Phone: 609-645-8884
Main Fax: 609 645 9780
Billing Fax: 609 645 9782

Fax: 609 645 9780 , Billing Fax: 609 645 9782
(Page 1)
New Patient Chemical Dependency Form
You have the options of filing out the form and submitting it, printing it and bringing it in or printing it and faxing it in. We prefer you submit it electrotonically. Please see the bottom of the form for printing options.
First Name*:
Last Name*:
Age*:

Street Address*:
City*:
Zip*:

Date of Birth*:
Social Security#:

If you wish not to please put last 4 digits of ss#.
Sex?*
Male Female
Married?
Yes No
We are required to ask about your Race?
African American Asian Caucasian Hispanic Other
Home Phone*:
Cell Phone*:
Work:

Employer:
Can we call you at work?
Yes No
E-mail Address*:
Want to join our mailing list?
Yes No
Are you working?
Yes No (If Yes) Full Time Part Time


(Page 2)
If you have NO INSURANCE, please check here:
PLEASE FILL OUT ALL INFORMATION!
A) Primary Medical Insurance: (Note if we do not participate with your insurance and you don't have out of network benefits, payment will be your responsibility. If referrals are needed, it is your responsibility to get them). If this is a workman's comp or motor vehicle accident we still need your primary medical information.
Name of Insurance*: ID #*:
Name of Subscriber:* SSN#*:
Date of Birth*: Relationship to subscriber:
B) Secondary Medical Insurance:
Name of Insurance: ID #:
Name of Subscriber: SSN#:
Date of Birth: Relationship to subscriber:
C) Is this a: Workman's Compensation? OR Motor Vehicle Accident?
If this does not apply please move to section B
Date of accident or injury:
Insurance Company: Claim#:
Company Address: Adjuster:
Adjuster Phone #: Attorney:
Attorney's Phone #: Address of Attorney:


(Page 3)
Height*: Weight*:
Handed: RightLeft Occupation:
Primary Physician: Primary Physician Phone:
Referring Physician: Referring Physicia Phone:
How did you hear about us*? Friend/Relative Insurance
Referral Other
Do you have pain? Yes No   If yes where?
Is it related to ? Car Accident or Work Injury


(Page 4)
Do you have pain? Yes No Where is your pain located?
Please list all physicians you have seen for your pain (if any)
Name
Address
Phone
1
2
3
4
5
Please list all medications you have taken for your pain:
1
How did it work?
2
How did it work?
3
How did it work?
4
How did it work?
5
How did it work?
Describe your pain in detail: (Constant, Intermittent, Dull, Sharp, Burning, Shooting, ETC)
pain detail:
What makes it worse:
What makes it better:
On a scale of 0 to 9 ( 0 = no pain and 9 = worst) how would you rate your pain at it's baseline: No Pain..    0  1  2  3  4  5  6  7  8  9    ..WORST
and when it is at it's worse:
How well are you coping with your pain? Select below. Numbers near 9 Worse and near 0 Well.
WELL..    0  1  2  3  4  5  6  7  8  9    ..WORSE
Please indicate your level of functional limitation: Check below
 Unlimited  Somehow Unlimited  Limited  Very Limited


(Page 5)
Allergies
List allergies to any medications: 1
2
3
Allergies (to include food): 1
2
3
Check all that apply:
High Blood, Difficulty Breathing, Emphysema, Diabetes, Angina
Heart Disease, Asthma, Hepatitis, HIV
Other
Are you currently taking Coumadine or any other blood thinners? Have you ever had a DEXA Scan to
test your bone density?
Yes No
When:
Please list all surgical procedures that you have had:
Medication List
(includes herbals, over the counter meds and home remedies)
Name of Med
Purpose
Dose
Schedule
Started
Stopped
Side Effects
1
2
3
4
5
6
7
8
9
10
Have you had an surgery in the past?
(For office use only)
Date Reviewed: By:
Last Name: First Name:


