 minutes) and no-show events are subject to a

fee of $50.00 for office visits and $150.00 for procedures. Patients who consistently fail to

show up for their scheduled appointments without providing 24 hour advanced notice may be

terminated from the practice. Initial: _____

I N S U R A N C E PAYMEN TS

5. Financial Responsibility. Your insurance policy is a contract between you and your insurance carrier.

You are ultimately responsible for payment-in-full for all medical services provided to you. Any charges

not paid by your insurance carrier will be your responsibility, except as limited by the Practice’s specific

network agreement with your insurance carrier, if such an agreement is in place. Initial: ____

6. Coverage Changes and Timely Submission. If there are any changes in your insurance, it is your

responsibility to inform us and provide the detailed changes of your insurance. We request that you

inform us at least 24 hours prior to your appointment. Your insurance carrier places a t ime limit within

which the Practice can submit a claim on your behalf. If the Practice is unable to process your claim

within this period due to your providing incorrect insurance information or not responding to insurance

carrier inquiries, you will be responsible for all charges. Initial: ______

B E N E F I T S AN D A UT H O R I Z A T I O N

7. Insurance Plan Participation. The Practice has specific network agreements with many insurance

carriers, but not all insurance carriers. It is your responsibility to contact your insurance carrier to

verify that your assigned provider participates in your plan. Be aware, our participation can change

at any time and you are responsible to contact your insurance carrier to ensure we are contracted

Page 2 of 3

with your insurance plan. Your insurance carrier’s plan may have out-of-network charges that have

higher deductibles and copayments, which you will be responsible for. Initial: _____

8. Referrals. Referral and prior authorization requirements vary among insurance carriers and plans. If

your insurance carrier requires a referral for you to be seen by the Practice, it is your responsibility to

obtain this referral prior to your appointment. Pursuant to HIPAA, your referring health care provider,

and the Practice, are expressly permitted to disclose your Protected Health Information (PHI) to each

other and other healthcare providers and facilities for your treatment.

As a matter of course, the practice will inform your referring physician of your patient care plan and

progress either by using any secure electronic transmission machine or by an employee of the Practice.

Initial: _____

9. Prior Authorization and Non-Covered Services. The Practice may provide services that your insurance

carrier’s plan excludes or requires prior authorization. The Practice as a courtesy to our patients, will

make a good-faith effort to determine if services we provide are covered by your insurance carrier’s

plan, and, if so, determine if prior authorization for treatment is required. If determined that a prior

authorization is required, we will attempt to obtain such authorization on your behalf. If we are unable

to obtain prior authorization, we will either reschedule the procedure or offer a self-pay option.

Ultimately, it is your responsibility to ensure that services provided to you are covered benefits and

authorized by your insurance carrier. Initial: _____

10. Out-of-Network Payments and Direct Insurer Payments. You are personally responsible for all

charges. If the Practice is not part of your insurance carrier’s network (out-of-network) or your

insurance carrier pays you directly, you are obligated to forward the payment or payment proceeds to

the Practice immediately. Initial: _____

A CCOUNT B A LA N CE S AND PAY M E N T S

11. Reassignment of Balances. If your insurance carrier does not pay for serv ices within a reasonable

time, according to the provisions of our agreement with your insurance carrier, we may transfer the

balance to your sole responsibility. Please follow up with your insurance carrier to resolve non-

payment issues. Balances are due within 30 days of receiving an initial statement. Initial: _____

12. Collection of Unpaid Accounts. If you have an outstanding balance over 120 days old and have

failed to make payment arrangements (or become delinquent on an existing payment plan), we may

turn your balance over to a collection agency and/or an attorney for collection. This may result in

adverse reporting to credit bureaus and additional legal action. In addition, any fees charged by the

collection agency or attorney will be added to your account balance as your responsibility. The Practice

reserves the right to refuse treatment to patients with outstanding balances over 120 days old. You

agree, in order for us to service our account or to collect any amounts you may owe, we may contact

you at any telephone number associated with your account, including cellular numbers, which could

result in charges to you. We may also contact you by text message or e-mail, using any e-mail address

you provide. Methods of contact may include using pre-recorded/artificial voice messages and/or use of

