New Iberia New Patients

Assignment of Benefits
Patient Name*

First NameMiddle NameLast NameSuffix
Primary Insurance
Policy Number
Secondary Insurance
Policy Number
Patient / Policyholder Social Security # / ID
I hereby assign and authorize payment made directly to the above health provider for covered insurance benefits. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. Any payment made directly to me by my insurance company for services, will be endorsed by me and forwarded to the billing office above. I fully understand that I am financially responsible for and agree to pay all charges not paid by my health coverage, including deductibles, co-insurance and payments from insurance companies sent directly to me. I hereby agree to pay the provider any balance due within 30 days from presentation of my bill. Should my account become delinquent and collection efforts become necessary, I agree to pay all collection or attorney's fees incurred.

I have disclosed the names of all my health insurance providers including secondary and any liability coverage and I represent that such health care coverage is in full force and effect at this time. I have indicated in the record if my pain is the result of an injury or motor vehicle accident. I agree to promptly notify your office of any change of address or changes of insurance coverage. I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in this

This Assignment shall apply to all services now rendered and to be rendered in the future until it is revoked by myself in writing. A photocopy of this Assignment shall be considered as effective and valid as the original.

I have had an opportunity to discuss with the physician or his staff to my satisfaction the nature of the services provided. I acknowledge that no guarantees have been made to me as to the results. I am satisfied that I fully understand this assignment and its significance.

I hereby authorize on my behalf, the provider to appeal any disputed unpaid health claims with the party responsible for payment. I authorize my provider to initiate a complaint to the Insurance Commissioner for any reason on my behalf.
Today's Date*

MonthDayYear
Date

Assignment of Insurance Benefits and Statement of Service
I hereby assign and authorize payment made directly to Radiology Associates of Iberia of the covered insurance benefits, including major medical benefits, whether payable to me by Medicare, Medicaid, or Medigap. I fully understand that I am financially responsible for and agree to pay all charges not paid by my health coverage, including deductibles, co-insurance, and payments from insurance companies sent directly to me. In consideration of the medical services furnished to me, I hereby agree to pay Radiology Associates of Iberia any balance due within sixty days from presentation of my bill. If my account should become delinquent and collection efforts become necessary, I agree to pay any reasonable collection or attorney's fees incurred.

This assignment shall apply to all services now rendered and to be rendered in the future until it is revoked.

I have disclosed the names of all my health insurance providers including secondary and tie-in coverage andI represent that such heath care coverage is in full force and effect at this time.

I authorize the release of medical information as may be required to process the claims for payment of the medical services rendered and it is expressly understood that the right of such information to be privileged is hereby waived.

If prior authorization or certification for medical services is required under my health care coverage, I agree to obtain and furnish such authorization or certification.

I have had an opportunity to discuss with the physician or his staff to my satisfaction the nature of the services provided. I acknowledge that no guarantees have been made to me as to the results. I am satisfied that I fully understand this assignment and significance.

I agree to promptly notify your office of any change of address or changes in insurance coverage.

A copy of this assignment shall be considered as valid as the original.
Type your initials to confirm your agreement.*
Today's Date*

MonthDayYear
Date
Patient's Social Security #*
Patient's Employer-Firm
Today's Date*

MonthDayYear
Date
Guarantor's Name (if different from patient)

First NameMiddle NameLast NameSuffix
Guarantor's Social Security # (if applicable)
Guarantor's Employer-Firm (if applicable)
Primary Insurance
Secondary Insurance

Complete this section if you have a Medigap Insurance Policy (A secondary policy to Medicare)
Medicare Lifetime Medigap Assignment
I assign and authorize payment of Medigap benefits to Houma Radiology for any services furnished to me by them. | authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services (CMS) and its agents any information needed to determine these benefits or the benefits payable for related services.
Today's Date

MonthDayYear
Date
Medigap No.
Medigap Insurer
(This assignment covers the physician's charges for their services. Surgicenter or Hospital charges are billed separately

Acknowledgment of Receipt of Notice of Privacy Practices

I acknowledge that I have received from the Group a copy of a separate document, titled “Notice of Privacy Practices,” which sets forth this Group’s privacy practices and my rights regarding privacy of my protected health information. Review our Privacy Practices here.
Type your initials to accept.*
Today's Date*

