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Insurance Information
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The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance or deductible. I understand that it is my responsibility to verify my insurance coverage. I also authorize Oklahoma Center for Spine & Pain Solutions or insurance company release any information required to process my claims. If Medicare is my only insurance carrier, I understand that I am fully Responsible for 20% co-insurance due after Medicare payment.
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Patient History

Controlled Substance Contract
OKLAHOMA CENTER FOR SPINE & PAIN

Please read very carefully. Fill out all information and initial net to each letter
I, DOB: understand that in order to receive care for the treatment of pain in the use of controlled medications, I agree to and will comply with the following
A: PAIN MANAGEMENT PROGRAM OPTIONS: I recognize that my chronic pain represents a complex which may benefit from interventional treatments, physical therapy, psychotherapy and behavioral strategies. I also recognize that my active participation in the management of my pain is extremely I agree to actively participate in all aspects of the Pain Management Program to maximize and improve coping with my condition. If I am currently involved in any of the above therapies, I will those providers to exchange unrestricted information regarding my condition and treatment with Center for Spine & Pain Solutions, PC.
A: PAIN MANAGEMENT PROGRAM OPTIONS: I recognize that my chronic pain represents a complex

problem, which may benefit from interventional treatments, physical therapy, psychotherapy and behavioral medicine strategies. I also recognize that my active participation in the management of my pain is extremely important. I agree to actively participate in all aspects of the Pain Management Program to maximize function and improve coping with my condition. If I am currently involved in any of the above therapies, I will authorize those providers to exchange unrestricted information regarding my condition and treatment with Oklahoma Center for Spine & Pain Solutions, PC.
B: USE OF MEDICATIONS: E'ALL'MEDICATIONS AS PRESCRIBED I will speak with Oklahoma for Spine & Pain Solutions, PC before making any changes in either the dose or frequency of my medications. Narcotic pain medications must all be obtained from the same pharmacy each time (Unless and approved by OCSPS). I understand my medications are generally written for a limited time frame will follow the regiment directions. I also understand Oklahoma Center for Spine & Pain solutions, PC not authorize early refills regardless of reason, NO EXCEPTIONS.
B: USE OF MEDICATIONS: E'ALL'MEDICATIONS AS PRESCRIBED I will speak with Oklahoma

Center for Spine & Pain Solutions, PC before making any changes in either the dose or frequency of my medications. Narcotic pain medications must all be obtained from the same pharmacy each time (Unless notified and approved by OCSPS I understand my medications are generally written for a limited time frame and I will follow the regiment directions. I also understand Oklahoma Center for Spine & Pain solutions, PC will not authorize early refills regardless of reason, NO EXCEPTIONS.
C: SEEKING PRESCRIPTIONS: I will neither seek nor fill prescriptions for any controlled medication from other health care provider unless authorized in writing by Oklahoma Center for Spine & Pain Solutions, will not harass or repeatedly speak with my health care team (including my physicians, OCSPS staff, my & their staff) about refills. 1 will not call the health care provider after hours, nights, weekends; Etc. about my medication refills, as an appointment is needed for ALL refills unless otherwise by the physician. I understand that I am required to allow 48 72 business hours (Not including for prior authorizations to be processed.
C: SEEKING PRESCRIPTIONS: I will neither seek nor fill prescriptions for any controlled medication from ANY other health care provider unless authorized in writing by Oklahoma Center for Spine & Pain Solutions, PC. 1 will not harass or repeatedly speak with my health care team (including my physicians, OCSPS staff, my pharmacist & their staff) about refills. 1 will not call the health care provider after hours, nights, weekends; holidays, Etc. about my medication refills, as an appointment is needed for ALL refills unless otherwise authorized by the physician. I understand that I am required to allow 48-72 business hours (Not including weekends for prior authorizations to be processed.
D: MEDICAL RECORD RELEASES: I will inform ALL of my health care providers that 1 receive controlled medication or pain management and will maintain an unrestricted and current medical records release on
D: MEDICAL RECORD RELEASES: I will inform ALL of my health care providers that 1 receive controlled

medication or pain management and will maintain an unrestricted and current medical records release on
E: DRUG SCREENING: I will willingly participate in drug screenings as a part of my treatment plan. I that drug screenings will be conducted at every appointment or at the discretion of Oklahoma for Spine & Pain Solutions, PC staff and/or physicians. Screenings may include Urinalysis, blood PMP review, and/or pill counts. This process is to ensure my safety and to assist the physician n my treatment. I agree to pay all cost associated with drug testing not covered by my insurance. Refusal to screening at the time specified may result in termination of my care.
E: DRUG SCREENING: I will willingly participate in drug screenings as a part of my treatment plan. I understand that drug screenings will be conducted at every appointment or at the discretion of Oklahoma Center for Spine & Pain Solutions, PC staff and/or physicians. Screenings may include Urinalysis, blood testing, PMP review, and/or pill counts. This process is to ensure my safety and to assist the physician n my proper treatment. I agree to pay all cost associated with drug testing not covered by my insurance. Refusal to submit to screening at the time specified may result in termination of my care.
F: ILLEGALANI NON PRESCRIBED DRUG USE: I understand that the use of any controlled medication prescribed by Oklahoma Center for Spine & Pain Solutions, PC may result in termination of my care. I
F: ILLEGALANI NON-PRESCRIBED DRUG USE: I understand that the use of any controlled medication

