New Patient Information

I hereby give authorization for payment of insurance benefits to be made directly to Burns Family Practice, and any assuming providers for services rendered. I understand that I am financially responsible for all charges whether or not they are covered by insurance. In the event of default I agree to pay all costs of collections and reasonable attorney’s fees. I hereby authorize Burns Family Practice to release all information necessary to secure the payment of benefits. I further agree that a photocopy of this agreement shall be as valid as the original.

By signing below, I authorize Burns Family Practice to charge the credit card above for agreed-upon purchases and fees. I understand that my information will be saved for future transactions on my account. I may cancel this authorization at any time.

The purpose of this agreement is to set out the rules that this office follows in order to prescribed medications that are controlled by the Drug Enforcement Agency (DEA). We are committed to making sure we address your needs while providing you with alternatives designed to minimize the addictive potential of the controlled substance treatments we use. In this regard we may refer you to a pain management program or psychiatrist to ensure you have access to the best, safest treatments available. Controlled substance medications require ongoing prescriptions that have significant addiction potential, so we want to use in the safest way possible. To clarify our expectations in giving you this medication and to emphasize the risk of taking these substances we are requesting you to read and sign this agreement. By signing this you agree and understand that you are being prescribed a controlled substance and must adhere to the following restrictions lined out below. Failure to conform to any of the below listed restrictions may results in being dismissed as a patient and being reported to authorities as applicable.

• I will not use alcohol/illegal drugs while being prescribed controlled medications. I will not take any other prescribed controlled medications without first notifying my PCP.
• I will notify my PCP immediately of any other physician(s) currently prescribing me a controlled substance(s) or that have been prescribed to me in the past thirty days (including ER and urgent care center prescriptions). Legally, failure to do so is a crime (obtaining or attempting to obtain drugs by fraud and/or deceit).
• I will submit to random urine and/or serum drug screens as ordered by my PCP.
• I will only fill prescriptions for controlled substances at the pharmacy I have designated as my primary pharmacy.
• I will inform my PCP of any plans to change pharmacy so that it may be documented and I will not attempt to obtain controlled substances from more than one pharmacy at a time. The only exception will be for acute need outside of the local area or a documented backorder issue.
• I will authorize my PCP to communicate with my pharmacist. I authorize my PCP to communicate with all providers that I have seen.
• I understand that it is illegal to share this medication.
• I agree to keep my medication safe and secure in order to prevent loss or theft. I am aware that if my medication is lost or stolen it will not be replaced unless my PCP decides to with a copy of a completed police report.
• I understand that I will be taken off of this medication if there is any evidence of addiction and/or abuse.
• I understand that some of these medications may cause drowsiness and slowed responses, interfering with the ability to drive and operate machinery, and short and long-term memory impairment.
• I understand that taking more of this medication than prescribed can result in overdose and/or death.
• I agree to keep all scheduled appointments with my PCP. My medication may be weaned and discontinued if I fail to attend my scheduled appointments.
• I also understand that part of my treatment may involve education and discontinuation of any addictive medications. I understand and accept the risk of addiction that can occur with this/these medication(s).
• I authorize this office to release a copy of this controlled substance agreement if requested by the police department. I have not received any other controlled medications from any other provider in the last 30 days, unless otherwise noted below.
• I understand I may be called at any time to the office for a count of all of my remaining medications, I agree to arrive on the day notified and will be responsible for any costs this may incur.
• I waive my right of privacy and authorize my PCP to contact any health care provider, legal authority, or caregiver in order to obtain information about my care.
• No refills will be authorized on weekends, holidays, or after regular office hours. An exception may be made at the discretion of your provider but will not be routinely done.
• I will not allow anyone but myself to retrieve my controlled prescription from the pharmacy.
• I will perform the once yearly required Brain-View/Neuro-Scan testing as required by Burns Family Practice office policy. I understand that if my insurance does not reimburse this, I will be held responsible for a cash pay price of $250 that will be due prior to any further refills.
• I understand I will be the only one allowed to call and request my refills.

I have read the above, asked any questions that might be pertinent, and understand this agreement. If I violate this agreement, I know Burns Family Practice may discontinue my treatment and also may dismiss me as a patient.

Your appointment is very important. We understand that sometimes schedule adjustments are necessary. Therefore, we respectfully require at least 24 hours' notice prior to your scheduled appointment time for cancellations or rescheduling of appointments. Please notify us by answering service/e-mail if your cancellation is outside of our normal business hours or you’re unable to reach us by phone at (979) 297-4507. You may also leave a voicemail on our appointment line.

