New Patient Paperwork

I certify that the above information is accurate, complete, and true. I authorize Arkansas Spine and Pain and any associates, assistants, and other health care providers it may deem necessary, to treat my condition. I understand that no warranty or guarantee has been made of a specific result or cure. I agree to actively participate in my care to maximize its effectiveness. I give my consent for Arkansas Spine and Pain to retrieve and review my medication history. I understand that this will become part of my medical record. I acknowledge that I have had the opportunity to review the Notice of Privacy Practices of Arkansas Spine and Pain, which is displayed for public inspection at its facility and on its website. This Notice describes how my protected health information may be used and disclosed, and how I may access my health records. I authorize the Arakansas Spine and Pain to release my Protected Health Information (medical records) in accordance with its Notice of Privacy Practices. This includes, but is not limited to, release to my referring physician, primary care physician, and any physician(s) I may be referred to. I also authorize Arkansas Spine and Pain to release any information required in obtaining procedure authorization or the processing of any insurance claims. I understand that Arkansas Spine and Pain will not release my Protected Health Information to any other party (including family) without my completing a written “Patient Authorization for Use and Disclosure of Protected Health Information” form, available at its facility and on its website. In the event that I am asked to provide a urine, saliva and/or blood sample, I voluntarily seek laboratory services and hereby consent to provide a urine, saliva and/or blood sample as requested. I have the right to refuse specific tests but understand this may impact my pain management treatment. This agreement can be revoked by me at any time with written notification and is valid until revoked. I hereby assign to the Laboratory my right to the insurance benefits that may be payable to me for services provided, arising from any policy of insurance, self-insured health plan, Medicare, or Medicaid in my name or in my behalf. I further authorize payment of benefits directly to the Laboratory. I understand that acceptance of insurance assignment does not relieve me from any responsibility concerning payment for laboratory services and that I am financially responsible for all charges whether or not they are covered by my insurance. I also acknowledge that the Laboratory may be an out-of-network provider with my insurer. Payment in full is expected 30 days of being notified of any balance due. Please note that in the event that you fail to make payment when due, this account will be referred to a collection agency for collections. In that event, the contingency fee assessed by the collection agency will be added to the principal and interest due. You will be additionally liable for attorney fees. Both collection agency fees and attorney fees will increase the balance you owe.

I acknowledge that I have provided you with the most accurate and complete information about my medical history to the best of my ability.

We understand that situations may arise which makes it necessary to cancel your appointment. Accordingly, we request that you provide at least 24-hour notice of cancellation to avoid any fees. This will enable the physicians to offer that time slot to other patients who need care. Appointments with our specialists are in high demand, and your early cancellation will give another person access to timely medical care.

The Cancellation and No-Show fees are the sole responsibility of the guarantor and cannot be billed to the insurance company.

Cancellation Fees:

• Any appointment not cancelled 24 hours prior to the appointment time are subject to a $40.00 cancellation fee.
• Any procedure appointments (in a surgery center) not cancelled 48 hours prior to the scheduled appointment time are subject to a $100.00 cancellation fee.

No-Show Fees:

Patients who do not show up for their appointment and who do not call the office to cancel/reschedule, will be considered a No-Show and are subject to a No-Show fee. Patients who “No-Show” for two or more appointments within a 12-month period may be dismissed from the practice.

• $50.00 New Patient No-Show fee
• $40.00 Established Patient No-Show fee
• $100.00 Surgical Procedure (performed outside of office at surgery center) No-Show fee

 Payments can be made directly to our Billing Office (501-227-0184)

Welcome to Arkansas Spine and Pain. This document contains the Opioid and Controlled Medications Agreement/Contract, the Informed Consent for the Treatment of Chronic Pain with Opioid Pain Medications, and the Opioid Therapy Statement. If you plan to ask for an opioid or other controlled substance for the treatment of your pain, then please read all three of these documents carefully and sign or initial where indicated. If you have any questions, please do not hesitate to ask a provider or staff member.

Arkansas Spine and Pain is a comprehensive pain clinic which includes medication management and the full range interventional procedures. To ensure patient safety and optimize outcomes we require our patients to receive their care from only one pain practice. Hence, if we are providing medication management, we also require patients to undergo interventional procedures with us as well.

At Arkansas Spine and Pain, it is the goal of our physicians and staff to help give you your life back by reducing your pain and improving your daily functioning. We accomplish these goals with customized, safe, comprehensive, and effective treatment plans that reduce risks and maximize benefits.