(Page 6)
Do you smoke? Yes No How much a day?
Do you drink alcohol? Yes No How much per day?
Do you use recreational drugs? Yes No How much per day?
Do you wish to stop any of the above?
Do you have any other personal information we should be aware of? (urinary incontinence, impotence, premature ejaculation, lack of sexual interest, addiction to medication or substance abuse)
Name of your body part where pain starts:
Direction where pain goes:(left, right, up, down, covers large area)
Please select all that apply
1. GENERAL HEALTH: Unintentional weight loss, Unintentional weight gain, Fever, Night Sweats
2. CARDIO-VASCULAR: Chest Pain, History of Congestive Heart Failure, Heart Attack, Arrhythmia, High Blood Pressure, High Cholestrol
3. RESPIRATORY: COPD, Asthma, Use of O2, Sleep Apnea
4. GASTRO-INTESTINAL: Diarrhea, Constipation, Blood in stool, Hepatitis, Abdominal Pain
5. MUSCULO-SKELETAL: Pain or Tenderness
Swelling or Deformity in any of the following areas:
Neck, Mid-back, Low Back, Shoulder, Elbow, Wrist, Hip, Knee, Ankles, Use of cane or other assistive devices

6. NEUROLOGICAL: Headaches, Migraines, Facial Pain, Weakness, Stiffness, Dizziness, Daytime sleepiness, Numbness, Tingling, History of Carpal Tunnel Syndrome, Memory Loss, Stroke, Seizures, Insomnia

7. PSYCHIATRIC: Depression, Anxiety, Agitation, Schizophrenia / Hallucinations, Attention Deficit Disorder, Bipolar Disorder, Post Traumatic Stress Disorder, Obsessive Compulsive Disorder, Personality Disorder, Addiction History

8. INFECTIOUS DISEASE: Sexually Transmitted Disease, HIV, Hepatitis B or C, Shingles, chronic infection

9. ONCOLOGY: History of cancer, If yes, specify where:
10. GENITO-URINARY: Sexual Dysfunction, Premature Ejaculation, Impotence, Loss of Libido, Urinary Incontinence, Difficulty urinating

11. ENDOCRINOLOGY: Diabetes, Thyroid Dysfunction

12. RHEUMATOLOGY: Pain in Multiple Joints, Systemic Disease, Joint Stiffness or Swelling, Chronic Fatigue

13. Ophthalmology: Glaucoma, Blurred vision
14. EAR, NOSE AND THROAT: Hearing Problems, Snoring, Vertigo, Difficulty Swallowing, Hoarseness

15. DERMATOLOGY: Abnormal Hair Growth, Skin Lesions, Skin Redness, Signs of Skin Infections, Changes in Moles




(Page 7)
Please Enter Information Below Given By The Provider






Elaborate Abnormal Findings

BP: BP:




(Page 8)
This is an agreement between: (Full Name)
and Pain Specialists, P.A./Dr. Morris Antebi regarding the diagnosis of: Opiate dependence
for which the following medication(s) have been prescribed (narcotics): scheduled or controlled substances
I understand that there are alternative treatments, which have been explained to me.
The goal of my therapy is to reduce my pain to a level that is tolerable and will allow me to improve my ability to perform daily
activities. I understand that daily use of a narcotic increases certain risks, which include, but are not limited to:
• Addiction
• Allergic reactions, overdose, and/or fatal complications
• Breathing problems
• drowsiness, dizziness, and/or confusion
• Impaired judgment and inability tom operate machines or drive motor vehicles
• Nausea, vomiting and/or constipation
• Development of tolerance

I agree to the following guidelines:

1 I will take this medication only as prescribed and I will not change the amount or frequency without authorization from my physician. Unauthorized changes may result in my running out of medication early, and early refills will not be allowed. (See #2)

2 I understand that due to the high potential for abuse of these medications, the following rules apply: I will NOT be allowed to obtain early refills or receive replacement for lost or stolen medication. Refills will only be provided during regular office hours.

3 I will obtain ALL of my prescriptions through:
Dr. Antebi and/or Associates and will fill ALL my prescriptions at
(pharmacy name)
In an acute emergency, another prescriber may prescribe medications for me, if this occurs, I will notify my primary care physician or nurse practitioner as soon as possible.

4 I will submit to random urine or blood tests if requested by my physician or nurse practitioner to to access my compliance.

5 I agree to see : Dr. Antebi and/or Associates
And will keep regularly schedules appointments as long as I am taking this narcotic medication.

