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
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:
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:
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: