1 PATIENT HISTORY FORM Date:___________________ Patient Name:_____________________________ Date of Birth__________ AGE: ______ ******Primary Care Provider: ____________________________________ What medical problem brings you to our clinic? ______________________________________________________________________ ______________________________________________________________________ When did this begin? ______________________________________________________________________ What do you think caused it? (Circle One) Work Injury Auto Accident Other Please describe (For Auto accidents/Work Injury, please complete Auto Accident/WorkInjury Form)_________________________________ Social History: Martial Status: Single Married Divorced Widowed Separated Employment (Please Circle) Employed Student Self-Employed Homemaker Retired Unemployed If employed where: ____________________How Long in this position_______ What is your job title? _______________________________________ What are your specific duties?______________________________ Exercise: Type:_______________ Frequency: _______________________ How many Alcohol drinks do you have per week? ____________ Do you smoke? Yes No How many packs/day? __________ Do you use street drugs? Yes No Do you use Marijuana? Yes No Medicinal or Recreational How much________________ What Type? (Circle One) Smoke Edible Hash Oil
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PATIENT HISTORY FORM - Dr. Scott Ross · 2 Please list all medications you are currently taking Do you take any blood thinning medications such as: Aspirin, Coumadin/Warfarin, Aggrenox,
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PATIENT HISTORY FORM Date:___________________
Patient Name:_____________________________ Date of Birth__________ AGE: ______
******Primary Care Provider: ____________________________________
REVIEWED WITH PATIENT: ___________________________________
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PREVIOUS TREATMENT:
What treatment(s) have you had for this problem so
far?See below:
MEDICATION MANAGEMENT :
o LIST MEDICATIONS TRIED AND FAILED
_________________________________________
_________________________________________
PREVIOUS INJECTIONS OR SURGERY:
_________________________________________
PHYSICAL THERAPY:
o WHERE AND HOW LONG WAS THE TREATMENT
_________________________________________
_________________________________________
CHIROPRATIC TREATMENT
o WHERE AND HOW LONG WAS THE TREATMENT
_________________________________________
_________________________________________
What percent improvement have you had since onset
(0-100%)? ________%
PAIN SCALE:
On a scale in which 0 is no pain and 10 is the worst pain
you can imagine, please rate your pain:
Today (0-10)_______Best (0-10) ________
Worst (0-10)______ Usually(0-10)________
How long can you – Sit: ____Stand:___
Walk:___Drive:___
How much to you think you can currently lift?_____lbs
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Patient Name: _______________________ Date of Birth:______________Date of Service: _______ Mark these areas on your body where you feel these sensations Please use these Symbols: Numbness Pin and Needles Ache Pain ====== ooooo xxxxx ///// ====== ooooo xxxxx ///// ====== ooooo xxxxx /////
*By signing this agreement, I authorize Dr. Scott R. Ross to administer treatment and medication that is deemed necessary and advisable in the treatment and diagnosis of my condition(s). Narcotic Policy: *** Please Read Carefully – this policy is for your Safety ***
When appropriate after a thorough review of your medical history, failure of conservative medical and surgical management, it may be determined that you require narcotic medications for your chronic pain condition. You have been told of the risks, complications, and side effects of the medications, prior to proceeding with the therapy. This contract applies to all medications: Narcotic and Non-Narcotic, prescribed by Dr. Scott R. Ross. By signing below, you agree therapy and termination of treatment with Dr. Scott R. Ross. This is a legally binding contract and must be signed below.
I agree to the following terms and conditions in this contract:
When appropriate, Dr. Scott R. Ross may prescribe narcotic medications to treat pain (i.e. Vicodin, Percocet, OxyContin, etc.).
I will NOT obtain or consume narcotic drugs from other sources while under Dr. Scott R. Ross’s care. I will not ask ANY other physician to fill my narcotic medications from Dr. Scott R. Ross. I will not go to Urgent Care, Emergency Room, or any other medical practitioner and obtain narcotics without informing Dr. Scott R. Ross within one business day. I will notify the office of Dr. Scott R. Ross immediately if I obtain narcotics from any other provider.
I understand that I will need to pick up my prescription in person. ***********
I will not sell, share, or give any of my medications to another person; I understand that such a mishandling of my medications is a serious violation of this agreement and would result in my treatment being terminated without any recourse for appeal.
Lost or stolen prescriptions will not be replaced without a police report. This will only be allowed once. The medications will also NOT be replaced if lost or stolen for any reason unless a police report is obtained.
I will take my medications EXACTLY as prescribed by Dr. Scott R. Ross. I will not alter the way I take it without consulting with Dr. Scott R. Ross.
Dr. Scott R. Ross will not prescribe or refill narcotic medications over the phone. I realize that an office visit is required to request a medication/prescription changes until the next scheduled visit.
I will be required to fill out a visual analog pain scale questionnaire at every office visit.
I agree and consent to random urine drug screening at ANYTIME during my treatment with narcotics. I agree to pay ALL COSTS associated with the medications, the drug screens, physician office visits, and ANY COSTS associated with the Narcotic Treatment Program. I agree to follow up in one month intervals for medication refills. I agree that my functional status will be assessed at frequent intervals and if it is determined that medications are not working, they will be stopped.
I will keep my narcotic medication (s) in a safe and secure location and out of reach of children.
I will notify my physician of ANY side effects immediately. If I experience any sedation symptoms I will notify Dr. Scott R. Ross.
If I test positive for any illegal drugs, my narcotic medication may be stopped.
Prescribed narcotics are monitored by the Colorado Prescription Drug Monitoring Program (PDMP). We will obtain routine Colorado CPMP reports to validate that our patients are adhering to our policy of only obtaining narcotic based pain medications for our office.
