Patient Intake Consent Package

Kumar

PATIENT INTAKE: CONSENT and POLICIES

  • CONSENT FOR TREATMENT

    I do hereby consent to treatment of my condition by the staff of Complete Pain Care LLC, its subsidiaries and affiliates. I also certify that no guarantees or assurances have been made to me as to the results that may be obtained as a result of procedures, treatments and/or techniques used by Complete Pain Care LLC, its subsidiaries and affiliates. I further understand that while I am being assessed and/or treated at Complete Pain Care LLC, its subsidiaries and affiliates will not be held responsible for any injury sustained outside of immediate physical premises. I understand that it is the policy of Complete Pain Care not to prescribe medication on the initial visit.

    URINE TOXICOLOGY SCREEN

    Complete Pain Care LLC does not prescribe Opioids to any patient on their initial visit.

    Complete Pain Care LLC is committed to providing excellence in comprehensive pain management services. As a new patient at CPC you will be required to leave a urine sample. Your sample will be screened for medications and illicit substances, so that we can treat your pain safely and appropriately. All samples are then sent to an independent lab for confirmation. The results of your urine screen will become a part of your medical record. The results will be protected under the same privacy guidelines as your entire medical history. During your treatment you may be asked to leave a urine sample during any visit at random and without prior notice. Medications may not be prescribed without the urine toxicology screen being done. Continuation of care is dependent on adherence to the above guidelines.

    CANCELLATION POLICY

    Please keep in mind that appointments are time-slots reserved specifically by and for you. We require a 48 -hour advance notice if you are unable to keep your scheduled appointment. Please note that a cancellation for a Monday appointment must be done on Thursday and a Tuesday appointment must be done on Friday. As a courtesy, we offer appointment reminder calls. However, it is your responsibility to keep track of your appointments whether you receive a reminder call or not. If you miss or cancel/reschedule an appointment without a 48-hour notice, a “No Show” fee of $45 will be incurred to your account. This fee is not billable to your insurance and must be paid before future appointments can be scheduled. Patients with repeat cancellations or missed appointments may be discharged from our practice.

    My signature at the conclusion of this Agreement confirms that I give Consent To Treatment as described above and that I have read and agree to comply with Complete Pain Care LLC’s Policy on Urine Toxicology Screening and Complete Pain Care LLC’s Cancellation Policy.

    MOTOR VEHICLE ACCIDENT CERTIFICATION

    I certify that my pain complaint is not a result of a Motor Vehicle Accident.

    My signature at the conclusion of this Agreement confirms that my pain complaint is NOT a result of a Motor Vehicle Accident.

    FINANCIAL POLICY / ASSIGNMENT OF BENEFITS

    Payment is always PRIOR to service: We accept cash, personal checks, Visa or MasterCard. Returned check fee is $40. If you do not have payment for your copay, deductible, co-insurance or balance due at the time of the visit, you may be asked to reschedule your appointment and no show fees will apply. If needed, please ask about a payment plan. (By law, your insurer requires us to collect 100% of your financial responsibility under your contract. We are not permitted to waive or otherwise reduce this obligation on your behalf.) If you receive a statement, payment is due at the time you receive the statement.

    • Payments. Your share of co-pays, deductibles, and co-insurance are your responsibility, and payment is due at the time of service. We ask that you leave a credit card on file to pay your balance once your claim has been adjudicated by your insurance company. A finance charge of up to 5.0% per month will be charged for nonpayment of your account. See Collections below.
    • A valid picture ID, your insurance card(s) and a credit card are required at the time of your office visit. Please confirm your health insurance information at the time of scheduling.
    • For All Insurances. It is your responsibility to notify the staff of any changes in your address, phone number and/or insurance plan, and provide a current up-to-date insurance card at each visit. Failure to do so may cause your insurance claim to be rejected, thus making it your responsibility to pay for the total cost of the visit. Please review your benefit listing summary that you received from your insurance company to understand your coverage.
    • Participating Insurances. We participate with many, but not all insurance companies.
    • Referral from Your PCP. If your plan requires a referral from your primary care physician, it is your responsibility to obtain it prior to your visit and faxed it to our office 48 hours in advance of your appointment. If this office has not received your referral by that time your appointment may be rescheduled, and you will be held financially responsible for any costs incurred.
    • Non-Participating Insurances, Self-Pay.If we do not participate with your insurance plan, you are considered self-pay. Payment in full is required at the time of each service. Fees are available upon request.
    • Non-Copayment Plans. If your plan does not require a co pay and we participate, you are responsible for any deductible, co-insurance and balances that your plan indicates on the explanation of benefits.
    • High Deductible Plans. Payment in full is required at the time of each service. Fees are available upon request.
    • Secondary and Tertiary Insurances: If applicable, secondary and tertiary insurance claims will be filed once. If payment or denial has not been received within 30 days of filing, you will be responsible for payment in full. You must make us aware of any secondary and tertiary coverage at the time of your appointment.
    • Not Medically Necessary Procedures. Your insurance company may deem certain procedures as “not medically necessary” per their own internal protocols. If you and your doctor decide to continue with a procedure that may fall within this category, we require payment in full at the time of service.
    • Worker’s Compensation: If you wish to apply your Worker’s Compensation insurance to your visit, you must have a valid case number, caseworker name, contact number and billing address for verification and authorization purposes. If this information is not provided, you will be considered as a self-pay patient, and full payment will be expected at time of service.

