NOTE: We will bill your secondary insurance as a courtesy. If claims are not paid within 60 days the balance will be transferred to patient responsibility.

My signature below indicates that I have been given the chance to read and review the following and understand and agree to their terms:

*Patient Acknowledgement Form (see page 2)

*Financial Policy, Consent for Treatment, and Release of Medical Information Form (see page 3)

*Notice of Privacy Practices at my discretion (located at front desk).

I agree that the above information is true and I authorize Procura Pain and Spine to use this information to obtain financial reimbursement. Additionally, I authorize Procura Pain and Spine to administer treatment and perform procedures as may be deemed necessary or advisable in my diagnosis. I further authorize the release of any medical information necessary to process my insurance claim and request payment of medical services to be assigned directly to Procura Pain and Spine. In the event my insurance does not cover services rendered, I agree to be personally and fully responsible for payment. This authorization is to remain in full force unless I revoke the same in writing.

Use the pain scale described below to rate your pain for the questions below:

0. Pain-free

1. Very minor annoyance, occasional minor twinges

2. Minor annoyance, occasional strong twinges

3. Annoying enough to be distracting

4. Can be ignored if you are really involved in your work/task, but still distracting

5. Cannot be ignored for more than 30 minutes

6. Cannot be ignored for any length of time, but you can still go to work and participate in social activities

7. Makes it difficult to concentrate, interferes with sleep, but you can still function with effort

8.Physical activity is severely limited. You can read and talk with effort. Nausea and dizziness caused by pain.

9. Unable to speak, crying out or moaning uncontrollably, near delirium

10. Unconscious, pain makes you pass out

I understand that the patient's health information is private and confidential. I understand that Procura Pain & Spine works very hard to protect the patient's privacy and preserve the confidentiality of the patient's personal health information. Procura Pain & Spine displays a copy of their "NOTICE OF PRIVACY PRACTICES" in every office location.

I understand that Procura Pain & Spine may use and disclose the patient's personal health information to help provide health care to the patient, to handle billing and payment, and to take care of other health care operations. In general, there will be no other uses and disclosures of this information unless I permit it. I understand that there may be situations where Procura Pain & Spine is required by federal, state, or local law to release this information without my permission. One example would be in response to a warrant, summons, court order, subpoena or similar legal process.

Procura Pain & Spine has a detailed document called the "NOTICE OF PRIVACY PRACTICES". It contains more information about the policies and practices protecting the patient's privacy including other potential disclosures and uses of patient's health information. I understand that I can receive a copy of this document at any time of my choosing. One example would be disclosure of health information for research purposes. I understand that I have the right to read the "NOTICE OF PRIVACY PRACTICES" before signing this Acknowledgment. Procura Pain & Spine may update this Acknowledgment and "Notice of Privacy Practices". If I ask, Procura Pain & Spine will provide me with the most current "Notice of Privacy Practices". Within this Notice of Privacy Practices is contained a complete description of my privacy/confidentiality rights. These rights include, but are not limited to, access to my medical records; restrictions on certain uses; receiving an accounting of disclosures as required by law; and requesting communication be by specified methods of communications or alternative locations.

Procura Pain & Spine has established procedures that help them meet their obligations to patients. These procedures may include other signature requirements, written acknowledgments, and authorizations; reasonable time frames for requesting information; charges for copies and non- routine information needs; etc. I will assist Procura Pain & Spine by following these procedures if I choose to exercise any of my rights described in the "Notice of Privacy Practices".

Thank you for choosing Procura Pain & Spine as your health care provider

*PLEASE READ CAREFULLY*

You and your insurance carrier are responsible for your bill. Knowing your insurance plan benefits is your responsibility.

If you have medical insurance, we are anxious to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance and your understanding of our financial policy.