not prescribed by Oklahoma Center for Spine & Pain Solutions, PC may result in termination of my care. I
OKLAHOMA CENTER FOR SPINE & PAIN

authorize the practice to cooperate fully with any city, state, or federal law enforcement agency, including this state's board of pharmacy, in the investigation of any possible misuse, sale, or other diversion of controlled medications. I authorize the practice to provide a copy of the agreement to my pharmacy and/or my other health care providers. 1 agree to waive any applicable privilege or right of privacy or confidentiality with respect to these authorizations. I also understand that the use of any illegal substance, including marijuana without a valid medical marijuana card, will result in immediate termination of care, and I will not receive any more medications at this time.
G: LOST OR STOLEN MEDICATION: 1 agree to safeguard all medications prescribed by Oklahoma Center Spine & Pain Solutions, PC and understand that lost, stolen, or damaged medication will NOT be replaced, of any reason, NO exceptions.
G: LOST OR STOLEN MEDICATION: 1 agree to safeguard all medications prescribed by Oklahoma Center

for Spine & Pain Solutions, PC and understand that lost, stolen, or damaged medication will NOT be replaced, regardless of any reason, NO exceptions.
H: DRIVING & OPERATING EQUIPTMENT: Many medications can cause drowsiness and/or very relaxed of mind causing operation of equipment or vehicles to be dangerous. I agree to refrain from driving or dangerous equipment for 72 hours after any change in medication dosage and whenever I feel
H: DRIVING & OPERATING EQUIPTMENT: Many medications can cause drowsiness and/or very relaxed

state of mind causing operation of equipment or vehicles to be dangerous. I agree to refrain from driving or operating dangerous equipment for 72 hours after any change in medication dosage and whenever I feel drowsy. I: OTHER RESTRICTIONS AND/OR CONSIDERATIONS: I agree to make and keep my routine appointments scheduled by Oklahoma Center for Spine & Pain Solutions, PC in order to continue receiving controlled substances. I understand that the use of opioids in conjunction with alcohol, benzodiazepines, or any central nervous system suppressing medication could increase risk of death. ! also understand that controlled medications may be addictive. This means the body may begin to depend on the medication and I may experience withdrawal such as nausea, shakes, sweating, rapid heat rate, diarrhea, high blood pressure, pain or severe nervousness/anxiety if I suddenly stop taking the medication. This is why it is vital I take my medications as prescribed.
J: TERMINATION: I will no longer be eligible for care if I am in possession of illicit/illegal drugs or trafficking in controlled substances, intoxicated, or if arrested for DUI. If I alter my prescription way, sell or share my medications, I will no longer be eligible for care.
J: TERMINATION: I will no longer be eligible for care if I am in possession of illicit/illegal drugs or

substances, trafficking in controlled substances, intoxicated, or if arrested for DUI. If I alter my prescription in any way, sell or share my medications, I will no longer be eligible for care.

I UNDERSTAND AND AGREE TO THE CONDITIONS OF CARE DESRIBED ABOVE AND WILL COMPLY WITH

THEM. I UNDERSTAND THAT OKLAHOMA CENTER FOR SPINE & PAIN SOLUTIONS, PC RESERVES THE RIGHT TO TERMINATE OUR RELATIONSHIP AATH THEIR DISCRETION AT ANY TIME. ALL OF MY QUESTIONS ABOUT

THE TERMS OF THIS AGREEMENT AND ALL OTHER DOCUMENTS THAT I HAVE SIGNED AT OKLAHOMA CENTER FOR SPINE & PAIN SOLUTIONS, PC HAVE BEEN ANSWERED TO MY SATISFACTION. FAILURE TO COMPLY WITH ANY OF THE TERMS OF THIS AGREEMENT MAYRESULT IN AN IMMEDIATE TERMINATION OF
Patient Signature

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HIPAA AUTHORIZATION FOR THE USE OR DISCLOSURE OF HEALTH INFORMATION
OKLAHOMA CENTER FOR SPINE AND PAIN SOLUTIONS

13700 S. WESTERN, AVE. SUITE 100, OKLAHOMA CITY, OK 73170

PH. 405-806-7246 FAX: 405-703-1583

This form is for use when such authorization is required and complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards.
HIPAA AUTHORIZATION FOR THE USE OR DISCLOSURE OF HEALTH INFORMATION
Print Name of Patient
Date of Birth

MonthDayYear
MY AUTHORIZATION:
I authorize Oklahoma Center for Spine and Pain Solutions to use or disclose the following health information.