      If your pain issue is determined to be due to a work related injury after you have received treatment by us and Medicare or your insurance company then takes back the money paid to us for your care, you will be responsible for the cost of payments received at a self-pay rate.

    • Account Balances and Collection Procedures. You're responsible for timely payment of your account. Your balance is due in full unless a previous payment agreement has been made. We reserve the right to reschedule or deny a future appointment on delinquent accounts.
    • Additional Charges/Policies
      • Payment Challenges. Services that we provide are not eligible for payment challenges after services are rendered.
      • Release of Medical Records: The fee for a medical record is $35.00. Please allow 14 business days for processing the medical records before calling to check the status of your request. Additional postage will be charged unless records are picked up from the office.
      • After Hours Call: After hours paging is for Emergencies only. Non-emergency calls may result in a charge of $45.00.
    • Assignment of benefits. I certify that I (or my dependent(s)) have active and valid insurance coverage and have supplied Complete Pain Care, LLC with the up-to-date and correct insurance identification card(s) as well as all necessary information regarding the guarantor of the insurance policy(ies) and the subscriber as is required to submit medical claims for reimbursement. I understand that failure to provide updates to any of the information supplied may result in denial of payment(s) to Complete Pain Care, LLC. I understand that resubmitted claims with corrected updated information may still be denied due to the fact that the corrected information was not supplied in a timely fashion.

      I, the undersigned Patient assign all rights and benefits of insurance of any and all applicable medical payments and/or other insurance (including legal suits if applicable) to Complete Pain Care LLC and/or its affiliates and subsidiaries for services and/or supplies to the undersigned Patient and Worker’s Compensation or other insurance coverage under my policy, in accordance with Mass. General Laws Ch. 90. Sec. 34M.

      I hereby instruct the insurance carrier that in the event my medical benefits are disputed for any reason, (including medical relatedness, reasonableness and/or necessity) or any take back by the insurance carrier, that the amount of benefits claimed by Complete Pain Care LLC is to be set aside and not disbursed until the dispute is fully resolved.

      I understand that it is my responsibility to pay Complete Pain Care, LLC for those medical services rendered to me or my dependent(s). I understand that I am financially responsible and I personally guarantee payment for all charges whether or not paid by insurance.

    • Collections. If no payment is received within the 3rd statement cycle (approximately 90 days from my date of service), my account will be considered delinquent and will be referred to an outside collection agency or the local court system. Referral to outside collections results in a service charge of $35 and may damage my credit rating. (Please contact our Billing Department to work out payment arrangements so that we can avoid this step.)

      I understand that if my account is referred to an outside collection agency or taken to court, I agree to pay any collection fees, reasonable legal fees, court costs, and other expenses incurred as a result of said collection or court date. Further, I understand that a late payment charge (5.0%) will be applied monthly to any balance carried forward.

    I certify that the information I have reported with regard to my insurance coverage is correct and I hereby authorize Complete Pain Care, LLC, the release of any information relating to any claim for benefits, in order to process any claim for benefits and to secure the payment of benefits. I authorize the use of this signature on all insurance submissions. I am irrevocably consenting to allow Complete Pain Care, LLC to use and disclose my protected health information to any Credit Card Entity, Bank, or Financing Company when they request such information to process an account and assist with payment. I acknowledge that I will not challenge any payments (including credit, debit, or financing card payments) once the services are provided. If correct insurance is not given or if there is a lapse in coverage or a change to my health insurance policy, I am financially responsible for payment for all charges.

    By signing below, I also acknowledge the receipt of Complete Pain Care’s Notice of Privacy Practices which provides me with detailed information about how they may use and disclose my protected health information for the purposes of treatment, payment, and health care operations. I can also obtain a copy at www.completepaincare.com/hipaa.