MonthDayYear
Date

Disclosure of Ownership
The information provided is designed to disclose ownership and to answer any questions you may have regarding yourmedical care while you are a patient at Headache and Pain Center, AMC, Day Surgery, Inc. or One Day Surgery, LLC.Headache and Pain Center, AMC and all equipment therein is owned and operated by Jimmy N. Ponder, Jr., M.D. Thisincludes open MRI, X-ray, and Bone Density testing. Your provider may order diagnostic tests during your treatment atHeadache and Pain Center, AMC. Advanced Imaging will be performed at Headache and Pain Center, AMC unless younotify us on your first visit.

HOURS OF OPERATION

Headache and Pain Center, AMC operational hours are 7:00 a.m. to 5:00 p.m. Monday and Thursday, 8:00 a.m. to 5:00p.m. Tuesday and Wednesday and 8:00 a.m. to 12:00 p.m. Friday. Except on occasion, Day Surgery, Inc. is closed Tuesdayand Wednesday and open 8:00 a.m. to 4:00 p.m. Monday, Thursday, and Friday. Except on occasion, One Day Surgery,LLC is closed Monday, Thursday, and Friday and open Tuesday and Wednesday 8:00 a.m. to 4:00 p.m. We will make everyeffort to perform scheduled procedures on time.

FEES AND PAYMENT

You will receive separate statements which require separate payment to each company listed below if you are sedatedfor procedures performed at Day surgery, Inc. or One Day Surgery, LLC.
1. Headache and Pain Center, AMC (physician's surgical/professional services
2. Day Surgery, Inc. (for use of the surgical facility in Gray, LA
3. One Day Surgery, LLC (for use of the surgical facility in New Iberia, LA
4. Advanced Anesthesia Services, LLC (if intravenous anesthesia is used for your procedure).
If you have insurance, including Medicare, we will help you receive maximum benefits by filing for you; however, we will expect payment of co-pays, co-insurance, and deductibles at the time of service. The undersigned individual guarantees prompt payment of all charges if the insurance carrier rejects the claim of any charges related to this account whether the above entity is in network or out of network. If charges remain unpaid, it may become necessary to turn the account over to a collection agency or attorney, these fees will be your responsibility.

PERSONAL VALUABLES AND MEDICATIONS

It is understood and agreed that Headache and Pain Center, AMC, Advanced Anesthesia Services, LLC, Day Surgery, Inc., or One Day Surgery, LLC will not be liable for any loss or damage to valuables, including but not limited to money, jewelry, glasses, dentures, fur items, documents, canes, or personal medical equipment or supplies, clothing, shoes or other apparel.
LIVING WILL/ADVANCE DIRECTIVES
Do you have a living will (advance directives)?

YesNo
If yes, please provide a copy in the event you are transferred from our facility to another facility. If no, you may request information or forms regarding living will/advanced directives,alternative facilities, as well as Louisiana law and documents. I understand that the providers have not consented to honora living will/advance directive and will not be liable for its terms.

I have read, or have had read to me, the above information and have received a copy of the Patient Rights and Responsibilities.
Type your initials to confirm your acceptance.*
Today's Date*

MonthDayYear
Date

Patient Intake Form
Today's date*

MonthDayYear
Date
When did your pain begin?
How did you find out about Headache & Pain Center?
Who referred you to us?
Who is your primary care physician family doctor (PCP)?
List your other current doctors:
To which doctors should we send our clinic notes?
Have you seen anyone else for this problem (doctors, therapists, chiropractors)?

YesNo
Who have you seen?

Which treatments have you had for pain?

	Date	It was helpful	By whom?
Epidurals / Nerve Blocks / Other Injections (describe)
Spine or Joint Surgery
Therapy (Physical, Occupational, other)
TENS / Neuromuscular Stimulator
Chiropractor
Biofeedback / Counseling
Acupuncture
*Other

*Describe other treatment:

Which of the following tests have you had to evaluate your pain?

	Date done?	What part of body?	What facility?	Results, if known?
MRI
CAT (CT) Scan
X-Ray
EMG (test for nerve damage)
Myelogram
Bone Scan
Laboratory (blood test)
Bone Density
EKG
Other*

*Explain other test:
Are you ALLERGIC to medications, foods, or latex?