• Insurance information must be presented/updated at the time of making your appointment not at the time of service. Most insurance companies have requirements for authorization of services and/or referrals from the Primary Care Provider prior to the services. If you present for your appointment and you have not provided your correct insurance to ensure verification, authorization of services and all required referrals you will not be seen and your appointment will be rescheduled.
• Payment in Full for non-insurance services is expected at the time of service. Co-payments for services are required at the time of registration. Please be advised that we are contractually obligated by your insurance carrier to collect your co-payment at the time of service. If you arrive without the ability to pay for your services or your co-pay you will not be seen and your visit will be rescheduled.
• If you have insurance, as a courtesy to you, we will file your primary and secondary insurance claim for services at no cost to you. However, we will not wait more than 45 days for the insurance to pay. After 45 days it is your responsibility to contact your insurance company and follow up on why your claim has not been paid. You must take the necessary action required to get your claim paid and communicate your actions to our office. Failure to assist our office in timely payment of your insurance claim will result in the total charges being transferred to patient liability. Any patient liability assigned to you by your insurance carrier will be billed to you. Once insurance has paid, payment in full of the patient assigned liability will be expected with the receipt of your statement. You will receive two billing statements regarding your balance. If we do not hear from you after these two statements, your account will be subject to our collection process unless prior arrangements are made with our financial office.
• Procura Pain & Spine is committed to providing the highest quality care for our patients and we charge what is usual and customary for our area. You are ultimately responsible for all clinic and surgery fees relating to your care. You are responsible for payment regardless of your insurance company's arbitrary determination of usual and customary rates. Your insurance policy is a contract between you and your insurance company. Any disagreement you have concerning the amount your insurance pays should be directed to your insurance company.
• Procura Pain & Spine is not contracted with Texas Traditional Medicaid. You will be responsible for your 20%Medicare coinsurance. This does not apply if you have Texas Medicaid QMB.
• Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover or which they may consider medically unnecessary, and, in some instances, you will be responsible for these amounts. Your policy may also contain plan specific limitations that apply to referrals, referral dates and number of visits. We will make every effort to ascertain your coverage for our services before treatment and will make you aware of our findings. However, this does not guarantee payment from your insurance carrier. The contract of coverage is between you and your insurance carrier and it is your responsibility to understand your coverage, coverage requirements and limitations due to the variations between policies. You will be expected to pay for the patient liability assigned to you by your insurance carrier.
• For services that are not covered by insurance, the practice requires payment of 100% of the total estimated charges unless prior payment arrangements have been set up with our office.
• Insured individuals electing to be self-pay. The patient has the right to elect not to file their health insurance and elect to be a self-pay patient for services provided. The patient will be financially responsible for charges incurred and payment will be due at the time of service. After services have been rendered, the patient will not be able to file their health insurance for the services due to insurance claim submission requirements. Procura Pain & Spine will not file insurance for any services where the patient elected to be self-pay. The patient's election to not file the services to their insurance company does not affect or reduce any out of pocket financial responsibility for future services as determined by their insurance plan.
• If you do not have insurance coverage for the service, are self-pay, or have insurance that Procura Pain & Spine does not participate in or accept, payment is expected at the time of service. Procura Pain & Spine has established a discounted self-pay rate for our services. Prior financial arrangements must be made and approved before your visit if you cannot pay 100% at the time of service. No discount of assigned insurance patient liability (co-pay, deductibles, co-insurance) will be made to comply with federal insurance regulations and law. If financial arrangements have not been made and you arrive without the ability to pay for the services you will not be seen and your visit will be rescheduled.
• Out of Network Insurance - Some insurance plans require you to pay different out-of-pocket amounts based on the provider and/or location where the service is performed. Deductibles, co-insurance and co- payments may also apply according to your insurance plan. By law, you are responsible for these amounts, as well as any non-covered services outlined in your health plan. It is your responsibility to inquire about any plan specific coverage limitations with your insurance company. You can choose to have the services performed as "Out of Network" or as self pay. You may also apply for financial hardship review if the "Out of Network" patient liability exceeds your ability to pay.
• Insurance information provided after the services have been provided will be billed or not billed at the discretion of Procura Pain & Spine. Due to the insurance contractual requirements for referrals, authorization of services and timely filing limitations insurance must be presented prior to services being provided. If Procura Pain & Spine agrees to bill your insurance you will be held liable for the charges if the insurance denies your claim as untimely because of late presentation of coverage or for lack of timely authorizations or referrals.
• Patients who request payment arrangements and/or financial hardship adjustments are required to supply financial documentation to support their request. Financial documentation will include income and expenses as outlined on our financial assistance application. Failure to supply the required documentation will result in normal collection activity being adhered to.
• In the event your account/s must be turned over for outside collections, you will be billed and are responsible for all fees involved in the collection process. Returned checks are subject to a handling fee of $30.00
• Please note that our office charges $50.00 for missed appointments and $100.00 for missed procedures. Please contact our office 24 hours in advance to reschedule your appointment in order to avoid this fee.
• You will be charged a $25 fee per call for excessive phone calls (3 or more) within a 24-hour period. If we do not answer, please leave a message on the proper voicemail when prompted.
• In the event you have an account with a credit balance, we reserve the right to transfer credits to any other outstanding account balances prior to issuing a refund.
• Patients with a history of presenting for their appointment without the ability to pay their co-pay, short notice (less than 24 hours) cancelling of appointment or not showing up for their appointments will be subject to review for dismissal from our practice.
• We do not complete disability/FMLA paperwork or provide parking placards.