Patients who are prescribed narcotics require a three-month office follow up visits to be evaluated. These visits should be scheduled well in advance of prescription(s) running out.
Dr. Scott R. Ross will only prescribe up to one-month supply of narcotic medications at each visit.
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I will only use one pharmacy for ALL my prescriptions and will advise Dr. Scott R. Ross immediately if this changes. My pharmacy name and phone number are as follows: ***________________________ ________________ Pharmacy Name Phone Number ANY violation of this narcotic policy may result in Dr. Scott R. Ross discharging me from his practice.
Appointment Policy: Canceled Appointments/No Show Appointments: As a courtesy to Dr. Scott R. Ross, and other patients, please provide at least 48 hrs. when cancelling an appointment. Appointments cancelled less than 48 hrs. in advance will be subject to a $50 cancellation fee. Patients, who are more than 15 minutes late for an appointment, may be asked to reschedule. If you NO SHOW/Cancel appointment without calling within 48 hrs one will be subject to a $50.00 No Show Fee. If you NO SHOW without calling or to call cancel appointments three times – discharge from the practice will follow.
Medication Refill Policy: Medication renewals are NOT a medical emergency. As a patient, I am responsible for ensuring that I stay current on my medications and advise Dr. Scott R. Ross’ office of refill requests at least one week prior to running out of medication. Please allow up to 3 to 4 days for refills to be processed.
Arbitration Agreement
Signing the Arbitration Agreement is part of this Treatment Agreement and requires my signature. Consumer Notice
Medical Doctors are licensed and regulated by the Colorado Board of Medical Examiners (303) 894-7690, or www.dora.state.co.us/medical. Fees for Additional Services (Generally not covered by Insurance).
Forms: Filling out forms is very time consuming and takes Dr. Scott Ross away from scheduled patient care. Therefore, a charge applies for forms that patients request to be filled out by Dr. Scott R. Ross. Examples of such forms include those for DMV, jury duty, disability, etc. Most forms can be completed for a fee of $30.00.
Financial Obligations and Assignment of Benefits
Co-pays and insurance deductibles are due at the time of service for office visits.
As a courtesy, my insurance will be billed by Dr. Scott R. Ross.
I assigned benefits and hereby authorize my insurance carrier to pay Scott R. Ross, D.O., directly for services I require from Dr. Scott R. Ross.
If I receive a check from my insurance for services provided by Scott R. Ross, D.O., I agree to immediately endorse the back of the check to Scott R. Ross, D.O. and send it to: Release of Medical Information to and by Scott R. Ross, D.O.
As a patient, I authorize Scott R. Ross, D.O. (dba “Pain Management of the Rockies, PC.”) to use and/or disclose my health information which specifically identifies me or which can reasonably be used to identifies me to carry out my treatment, payment, and healthcare operations to any person, corporation, or entity including, but not limited to, the Social Security Administrations, Insurance Carriers, Worker’s Compensation carriers, welfare funds, or employers; providing such agents have a financial responsibility concerning my care. This is outlined I the Notice of Privacy Practices.
I understand that I may revoke this consent at any time by notifying Dr. Scott R. Ross, D.O. in Writing, but if I revoke my consent, such revocation will not affect any actions that Scott R. Ross, D.O., took before receiving my revocation.
Signature of patient or representative _____________________________Date of Birth____________ Printed name of patient or representative _____________________________ Date__________________ Relationship to Patient ___________________ revised 08172017
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2222 North Nevada Avenue, Suite 5003, Colorado Springs, CO 80907 Main Number: (719) 471-3372 * Fax (719) 471-3927
AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION TO
PAIN MANAGEMENT OF THE ROCKIES, PC.
_______________________________________ ______________________________________ Name of Patient Date of Birth _______________________________________ ______________________________________ Street Address City, State, Zip Code
I hereby authorize the disclosure of my protected health information to Pain Management of the Rockies, PC. as described below:
Information to be released: ____Medical History, Examination Reports _____Surgical Reports ____Treatment or Tests _____Hospital Records including reports ____X-Ray Reports/Films _____Development Disabilities ____Laboratory Reports _____Prescriptions ____HIV Test Results* _____Consultations ____Mental Health _____Allergy Records ____Sexually Transmitted Disease _____Drug Records ____Alcoholism _____Other (Please Specify)________________ * A listing of the statutory exceptions to release of HIV Test results with consent is available. Purpose for Need of Disclosure ______All the request of the individual ______Other (Please Specify)_________________________________________________________________________ I understand that I have the right to:
Receive a Copy of Authorization Revoke This Authorization, except to the extent that the person(s) and or organization(s)
listed above have already made in reference to this authorization. This authorization will remain in effect until the following dates(s): ___________________________ __________________________________________________________ ______________________________________ Signature of Patient (or Legal Representative) Date
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Prescribing Drug Monitoring Program Awareness Form
If a patient is prescribed any controlled substance, your pharmacist puts that
information in a database. The PDMP (Prescription Drug Monitoring Program) may
be queried by authorized individuals who are licensed in the State of Colorado as
Physicians, Pharmacist, and Nurses with prescribing authority, Dentist, Optometrist,
Podiatrists, Veterinarians, Physician Assistants, and Resident Physicians, with
training license who are under the supervision of a licensed Physician.
Each Pharmacy must disclose to patients who are receiving controlled substances
that their prescription information will be loaded in to the PDMP and may be
queried by authorized individuals.
Please sign to indicate you have been made aware of this requirement.
Patient’s Name Printed / Patient Signature Date of Birth Date