ALLERGIES:

	What medicine?	What happens? (i.e. rash, swollen throat, can't breathe, etc.)
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Ambulatory Surgery Center

Patient Rights and Responsibilities

Patient Rights

Patients have:
1. The right to quality care and treatment given with respect, consideration and dignity.
2. The right to appropriate privacy.
3. The right to the privacy of information regarding patient’s diagnosis, treatment options, communication, and the potential outcomes of the treatment as well as access to information contained in his/her medical record.
4. The right to participate in decisions concerning care and treatment.
5. The right to know if the physician performing his/her procedure may have financial interest or ownership in this ASC.
6. The right to be informed of patient responsibilities, conduct, and ASC rules affecting the patient’s treatment.
7. The right to knowledge of services provided at this facility.
8. The right to discharge instructions, including information about after hours’ care.
9. The right to detailed information regarding service fees and all charges.
10. The right to refuse participation in experimental research.
11. The right to receive the policy on advance directives, and living wills in the facility and to be given information upon request.
12. The right to receive information on this ASC’s non participation in advanced directives.
13. The right to knowledge of the medical staff credentialing process, upon request.
14. The right to know the names of those treating the patient.
15. The right to truthful marketing or advertising utilized by the facility.
16. The right to be informed if the physician does not carry malpractice insurance.
17. The right to address a grievance.
18. The right to refuse a treatment, as permitted by law. One can refuse treatment and still receive alternate care.
19. The right to be fully informed regarding one’s condition.
20. The right to understand and sign an Informed Consent form before receiving care.
21. The right to appropriate assessment and management of pain.
22. The right to continuity of care. If overnight care is required, staff will arrange for transportation of a patient to the transfer hospital.
23. The right to respectful, safe care and treatment free from seclusion, restraints, abuse and harassment.
24. The right to have a family member notified of his/her admission as well as notification of his/her personal physician, if requested by the patient.
25. The right to leave the facility against the advice of his/her physician.
26. The right to express spiritual and cultural beliefs.
27. You have the right to exercise the above without being subjected to discrimination or reprisal.
Patient Responsibilities
1. The patient is responsible for providing accurate/complete information related to his/her health; reporting perceived risks in his/her care, and for reporting unexpected changes in his/her health.
2. The patient and family are responsible for asking questions when they do not understand, what a staff member has told them about the patient’s care or expectations of what they are to do.
3. The patient is responsible for following the treatment plan established by his/her physician, including the instructions of nurses and other health professionals as they carry out the physician’s orders.
4. The patient is responsible for notifying the ASC office when unable to keep a scheduled appointment.
5. The patient is responsible for providing his/her healthcare insurance information, and assuring the financial obligations of his/her care are fulfilled as promptly as possible.
6. The patient is responsible for the consequences if he/she refuses treatment or fails to follow the practitioner’s instructions.
7. The patient is responsible for being respectful and considerate of other patients and organizational personnel.
These rights and responsibilities outline the basic concepts of service here at the Ambulatory Surgery Center. If you believe, at any time, our staff has not met one or more of the statements during your care here, please ask to speak to the Medical Director or Nurse Manager. We will make every attempt to understand your complaint/concern. We will correct the issue you have if it is within our control, and you will receive a written response.

Kristen Cole, RN, DON
One Day Surgery, LLC
531-B Jefferson Terrace Blvd.
New Iberia, LA 70560-4949
337.560.0880

Jenny Haines, Certified Program Manager (DHH)
P.O. Box 3767 Baton Rouge, LA 70821-0629
Phone: 225.342.9348
Fax: 225.342.0157
Complaints can also be filed online through the LA Department of Health and Hospitals website:
http://www.dhh.louisiana.gov

Karen Price, Medicare Beneficiary Ombudsman for Louisiana
Phone: 225.342.7100
Web site for the Office of the Medicare Beneficiary Ombudsman: visit www.medicare.gov, or call 1-800-MEDICARE (1-800-633-4227) or use www.cms.hhs.gov/center/ombudsman