We realize that temporary financial problems do occur. If such problems do arise, we encourage you to contact us promptly for assistance. If you have any questions about the above information, or any uncertainty regarding your insurance coverage, PLEASE do not hesitate to ask us.

Authorization: I hereby authorize Procura Pain & Spine to administer treatment, diagnostic testing and perform procedures as may be deemed necessary or advisable in my diagnosis. I further authorize the release of any medical information necessary to process my insurance claim and request payment of medical services to be assigned directly to Procura Pain & Spine. In the event my insurance makes payment directly to me for services I will immediately endorse and assign the payment to Procura Pain & Spine. If my insurance does not cover services rendered, I agree to be personally and fully responsible for payment. I give Procura Pain & Spine permission to appeal any denials by my insurance for services rendered on my behalf. I will assist Procura Pain & Spine with follow up of timely payment, requests for information and appeals to my insurance as necessary to ensure full and timely payment for services received.

 

I have read Procura Pain and Spine Financial Policy, Consent for Treatment, Release of Medical Information, and understand and agree to each document's terms. This authorization is to remain in full force unless I revoke the same in writing.

I agree to and accept the following conditions for my pain management:

** Your initials are required next to each statement in the space provided

 

I have thoroughly read, understand and accept all of the above provisions. Any questions I had regarding this agreement have been answered to my satisfaction. I understand all the policies regarding the prescribing and use of opioids and other medications. I agree to comply with the pain management program. I also agree to testing physiological, toxicology and/or psychological and detoxification if indicated.

Your physician understands that emergencies can occur and under some circumstances exceptions to these guidelines may be made. Emergencies will be considered on an individual basis.

Lack of strict adherence to any provision of this agreement by your physician in no way invalidates any other provisions of this agreement.

If at any time you are concerned about your medication or side effects of your medication, you may call the office at 713-714- 1399.

Telemedicine Services

Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care and satisfaction. Providers may include primary care practitioners, specialists, and/or subspecialists. The information provided during a telemedicine visit may be used for diagnosis, therapy, follow-up, and/or education, and may include any of the following:

• Patient medical records
• Medical images
• Live two-way audio and video
• Output data from medical devices and sound and video files

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Expected Benefits

Expected benefits of telemedicine health services may include the following:

• Improved access to medical care by enabling the patient to communicate with the physician or other practitioner at a distance.
• More efficient medical evaluation and management of health conditions.
• Obtaining expertise of a distant specialist.

Possible Risks

As with any health care service, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:

• In rare cases, information transmitted may not be sufficient (e.g. poor image resolution) to allow for appropriate medical decision-making by the physician or other practitioner, which may necessitate an in-person medical evaluation.
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment. In the event of an equipment failure, the physician or other practitioner will make a determination as to whether or not the visit can be continued via telephone. If it is determined that a telephone call is insufficient, the physician or other practitioner may determine that the appointment should be rescheduled.
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information.