an automatic dialing device. Initial: _____

13. Returned Checks. You will be charged $30 per incident for returned checks (including any Bank Fees).

Initial: _____

14. Refunds. Refunds for overpayment are processed only after full insurance reimbursement of all

medical services has been received. Please allow up to 4 weeks for your refund to be processed. You

may also email questions you have about your refund to [email protected] for

Austin and San Antonio patients, or [email protected] for Dallas and

Houston patients. Initial: _____

15. Statements. Charges shown by statement are agreed to be correct and reasonable unless protested

in writing within 30 days of the receipt. Depending on services rendered, your account balance may be

split between multiple statements. Initial: _____

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A DDITION AL F EES

16. Medical Records Requests. The HIPAA Privacy Rule and state law allows you to receive a copy of your

personal medical and billing records, and allows the Practice to require individuals to complete and sign

an Authorization for Disclosure and Release of Medical Records Form. There is no charge to transfer a

copy of your medical records to a new Provider. Initial: _____

17. Other Forms. During your visit, the Provider will determine a response to requests for the completion of

certain medical forms (FMLA, Short Term Disability & Temporary Disability Parking Permit) according to

the medical discretion of your Provider. Depending upon the circumstances, we charge a fee for

completing certain forms. Initial: _____

18. Acknowledgment of Notice of Privacy Practice. By initialing this section, I acknowledge that I have

received and reviewed a copy of the Practice’s Notice of Privacy Practice. Initial: _____

19. Public Fee Schedule. By initialing this section, I acknowledge that I have received a copy of the Practice’s

Public Fee Schedule. Initial: _____

USAP and its affiliates has adopted this Public Fee Schedule in order to comply with the Health Insurance

Portability and Accountability Act of 1996 (“HIPAA”) and applicable state law.

ITEM FEE CHARGED

Failure to Cancel your Appointment $50.00 per Clinic Incident

within 24 hours of the schedule time $150.00 per Procedure, EMG or MRI incident

No Show for your appointment $50.00 per Clinic Incident

$150.00 per Procedure, EMG or MRI incident

Late Arrivals. If you arrive 15 minutes $50.00 per Clinic Incident

past your arrival time, and we must $150.00 per Procedure, EMG or MRI incident

reschedule your appointment

Completion of Disability Forms Costs below are per each occurrence:

FMLA - $50.00

Short Term Disability - $30.00

Life Insurance - $30.00

Other forms requested by third party/patient -

$30.00

I have read and understand the Financial Policy of the Practice and I agree to abide by its terms. I hereby assign

all of my medical and surgical insurance benefits and authorize my insurance carrier(s) to issue payment directly

to USAP for services provided by the Practice. I understand that I am financially responsible for all services I

receive from the Practice. This financial agreement is binding upon me and my estate, executors and/or

administrators, if applicable.

Printed Name: _________________________________________

Signed: _______________________________________________

Date: _____________________

Public Fee Schedule

Agreement and Assignment of Benefits

Practice Code of Conduct

Rev. 7.27.17 Page 1 of 1

We are pleased to serve you and glad that you chose the Practice as your new pain management provider. We

will always strive to provide exceptional care for you.

Reasons that we may ask you to seek health care services elsewhere might include, but are not limited to the

following:

• Disruptive, rude, uncooperative or violent behavior to staff via in-person or telephone - this also

applies to your family members and/or friends

• Repeated no shows, cancellations, or continual late arrivals for office visits or procedures

• Refusal to adhere to the plan of care as outlined by your Provider

• Violation of controlled substance agreement

• Failure to pay for services rendered

• The patient terminates the relationship with their provider

Our goal is to help you by providing you with the highest quality care possible. Therefore, we ask that you

schedule and keep all follow up appointments, participate in all treatments and diagnostic testing.

Printed Name: ______________________________________________

Signed: ____________________________________________________

Date: _____________________________

New Patient Packet 102417 - Pain Doctor · Baclofen Methocarbamol (Robaxin) Carisoprodol (Soma) Cyclobenzaprine (Flexeril, Amrix) Metaxalone (Skelaxin) Tizanidine (Zanaflex) Other:_____

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