To protect our patients from the significant risks associated with opioid therapies including addiction, we follow recommendations and applicable guidelines from the Drug Enforcement Agency (DEA), Colorado state regulatory agencies and the Colorado Medical Board regarding the safe and responsible prescribing of these medications. We first try non opioid medications and other treatments before progressing to treating pain with opiates. Furthermore, we only prescribe opioid medications if, after thorough screening, risk stratification from the forms you fill out, and after thorough history and physical, we determine that a patient’s pathology warrants their use, they meet specific criteria, and other treatment options, including alternative non-opioid pain medications, have failed to achieve satisfactory results.

The opioid therapy statement and patient agreement serve to document that both you and your clinician agree on a care plan so that controlled substances are used in a way that is safe and effective in treating your pain.

Arkansas Spine and Pain takes a conservative approach to opioid therapy. Depending on a patient’s specific situation, these medications may not be prescribed at all, may be prescribed at a lower dose, or changed to a safer, more appropriate alternative opioid. Research results continue to demonstrate conflicting evidence for the longterm use of opioid medications for chronic non-cancer pain. High doses or ever-escalating doses can result in a greater risk of physical dependence, tolerance addiction, and increased pain (opioid induced hyperalgesia). The lowest effective dosage of opioids used in conjunction with non-opioid medications in concert with pain management procedures, physical therapy, mental health therapy and other conservative treatments have been shown to produce the best long-term, effective results.

We track our treatment outcomes to do our best to ensure that our patients are being helped. We are proud of our results and believe that if you suffer from chronic pain, we can help you. We provide a multidisciplinary approach to pain management that is safe, minimally invasive, and clinically proven to be effective.

Side Effects of Opioid Medications

I understand that the medication I will be taking may cause side effects to include, but not limited to sleepiness or drowsiness, constipation, inability to urinate, nausea, vomiting, dizziness, an allergic reaction, immune suppression, hormone deficiencies, sexual problems, lack of coordination, kidney or liver disease, and bone thinning/weakness. Furthermore, the medication may cause my reflexes and reaction time to slow down. Finally, the medication may cause my breathing to become shallow and slower, leading to decreased oxygen supply to my body, which may lead to permanent neurological, mental, cognitive, and physical deficits and possibly death.

I have read, understand, and acknowledge the Arkansas Spine and Pain Opiate Therapy Statement.

Right to Discontinue Treatment or Medication

I understand that I may discontinue using my medication at any time and I agree to notify physician and/or his staff immediately upon discontinuing the use of my medication. I understand that I may be provided supervision if needed by my physician and/or his staff if I choose to discontinue my medication. In this situation, alternative care by other pain or addiction providers will be suggested and you would then be released of this agreement.

I know that these opioid and controlled medications will be stopped by the Arkansas Spine and Pain providers if any of the following occurs:

• I trade, sell, give away, misuse, or abuse these medications.
• I do not present immediately for a blood, urine or saliva test, or pill count, if requested by Arkansas Spine and Pain. I will authorize Arkansas Spine and Pain staff to count my pills if necessary.
• My blood, urine, or saliva tests show the presence of controlled or non controlled medications that have not been previously reported to Arkansas Spine and Pain, the presence of illegal drugs or alcohol, or fail to show opioid and other controlled medications that I am being prescribed by Arkansas Spine and Pain.
• I receive prescriptions for opioid and controlled medications from sources other than Arkansas Spine and Pain, unless arranged and discussed previously with my Arkansas Spine and Pain physician or provider.
• Any member of the professional staff at Arkansas Spine and Pain feels that it is in my best interest, from a safety or accountability standpoint, that opioid and controlled medication treatment be discontinued.
• I demonstrate ANY aggressive, belligerent, or unacceptable behavior toward any physician, provider, patient, or staff member at Arkansas Spine and Pain.
• I consistently miss scheduled appointments at Arkansas Spine and Pain, including office visits and procedures scheduled at Arkansas Spine and Pain or any other facility utilized by Arkansas Spine and Pain.
• Illicit Drug use (i.e., cocaine, methamphetamine, heroin, kratom).
• Misrepresenting or lying about medical history including not disclosing risks to addiction such as family history of abuse, prior abuse of drugs or alcohol, or prior military experience.

My signature indicates that I understand and agree to abide by each issue displayed on this page and I understand that if I fail to abide to any issue displayed on this page, I may be discharged from this clinic.

I attest that I have explained each issue displayed on this page to said patient and said patient indicated their understanding of each issue by signing each indicated area on this form.