6 If I do not follow these guidelines, I understand that my treatment may be terminated.

I have discussed these risks, benefits, and alternatives to narcotic treatment with my provider. I have had an opportunity to ask questions and receive answers to those questions to my satisfaction.
Patient Name: Date:
Physician/A.P.N. Name Date:


(Page 9)
PLEASE BE AWARE WE RANDOMLY TEST ALL PATIENTS. THERE WILL BE A CHARGE AT THE TIME OF TESTING OF $35.OO PER TEST USED. FOR PATIENTS WHO HAVE INSURANCE, WE WILL BILL YOUR INSURANCE COMPANY, HOWEVER IF THEY DO NOT COVER THE CHARGE, IT WILL BE YOUR RESPONSIBILITY. SERVICES WILL NOT BE RENDERED (INCLUDING PRISCRIPTIONS) IF YOU REFUSE TO TAKE THE TEST.


Please click below to acknowledge that you have read the above and understand this charge is your responsibility.


I agree and responsible for this charge:
HIPPA – Policies of our office to protect your privacy


THIS NOTICE DESCIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY AND SIGN BELOW. IF YOU HAVE ANY QUESTIONS, PLEASE DO NOT HESITATE TO ASK.

Your protected health information (PHI) will only be used with your consent to provide you treatment, to obtain payment from your health insurer, for case management and care coordination and health care operations. For any disclosure of PHI outside of this consent we will require written authorization from you. We may use or disclose your PHI if law or regulations requires the use or disclosure, such as but not limited to, legal proceeding, workman's compensation laws, and a threat to the health and safety of others.

Your PHI will not be shared with a family member, close friend or any other person without written consent by you. The only exception is for minor children (age 17 and under); the parent or legal guardian will have the right to the information.

You have the right to inspect and obtain a copy of your PHI. You may request an amendment of your PHI for as long as the PHI is maintained in the records. You have the right to request in writing, that we not use any part of your PHI for treatment, payment or health care operations. However, if we believe that the restriction is not in the best interest of either party or we cannot reasonably accommodate the request; we are not required to agree to your request. You have the right to receive confidential communication by alternative means and at alternative locations. For example, you can request your bills be sent to another address.

We cannot control or be held responsible for any third party misuse of your PHI. If you feel that your rights have been violated, please contact the office manager. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services.

For further information, please do not hesitate to contact our practice manager.

I authorize Pain Specialists to release any medical or incidental information to the following individuals:



Name Relationship to the patient
By clicking below, you state you have read and understand the above information and consent to the use of your PHI as outlined,
I agree about the use of PHI:


(Page 10)
Assignment of Benefits Form


I (Enter Name) hereby authorize benefits to be assigned to Pain Specialists, for healthcare services provided to me by Pain Specialists. I hereby certify that the insurance information that I have provided Pain Specialists 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 and 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 Pain Specialists to submit claims, on my behalf, to the insurance company listed on the copy of the current insurance card I have provided Pain Specialists, 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 Pain Specialists 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 Pain Specialists 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 and all applicable ERISA plan benefits and rights to Pain Specialists and any business associates working with them to make sure all rights and benefits are administered accurately, including the right to receive any applicable plan documents/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 including the right for administrative review by the appropriate governing body.

I hereby instruct and direct my Insurance Company to pay Pain Specialists 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 ERSIA regulations hereby instruct and direct my Insurance Company to provide SPD documentation stating such non-assign ability clause to myself and Pain Specialists. Upon proof of non-assign ability documentation I 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.

There will be a administrative fee of $1 per page up to $100 per record.

I agree and understand that any funds I receive by my insurance company due for services rendered by Pain Specialists / Sea Ambulatory Surgery Center will be immediately signed over and sent directly to Pain Specialists.

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 Pain Specialists 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 Pain Specialists to be my personal representative, which allows Pain Specialists 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 benefits based on billed charges, within ninety (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 Pain Specialists for acting as my personal representative.

I authorize Pain Specialists and its associates to provide medical care reasonable by todays standards. A photocopy of this Assignment shall be considered as effective and valid as the original.


Name of Patient/Guarantor
Name of Policy Holder
Date:





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