By signing this form, I understand:

1. The laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to other health care entities without my consent.

2. I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.

3. I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction, and may receive copies of this information.

4. A variety of alternative methods of medical care may be available to me, and I may choose one or more of these at any time. My physician has explained the alternatives to my satisfaction. My physician may require that I schedule an in-person medical evaluation to follow up in certain

5. Telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas.

6. It is my duty to inform my physician of electronic interactions regarding my care that I may have with other health care practitioners.

7. I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.

Notice Concerning Complaints

Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018. Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353. For more information, please visit the Texas Medical Board website at www.tmb.state.tx.us.

Patient Consent to Use of Telemedicine

I have read and understand the information provided above regarding telemedicine, have discussed it with my physician, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care.

I hereby authorize the performing provider to use telemedicine in the course of my diagnosis and

COPAYS AND DEDUCTIBLES ARE DUE AT THE TIME OF SERVICE

PLEASE NOTE THAT WE DO CHARGE THE FOLLOWING FOR ANY CANCELLED AND NO- SHOW APPOINTMENTS THAT ARE NOT CANCELLED WITHIN A 24-HOUR PERIOD.

$50.00 - OFFICE VISITS & CONSULTS

$100.00 - SURGICAL PROCEDURES

NOTICE TO PATIENTS REGARDING DRUG TESTING

Our clinic will do its best to send your Urine, Blood, and Toxicology samples to a facility that is in-network with your insurance plan. Please note that Procura Pain and Spine has NO FINANCIAL INTEREST with any of the following:

• Sagis
• Tribal Diagnostics
• FirsTox Laboratories
• North Lakes Pain Consultants
• Quest Diagnostics
• LabCorp Services

All questions regarding your invoice should be directed directly to the Testing Facility.

PHYSICIAN DISCLOSURE OF FINANCIAL INTEREST

Thank you for the opportunity to provide your interventional pain, medication management, behavioral health and wellness needs. We are committed to assuring your complete satisfaction.

The purpose of the disclosure¹² notice is to inform you that we, the physicians at Procura Pain and Spine have financial interests in the following facilities in Texas - North Pines Surgery Center & Essential Imaging.

You have the right by law to choose the provider of your health care services as well as the option of utilizing an alternate medical facility, monitoring or implant company. You will not be treated differently by your physician if you choose to obtain health care services at another facility, or to utilize another monitoring or implant company, if applicable. We welcome you as a patient and value our relationship with you.

By signing this Disclosure, you acknowledge that you have read and understand the foregoing notice and hereby understand that your physician has a financial interest in the listed facilities and acknowledge the above stated fees & services.

1 Texas Administrative Code § 190.8(2H)

2 American Medical Association E-8.03

The protected health information may be disclosed to: Procura Pain & Spine.

This protected health information is being used or disclosed for the following purpose(s): EVALUATION AND TREATMENT

I understand that, as set forth in the Pain Addiction Consultants' Privacy Notice, I have the right to revoke this authorization, in writing, at any time by sending written notification to:

Procura Pain and Spine, PLLC

111 Vision Park Blvd, Suite 100

Shenandoah, Texas 77384

SEE PRIVACY NOTICE CONCERNING ADDITIONAL DISCLOSURE INFORMATION

I understand that I have a right to:

1. Inspect or copy my protected health information to be used or disclosed as permitted under fereal/state law.

2. Refuse to sign this authorization.

 

I authorize Procura Pain and Spine to discuss and/or disclose my health information with the following person(s) listed below:

I understand that this information may include any and all: treatment plans, medication issues, history of acquired immunodeficiency syndrome (AIDS), sexually transmitted diseases, human immunodeficiency virus (HIV) infection, behavioral health service/psychiatric care and evaluations, treatment for alcohol and/or drug abuse, or similar conditions.

The following information should not be released:

This form is valid for one year from patient signature date.