Oklahoma Center for Spine and Pain Solutions may disclose this health information to the following recipients. I authorize the following individuals to call our office on my behalf to verify the status of appointments, treatment plans, medications, and account information. These individuals may also pick up prescriptions and/or samples that I have requested.
Name
Relationship
Name
Relationship
Name
Relationship
Name
Relationship
I DO NOT WISH FOR ANY/ALL OF MY PROTECTED HEALTH INFORMATION TO BE RELEASED, INCLUDING APPOINTMENTS, TREATMENT PLANS, MEDICATIONS, AND ACCOUNT INFORMATION.
Initial the Agreement Above
HIPAA AUTHORIZATION FOR THE USE OR DISCLOSURE OF HEALTH INFORMATION
MY RIGHTS:
I understand that I have the right to revoke this authorization, in writing, at any time, except where uses or disclosures have already been made based upon my original permission. I may not be able to revoke this authorization if its purpose was to obtain insurance. In order to revoke this authorization, I must do so in writing and send it to the appropriate disclosing party.

I understand that uses and disclosures already made based on my original permission cannot be taken back. I understand that it is possible that information used or disclosed with my permission may be re-disclosed by the recipient and is no longer protected by the HIPAA Privacy Standards. I understand that treatment by any party may not be conditioned upon my signing of this authorization (unless treatment is sought only to create health information for a third party or to take part in a research study) and that I have the right to refuse to sign this authorization. I understand that this form allows you to request that we communicate with you in a confidential way. Please use this form to describe the limitations on the use and disclosure of your protected health information. The law states that we are not required to honor your request of limitations, however, if we choose, we will comply with your request unless the information is needed to prove medical treatment, payment, operations, and if legally required by federal or state laws.
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Payment Policy
OKLAHOMA CENTER TOR SPINE & PAIN

Payment Policy

By signing this form you are giving the Oklahoma Center for Spine and Pain Solutions permission to bill your insurance for services rendered in the office. Patients are responsible for copays, deductibles, coinsurance, and services that are not covered by their health insurance plans. Patient responsibility is based on an Explanation of Benefits (EOB) detailing coverage by the patient's insurance company. In the event which you do not have insurance, you understand you will be financially responsible for all visit charges. Medical insurance plan coverage and benefits vary from one plan to another. We do not know each individual plan's benefits. We cannot guarantee coverage, benefits, or payment from insurance companies, even if our office does courtesy benefit verification and gets a quote from insurance companies. Insurances determine coverage and benefits. If you have any questions about coverage and benefits, please be advised to contact your insurance carrier for more information.

With all HMO insurance plans, we require an Insurance and Provider referral.

Self-pay payments, copays, coinsurance, deductible, and past due balances are due upon arrival of appointment. Any outstanding balances must be resolved prior to your next provider visit.

Cancellation Policy

We ask that all patients/clients provide us with a valid credit card upon establishing care to be used for our 'Cancellation Policy.' Patients will be subject to the late cancellation/reschedule/no-show fee if the patient no-shows to their appointment or does not provide 24 hours of advanced notice. In-Office procedures and injections will require 7 business days advanced notice. Surgeries are a special case and require at least 10 business days advanced notice. Your credit card will be charged as follows: Same-Day Reschedule or Cancelation (less than 24 hours in advance): $100 No-Show Office Appointment: $100

No-Show Procedure/Injection: $250 No-Show/Reschedule Surgery within 10 Business Days: $750

Please be assured that all card numbers are kept in a secure password-protected system. By signing

Below, you acknowledge that you understand your financial responsibilities as a patient. You authorize payment in full via your credit card by your signature below for any and all payments due today and on the future dates of services. Please keep your credit card information updated. Questions about cancellation and no-show fees should be directed to the billing department at 405-956-3357. By signing below you acknowledge that you have had the opportunity to ask questions regarding this payment and cancellation policy and have had the opportunity to decline participation with this office. Patient Balance Policy

All balances are due upon receipt of receiving your statement. If the balance is not paid within 10 days of receiving your statement, a $25 fee will be added to your balance.
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New Patient Form

Patient Information

Insurance Information

Emergency Information

Patient History

Your symptoms

Prior treatments included

Prior spine imaging included:

Other Provider You Follow Up With

Please include all prescriptions, herbal supplements, and over-the-counter medication.

Please indicate - Father (F), Mother (M), Daughter (D), Son (S)

Have you filed a claim regarding this injury with any of the following?

If Yes please provide the adjuster's information and receive their approval prior to your visit.

If you answered yes, please provide the following information for the attorney:

Controlled Substance Contract

HIPAA AUTHORIZATION FOR THE USE OR DISCLOSURE OF HEALTH INFORMATION

MY AUTHORIZATION:

HIPAA AUTHORIZATION FOR THE USE OR DISCLOSURE OF HEALTH INFORMATION

MY RIGHTS: