pohlmanpainassociates.com - New Patient Form

NOTICE OF PRIVACY ACKNOWLEDGEMENT/ AUTHORIZATION FOR RELEASE OF CONFIDENTIAL MEDICAL INFORMATION

I understand that under Florida Law, the classification of records relating to treatment rendered to me are privileged and confidential and cannot be released to me or those designed by me or any legal guardian without an expressed and informed consent. In addition, I understand that those records will not be released to persons and agencies other than those designed by my personal representative or me or otherwise provided by Florida Law.
PATIENT NAME:
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PT’S ADDRESS:

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I authorize the release of my health records to Pohlman Pain Associates LLC as well as: Type a label Other: Name of Physician, Facility, Hospital, or Person

I authorize release of information covering treatment dates of Date to Date
The type and amount of information to be disclosed is as follows:

Entire Medical records,History and PhysicalLaboratory ReportsConsultationRadiology ReportsOperative ReportStress TestDischarge SummaryOther
(INITIALS) I understand that I have the right to withdraw my authorization at any time except to the extent that action has already been taken pursuant to this information. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the Medical Records Dept.

(INITIALS) I understand that authorizing the disclosure of this health information is voluntary, the information disclosed may be subject to re-disclosure by the recipient and is no longer protected by federal confidentiality laws.
I understand that under the health insurance Portability & Accountability Act of 1996 (HIPPA), I have the right to privacy regarding my protected health information. I understand that this information can and will be used to:
- Conduct, plan and direct my treatment and followup among multiple healthcare providers who may be involved in my treatment directly and indirectly.
- Obtain payment from third party payers. (e.g., Medical Insurance)
- Conduct normal healthcare operations such as quality assessment and physician certification.
I have reviewed and read your notice of Privacy practices. If I choose to, a complete copy of the Privacy Policy is available for me to keep. I understand that Pohlman Pain Associates LLC has the right to change its Notice of Privacy Practices from time to time, and I may review it any time. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or healthcare operations.
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Payment Policy/YOU MAY BE FINANCIALLY RESPONSIBLE!

Please read and sign this form as it concerns you, the patient….
You are responsible for your insurance policy.

Due to the many changes in insurance policies, we cannot be responsible for interpreting each individual policy. It is your responsibility to know your coverage and its limitations, as well as who is a provider on your plan. We advise you to check with your insurance company regarding your benefits package. Failure to comply could result in you, the patient, being responsible for all costs incurred. Remember that your insurance policy is a contract between you and your insurance company. It is your responsibility to know or find out, whether we are providers for your specific network.
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NO SHOW POLICY
This policy has been established to help us serve you better. It is necessary for us to make appointments to see our patients as efficiently as possible. When an appointment is made, it takes an available time slot away from another patient.No-shows and late-cancellations delay the delivery of healthcare to other patients, some who are quite ill. A “no-show” is missing a scheduled appointment.

We understand that situations such as medical, family or work emergencies occasionally arise. These situations will be considered on a case-by-case basis. Please understand that insurance companies consider this charge to be entirely the patient’s responsibility.

OFFICE VISITS: A CHARGE OF $25.00 WILL BE ASSESSED FOR EACH NO-SHOW.
PROCEDURES: (OUTPATIENT AND IN-OFFICE) A CHARGE OF $100.00 WILL BE ASSESSED
FOR EACH NO-SHOW OR LATE CANCELLATION (WITHIN 48 HOURS).
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PATIENT SIGNATURE

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FYI…

Referrals: If you are required to obtain a referral from your insurance company or from your primary physician to be seen in this office, the referral must be present at the time of your visit. If it is not available, it will be your responsibility to obtain a referral. You will need to reschedule
your appointment should a referral not be available. We request you call your primary care physician and have your referral faxed to us. Our fax number is (754) 229 - 3866.

Nonparticipating Provider Policy: If we are not a provider for your insurance company, we will collect the fee in full at the time of service

Your Financial Responsibility: you are responsible for payment of any copayments, coinsurance, deductibles, and non-covered services at the time of service. Because we are specialist, some diagnostic invasive procedures are not considered part of your office visit co-payment and may be applied to your deductible and/or coinsurance.