    My signature at the conclusion of this Agreement confirms that I have read and fully understand the FINANCIAL POLICY and ASSIGNMENT OF BENEFITS POLICY above and I acknowledge the receipt of Complete Pain Care’s NOTICE OF PRIVACY PRACTICES.

  • COMMUNICATION and YOUR CARE

    We want you to receive excellent care. The best way to meet this goal is good communication. Predictable outcomes depend on both doctor and patient working toward the same goals.

    YOUR COMMITMENT

    • Ask questions and be part of your care
    • Be honest about your history, symptoms, and other important information about your health
    • Tell your doctor about any changes in your health
    • Schedule accordingly based on the recommended care plan and follow your doctor's advice
    • Prepare for and keep scheduled visits or reschedule visits in advance whenever possible
    • Be respectful to office staff and healthcare providers
    • End every visit with a clear understanding of your doctor's expectations, and treatment goals.

    OUR COMMITMENT

    • Explain diagnosis, treatment recommendations, and outcomes in an easy-to-understand way
    • Listen to your questions and help you make decisions about the direction of your care
    • Keep treatments, discussions, and records private
    • Determine when a breakdown of the doctor-patient relationship is justification for terminating care
    • Determine when referral to another provider or specialist is appropriate
    • Share patient information with other providers involved in your healthcare, as appropriate.

    MEDIATION

    We encourage open communication and ask our patients to sign this mediation agreement. While we do not anticipate any issues or concerns during the course of your treatment, if any arise, you (and/or your legal counsel) and your healthcare provider (and/or their legal counsel) agree to meet with a neutral mediator and work toward a solution. Whether or not a solution is found, mediation may postpone but does not remove or block your legal rights. Importantly, you agree that any usage or inference to a "claim" will be understood and read as "potential claim" until the mediation is complete. This designation allows us to begin in a less formal manner that has been shown to expedite the resolution process. Your signature on the following page confirms that should a concern arise in any aspect of the care provided by this office, staff, and affiliated healthcare professionals, you agree to mediate first before pursuing legal action.

    AGREEMENT TO RECEIVE ELECTRONIC COMMUNICATION

    • I agree that the healthcare provider and office may communicate with me electronically at my email address.
    • I am aware that there is some level of risk that third parties might be able to read unencrypted emails.
    • I am responsible for providing the healthcare provider and office any updates to my email address.
    • I can withdraw my consent to electronic communications by calling this office.

    My signature at the conclusion of this Agreement confirms I certify that I have read or had read to me the contents of this form. I understand the possible advantages that compliance with professional healthcare recommendations can provide as well as potential consequences of non-compliance. I attest that I have had the opportunity to ask questions and all of my questions have been answered to my satisfaction.

  • CONSENT FOR TREATMENT and URINE TOXICOLOGY SCREEN ACKNOWLEDGEMENT

    I do hereby CONSENT TO TREATMENT of my condition/s by the staff of Complete Pain Care LLC as specified on page 1 of this patient intake form and I have read and agree to comply with Complete Pain Care LLC’s policy on URINE TOXICOLOGY SCREENING as described on page 1 of this patient intake form:

  • CANCELLATION POLICY ACKNOWLEDGEMENT

    I have read and agree to comply with Complete Pain Care LLC’s CANCELLATION POLCIY as described on page 1 of this patient intake form.

  • MOTOR VEHICLE ACCIDENT CERTIFICATION

    I certify that my pain complaint is NOT a result of Motor Vehicle Accident.

  • FINANCIAL POLICY / ASSIGNMENT OF BENEFITS ACKNOWLEDGEMENT/ NOTICE OF PRIVACY PRACTICES

    I have read and agree to comply with Complete Pain Care LLC’s FINANCIAL PAYMENT POLICY and ASSIGNMENT OF BENEFITS POLICY as described on pages 2 and 3 and I acknowledge the receipt of Complete Pain Care’s NOTICE OF PRIVACY PRACTICES.

  • COMMUNCIATION and YOUR CARE / MEDIATION /RECEIVE ELECTRONIC COMMUNCIATION

    I have read and understand the possible advantages that compliance with professional healthcare recommendations can provide as well as potential consequences of non-compliance. I attest that I have had the opportunity to ask questions and all of my questions have been answered to my satisfaction and agree with all the policies on pages 3 and 4 of this document.

  • We want you to understand this document and our policies and procedures, and we do not want you to be confused.

    If you have any questions or concerns about our Financial Policy, procedures or fees, our office our billing department can help. Please ask questions if necessary before signing below.

    I have read and agree to comply with all Complete Pain Care LLC’s policies contained in this package, specifically those that I have initialed above:

  • MM slash DD slash YYYY

  • If you have any questions, please call us at (508) 665-4344.

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