NEW PATIENT REGISTRATION PACKET

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NEW PATIENT REGISTRATION PACKET Today s Date DOB: Social Security # Last Name: First Name: Previous/Nickname: Sex: Male Female Marital Status: Married Single Divorced Widowed Other Patients Race: American Indian or Alaska native Asian Native Hawaiian or other Pacific island Black or African American White Hispanic or Latin Other Race Mailing Address: City: State: Zip Code: Patient s Street Address (If different from mailing address): If Patient resides in Skilled Nursing Facility what is the name of the facility? If Patient is a Hospice patient, what is the name of the Hospice Service? Patient s Primary Care Provider: Referring Provider: CONTACT INFORMATION Primary Phone #: (Extended) O.K. to leave message with detailed information Secondary Phone #: (Extended) O.K. to leave message with detailed information Alternate Phone: (Extended) O.K. to leave message with detailed information Email Address: Primary Language: EMERGENCY CONTACT INFO Contact Name: Primary Phone #: Relationship to Patient: Secondary Phone #: PREFERRED PHARMACY Pharmacy Name: Pharmacy Phone #: Authorization and Consent to View RX History from External Source: I authorize Commonwealth Pain & Spine to view all available RX History from an external source. I am aware that Commonwealth Pain & Spine uses a secure connection to cclinicalworks to send and receive prescriptions. (Signature of Patient, or Patient Representative) Date Relationship to Patient if not signed by Patient

Page 2: Patient Name: DOB: EMPLOYER INFORMATION Employer Name: Employer s Phone #: Status: FT PT Is this a work related injury or motor vehicle accident? Yes or No If yes, please answer the following questions: Date of Injury: Claim#: Case Manager: PATIENT INSURANCE Primary Insurance: Secondary Insurance: Cardholder (if not Patient): Name: DOB SSN# PATIENT HAS PROVIDED CP&S WITH A COPY OF THEIR MOST UP-TO-DATE AND ACCURATE INSURANCE CARDS Consent for Insurance Assignment/Payment: I hereby authorize the assignment of benefits (payments) directly to Commonwealth Pain & Spine for all my insurance claims related to services received. I agree to pay any and all charges that exceed, or are not covered by my insurance. I understand that co-pays, deductibles and non-covered services are due at the time of service. I authorize the release of any medical information necessary for the purpose of processing claims with my insurance company. I permit a copy of this authorization to be used in place of the original. Signature of Responsible Party: Date: (Authorization will remain in effect from date signed until revoked in writing by patient or patient representative) ACKNOWLEDGED RECEIPT OF HIPAA NOTICE Commonwealth Pain & Spine is concerned about the privacy of our patient s health care information. Our intent is to make you aware of the possible uses and disclosures of your protected health information and your privacy rights. The delivery of your health care service will in no way be conditioned upon your signed acknowledgment. If you decline to provide a signed acknowledgment, we will continue to provide your treatment, and will use and disclose your protected health information for treatment, payment, and health care operations when necessary. I acknowledge that I have received the HIPAA Notice of Privacy Practices and Patient Bill of Rights. (Attached) Patient or Legal Guardian Date In accordance with the HIPAA guidelines, Commonwealth Pain & Spine is authorized to discuss my medical information with the following individuals. HIPAA Authorized Person s Name Relationship to patient Phone Number Do you utilize a transportation service? Yes No If yes, may CP&S give information in regards to dates and times of appointments to this service? Yes No Do you have a medical Power of Attorney? Yes No If so, please provide a copy for our records

Page 3: Patient Name: DOB: CP&S FINANCIAL POLICY PLEASE READ THE FINANCIAL POLICY CAREFULLY BEFORE SIGNING In keeping with our philosophy of open communication and education, it is important that you understand the financial policies of the practice. It is equally important that you understand the terms of YOUR OWN medical coverage. Your insurance policy is a contract between you and your insurance company. Although our staff is very knowledgeable of most insurance plans, it is important that you know the details and terms of your personal plan. Typically, you will find the insurance company s phone number on the back of your insurance card and we encourage you to contact them with questions specific to your coverage. If your insurance plan requires a referral, you must contact your PCP prior to receiving care from us. Regretfully, many insurers will not cover specialty services that are rendered without a referral and you may be held responsible for the costs. Note: All ongoing referral renewals are the responsibility of the patient. At each office visit, you will be asked to: (1). Provide your most accurate and up-to-date insurance card (as well as any secondary or tertiary insurance info) (2). Provide us with a copy of your current photo identification (3). Verify your correct address and phone number (4). Make payment of your co-pay by cash, check, debit or credit card (Returned checks will be charged a $40.00 fee). Your insurance company REQUIRES us to collect co-payments at the time services are rendered. Failure to collect your co-payment may constitute fraud under state and federal law. Please be prepared to pay your co-payment on the date services are rendered. Our office requires a 24-hour notice to cancel an appointment. A $50 fee may be assessed to patients that do not provide this required notification. If you are having a medical procedure, our staff will obtain a pre-certification prior to your visit. We encourage you to contact your insurance company prior to your procedure date to obtain an accurate amount of the co-insurance or other monies that may be due relative to the portion of the charge that is your financial responsibility. CP&S participates in most major health plans and will submit claims for services. It is the patient s responsibility to provide all necessary information to file the claims prior to leaving our office. We will file your primary and secondary insurance claims and work diligently with the carrier to resolve any conflicts that may arise. However, your insurance company may need you to supply certain information directly. It is your responsibility to comply with this request. You may have coinsurance and/or deductible amounts required by your insurance carrier. Any outstanding balance on your account following insurance processing will be billed to you. If genuine financial difficulties exist, please call our office. We are happy to work with you in resolving your balance and may be able to set up payment arrangements. Any patient balances that remain delinquent after 90 days may be referred to a collection agency. You will be responsible for any and all costs associated with the collection agency up to and including all legal costs. Patients with account balances in excess of 120 days with no payment arrangements or hardship request may be discharged from the practice. If this occurs, you will have 30 days to seek alternative medical care and our physicians will only be able to treat you on an emergency basis. I understand the above financial policy. I give consent to Commonwealth Pain & Spine to bill my insurance carrier and agree that I am financially responsible for any and all charges whether or not they are covered by insurance. Signature of Patient or Legal Guardian Date

Page 4: Patient Name: DOB: AUTHORIZATION TO TREAT I, the undersigned patient, hereby authorize Commonwealth Pain & Spine and its staff to administer such treatment as is necessary, and to perform services and/or procedures as are considered necessary on the basis of findings during the course of delivery of health care services and treatment. I have read a fully understand the above Authorization to Treat, the reasons why the treatment is considered necessary, its advantages and possible complications, if any, as well as possible alternative methods of treatment which have been explained to me. I also certify that no guarantee or assurance has been made as to the results that may be obtained by services received at Commonwealth Pain Associates. Print Name: Patient Signature: Date: Witness: Date: TREATMENT AND RX AGREEMENT This agreement must be reviewed and signed in order to proceed with narcotic and/or non-narcotic treatment with Commonwealth Pain& Spine. Controlled substance medications are very useful but have significant potential for misuse and are, therefore, closely controlled. This agreement is required to comply with the law regarding controlled pharmaceuticals and to prevent any misunderstandings about any treatments you receive. Because a CP&S physician may be prescribing such medication as part of your plan of care, you must agree to the following: 1. I understand that the main goal of treatment is to improve my ability to function or work. In consideration of this goal and the fact that I am being given potent medication to help me reach that goal, I agree to help myself by following preventive and better health habits such as: exercising regularly, losing weight as directed by a physician, and abstaining from the use of tobacco, alcohol and illicit drugs. I will also participate in physical therapy as prescribed. 2. I agree to submit to a blood, urine or saliva test, if requested by my provider, to determine compliance with my program of pain medication and I waive privacy rights. 3. I understand that my first office visit may be a consultation only and no pain medication given at that time if further investigation and/or testing are deemed necessary. 4. I understand that I may be called at any time to bring all prescribed medication for a mandatory pill count within a specified time period (usually 24 hours- but typically same day). 5. I agree that I will use my medications ONLY as prescribed by my doctor. I understand that any change to my prescriptions will require an office visit. I understand that self-medicating is not tolerated. No refills will be made during evenings or weekends. I will call at least 24 hours, but no more than 48 hours before my medications run out to arrange for refills. 6. I will not use any illegal substances, including marijuana, cocaine, methamphetamines etc. 7. I understand that lost or stolen medication or unfilled prescriptions WILL NOT be replaced, and I will safeguard my medication from theft. 8. I understand that I will follow the guidelines on properly disposing of controlled substances that will be explained to me by clinical staff. I will not discard, flush, give away or in any way lose control of my medications. 9. I will not share, sell or trade my medications with anyone. 10. I will not alter the form of the medication nor will I take the medication in a route other than as prescribed by my provider. 11. I will not attempt to obtain controlled medication from any other provider, nor will I borrow or buy medication from any other person. (with the exception of certain benzodiazepines which are not prescribed by this practice) 12. In the event of an emergency, if I do obtain controlled substances from another provider, I understand I am required to disclose this information to CP&S within 48 hours of discharge or emergency service. I understand it is my