Patient's Demographic Information
Todays Date*

MonthDayYear
Date
Patient's Name*

First NameMiddle NameLast NameSuffix
Spouse's Name

First NameMiddle NameLast NameSuffix
Sex
Patient's Date of Birth*

MonthDayYear
Date
Patient's Age*
Patient's Social Security #*
Patient's Home Phone #
Patient's Cell Phone #
Patient's Email Address
example@example.com
Patient's Employer
Patient's Work Phone #
Self Employed?
Patient's Occupation
Primary Insurance
Secondary Insurance
Guarantor's Name (if different from patient)

First NameMiddle NameLast NameSuffix
Guarantor's Social Security #
Guarantor's Employer
Guarantor's Work Phone #
Was this condition due to an accident?*

YesNo
Date of Accident

MonthDayYear
Date
Do you currently have any open claims?*

YesNo
If yes, please give detailed information.
Workers' Compensation?*

YesNo
Through Whom:
Attorney or Liability Insurance?*

YesNo
Through Whom:
This form was read and completed by whom?*

HEADACHE & PAIN CENTER, AMC

AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION

You may refuse to complete this authorization.
Patient's Name

First NameMiddle NameLast NameSuffix
Patient's Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient's Date of Birth

MonthDayYear
Date
Patient's Social Security #
Facility / Provider Name
I hereby authorize:
Facility Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Facility Phone #
Facility Fax #
To release copies of my health information, specifically:

Any & all recordsOnly the following testOnly the following dates of treatmentOther specific information
Only the following test:
Only the following dates of treatment:
Other specific information:
To:

Facility/Provider Name: HEADACHE & PAIN CENTER, AMC

Address: 531-A Jefferson Terrace Blvd., New Iberia, LA 70560

Phone #: (337) 560-0880 Fax #: (337) 560-0870
Purpose of Disclosure:

The Patient Must Read and Initial the Following Statements:
Your initials* I understand that my healthcare and payment for my healthcare will not be affected if I do not sign this form.
Your initials* I understand that I may see and copy the information described on this form if I ask for it, and that the Headache & Pain Center, AMC, will give me a copy of this form after I sign it.
Your initials* I understand that if the organization authorized to receive this information is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations.
Your initials* I understand that I may revoke this authorization at any time by notifying the Headache & Pain Center, AMC, in writing, but if I do revoke it, the revocation will not have any affect on any actions the Headache & Pain Center, AMC, took before it received the revocation.
Today's Date*

MonthDayYear
Date
Printed Name of Patient*

First NameMiddle NameLast NameSuffix

Cancellation Policy

HEADACHE & PAIN CENTER, A MEDICAL CORPORATION
DAY SURGERY, INCORPORATED
ONE DAY SURGERY, LLC

Headache & Pain Center, A Medical Corporation:

Clinic appointments must be cancelled 24 hours before the scheduled appointment. Failure to do so will result in a $30.00 charge.

MRI appointments must be cancelled 24 hours before the scheduled appointment. Failure to do so will result in a $100.00 charge.

Day Surgery, Incorporated and One Day Surgery, LLC:

Scheduled surgery appointments must be cancelled 24 hours before the scheduled appointment. Failure to do so will result in a $100.00 charge.

All charges will be billed directly to the patient.
Type your initials to acknowledge that you have read the cancellation policy.*
Today's Date*

MonthDayYear
Date
Name of Patient or Legal Representative*

First NameMiddle NameLast NameSuffix
Should be Empty:

	Medication & Dose	How do you take it?	Why prescribed?	Doctor who prescribed it?
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Assignment of Benefits

Assignment of Insurance Benefits and Statement of Service

Medicare Lifetime Medigap Assignment

Headache & Pain Center, AMC Day Surgery, Inc. / One Day Surgery, LLC

Authorization to Disclose Protected Health Information (PHI)

Acknowledgment of Receipt of Notice of Privacy Practices

Disclosure of Ownership

HOURS OF OPERATION

FEES AND PAYMENT

PERSONAL VALUABLES AND MEDICATIONS

Patient Intake Form

Where is your pain?

Medications

Medical History

Headache Questions

Ambulatory Surgery Center

Patient Rights and Responsibilities

Patient's Demographic Information

HEADACHE & PAIN CENTER, AMC

AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION

To:

The Patient Must Read and Initial the Following Statements:

Cancellation Policy