ALL NO-SHOWS AND ANY APPOINTMENTS CANCELLED, RESCHEDULED, OR CHANGED WITHOUT 24 HOURS' NOTICE WILL BE BILLED TO YOUR ACCOUNT IN THE AMOUNT OF $50. THREE MISSED APOINTMENTS WITHOUT ADEQUATE NOTICE WILL RESULT IN DISMISSAL FROM OUR PRACTICE. NEW PATIENTS WILL REQUIRE A $50 DEPOSIT THAT WILL BE APPLIED TO SERVICES RENDERED.

Please keep in mind that insurance does not reimburse for missed appointments; therefore, you will be responsible for the full payment of the no show fee. These appointment slots could be replaced with a patient that needs them if cancelled adequately and ahead of time. You will be required to pay this fee prior to your next appointment scheduled.

Please remember that it is your responsibility to remember your appointment dates and times in order to prevent any missed appointments. Not receiving an electronic notification of your appointments from us is not sufficient reason to miss an appointment if the original confirmation notification was received timely.

It is mutually understood that if a cancellation is due to circumstances beyond any of our control, such as power outage, unfortunate incidence, illness, or weather that requires you or us to have to cancel or be closed during regular business hours, we will reschedule your existing appointment and no discount or rescheduling fee will apply.

ARRIVAL TIME
Please arrive at your appointment at least 5 minutes prior to your scheduled appointment time. An early arrival allows for a relaxed experience. If you arrive late your appointment may be rescheduled at the provider’s discretion.

LATE ARRIVAL POLICY
If a patient arrives more than 15 minutes late this will be considered a no-show appointment unless agreed on by the provider otherwise.

I have read and understood the cancellation and refund policy and agree to abide by the above conditions.

Any account balances are due prior to any future appointments. Complete payment is due for self-pay patients at the time of services rendered. For any billing questions or concerns, please contact the billing department at (979) 297-4507.

Consent to Treat
I hereby consent for outpatient medical care by Burns Family Practice and authorize Burns Family Practice to provide my medical treatment. I understand that Burns Family Practice will explain my condition(s), foreseeable risks, and methods of treatment for my condition before treatment is rendered. I authorize Burns Family Practice to perform any additional or different treatment that is deemed necessary if, in an emergency situation, a condition is discovered that was known previously.

ConfidentialityDiscussions between you and your provider are confidential. No information will be released without your written consent unless mandated by law. Possible exceptions to confidentiality include but are not limited to the following situations: child abuse; abuse of the elderly or disabled; abuse of patients in mental health facilities; sexual exploitation; criminal prosecutions; child custody cases, suits in which the mental health of a party is in issue; situations where the health care provider has a duty to disclose, or where, in the provider’s judgment, it is necessary to warn, notify, or disclose. If you have any questions regarding confidentiality, you should bring them to the attention of your provider to discuss this matter further.

After-Hour Concerns & Emergencies
As a general rule, it is our belief that important issues are better addressed within regularly scheduled business hours. However, you may contact your provider in between sessions, you may leave a message with the staff, on the answering machine/with the answering service, or through the online portal concerning the nature of your need. Your provider will do their best to respond in a timely manner. Please do not continue to call and leave voicemails as they will reach out to you within the time that their schedule allows. In the event of a medical or psychiatric emergency or an emergency involving a threat to your safety or the safety of others, please call 911 to request emergency assistance. Please be aware that refills will be handled during business hours and will not be conducted on weekends, holidays, or after hours. Please request your pharmacy to send a refill request.

CommunicationBy signing the Informed Consent for Treatment document, you are consenting for Burns Family Practice to communicate with you by phone, e-mail, and at the address provided on your client intake form. You agree to notify us if you need to opt out of any form of communication.

Notice of Privacy Practices Acknowledgement
I acknowledge that I have read the Notice of Privacy Practices provided by Burns Family Practice.

Release the above-identified information to the following physician, person, facility, or entity: BURNS FAMILY PRACTICE, PLLC

By signing this form, I authorize you to release confidential health information about me, by releasing a copy of my medical records, or a summary or narrative of my protected health information, to the physician, person, facility, or entity listed below.

This authorization is valid from the date of signature, unless revoked in writing. You may revoke this authorization at any time by providing written notice to the healthcare provider. However, revocation will not apply to information that has already been released in reliance on this authorization.