Page 5: Patient Name: DOB: responsibility to make sure CP&S is notified of any such treatments and that I am to check with staff before combining any pain medication with the prescriptions CP&S provides me. 13. I will notify CP&S of any change in name, address or phone number. I understand that I must at all times have an updated phone number with my provider. I cannot be on dangerous medications, such as opioids, if my provider cannot reach me in a reasonable period of time (usually considered within 24 hours of the initial attempt). I agree to return any phone call from CP&S within 24 business hours. 14. I authorize my provider to investigate fully any possible misuse of my pain medication using any city, state or federal law enforcement agency, including this state s Board of Pharmacy. 15. I understand that any follow-up appointment may be scheduled with a Licensed Nurse Practitioner or Physician Assistant. Additionally, I understand that refusing to see one of CP&S providers will likely result in my no longer being able to be treated by the practice. 16. Patient has designated one and only one preferred pharmacy. Once a prescription has been filled, all questions regarding that prescription should be directed to that pharmacy. Our practice will only fill with this pharmacy. 17. I understand that CP&S does not mail narcotic prescriptions under any circumstances. 18. I understand that with any controlled substance that is prescribed to me there are inherent risks, namely; i. loss of efficacy over time, symptoms of withdrawal if abruptly stopped, and addiction; ii. medication taken in excess (this is different for everyone ranging from the prescribed dose to taking more than prescribed or combining with other controlled substances or even alcohol) may result in respiratory suppression or failure or death; iii. sedation, loss of function, impairment may also occur I agree not to drive while under the influence of any prescribed controlled substance; iv. constipation, allergic reaction, itching, nausea and dry mouth are also common side effects; v. my immune system may be suppressed and my hormone levels may decrease over time while being on chronic opioids. 19. I understand that the combination of controlled substances and alcohol are contra-indicated; the combination may result in serious harm or even death. 20. I understand that non-professional or inappropriate behavior toward any CP&S staff, affiliate or provider will not be tolerated. I agree to be respectful to other patients I may encounter in the waiting room, lobby, hallways, etc. I understand that I may not loiter in the parking lot of any CP&S location. 21. I understand that CP&S providers utilize tests to determine the best option for my care. My unwillingness to complete the tests requested may result in being released from further care with CP&S. 22. I understand that non-compliance with my pain management treatment plan may result in providers inability to properly treat my symptoms and could cause symptoms to worsen or become life threatening. 23. I understand that I may be released from this practice for missing appointments or cancelling/rescheduling appointments with less than 24-hour notice. 24. I agree that the goals of pain management have been explained to me as to what is considered appropriate and reasonable and that alternative treatment plans, outside of use of controlled pain medications, have been made available to me. I have agreed to proceed with pain management after a full explanation of the risks and benefits. I understand if I break this agreement, it will result in a change in my treatment plan, including safe discontinuation of my opioid medications when applicable or complete termination of the provider/patient relationship. I understand that, if I violate any of the above conditions, my controlled substance prescriptions may be immediately terminated. If the violation involves obtaining controlled substances from another individual, or providing controlled substances to another individual, I may also be reported to my other healthcare providers, medical facilities and law enforcement officials. I have read this contract and have also been informed regarding psychological physical dependence to controlled substances. Print Name: Patient Signature: Date: Witness: Date:

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