Please call your insurance company and learn coverage. It may save you a lot of confusion and expense.

Pohlman Pain Associates (PPA) Opioid Contract
Pohlman Pain Associates understands that your pain is a significant hindrance to the quality of life you desire. To help you achieve your goals we may utilize oral narcotics or other medications supplemented with the procedures you receive here. Narcotics have a long history of safety when used in the proper manner. Side effects can include, but not limited to, constipation, urinary retention, itching, nausea, and sometimes confusion. Addiction to narcotics may occur with use over several weeks; therefore, we must weigh the risks versus benefits before using these medications. We will discuss these with you when they are prescribed, and your pharmacist will also give you more information. It is important to take all medications in the way that they are prescribed by your PPA physician. Taking more medication than is prescribed for you can result in, but not limited to, respiratory failure, cardiac arrhythmias. GI bleed and/or death. Please be certain to take your medications as prescribed. Listed below are the conditions you must adhere to be under the care of the PPA. If any of these rules are broken, we reserve the right to dismiss you from our care.
NAME:
SIGNATURE:

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DATE:

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PHARMACY NAME:
PHARMACY PHONE NUMBER:
Please enter a valid phone number.
PHARMACY CROSSROADS:
PLEASE INITIAL ALL OF THE FOLLOWING STATEMENTS
- I agree to take my medication as prescribed. If my pain level increases such that I need to increase my dosage, I will call the PPA and discuss this with a nurse or physician. If given narcotic medications from PPA, I will receive these only from PPA for the duration of my care. Initial
- I will take no other pain medications until I speak with a nurse or physician at PPA. I agree to receive my prescriptions from one pharmacy, to be recorded in my chart at the PPA. Initial
- I will protect my prescriptions and medications. NO lost or stolen prescription or medication will be replaced. When I travel or go on trips, I will not take my entire prescription with me. Initial
- If I am requesting early refills, I will consent to random drug testing. Initial
- In certain instances, you may be subject to medication pill counts if deemed necessary.Initial
- I understand that I will be financially responsible for my urine drug testing. Initial
- I will keep my scheduled appointments. If I need to cancel an appointment, I will give 24 hours’ notice and will call 754.206.1877 to cancel or reschedule. If not, then I may be charged a no-show fee of $25. Initial
- Appointments should be made 1-2 days prior to prescription ending so patient don't encounter days without medication If I am calling early, I will allow 48 hours for a refill request and my medications will not be refilled after office hours, on weekends or holidays. Initial
I understand my pain medications may be stopped if one of the following occurs:
- My physician feels that narcotics are not helping to relieve my pain Initial
- My ability to function has not improved Initial
- I develop rapid tolerance to the treatment, or the treatment fails to be effective Initial
- I develop side effects that are of concern to my physicianInitial
- I give, sell, or misuse the narcotics Initial
- I obtain narcotics from any other sources without notifying PPA (includes any ER visits) Initial
- I understand that PPA will randomly call pharmacies to ensure this contract is still valid.Initial
- An important part of my pain management plan may include non-narcotic treatment. If I do not follow through with all aspects of my care (including non-narcotic meds), my narcotic treatment may be re-evaluated or terminated. Initial
- If I have questions or concerns about my pain management, I will call Pohlman Pain Associates at (754) 206-1877 THIS CONTRACT WILL REMAIN IN EFFECT FOR THE DURATION OF MY CARE. I understand the above Information and agree to abide by this contract.
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PATIENT INFORMATION

MEDICAL HISTORY

NOTICE OF PRIVACY ACKNOWLEDGEMENT/ AUTHORIZATION FOR RELEASE OF CONFIDENTIAL MEDICAL INFORMATION

Payment Policy/YOU MAY BE FINANCIALLY RESPONSIBLE!

NO SHOW POLICY

Pohlman Pain Associates (PPA) Opioid Contract