Welcome To Our Practice

Office Hours: 

Pain Management:

Manchester Office:

Murfreesboro Office:

Addiction Clinic: Only open on Wednesdays and Saturdays in Manchester

Emergencies: For life-threatening situations, call 911 or go to the nearest Emergency Room. If you have an urgent problem during working hours, please call our office at (931) 728-5607 and a message will be given t o a nurse. After hours, please leave a message on our answering machine. Your call will be returned on the next business day. 

First Visit – Please come 30 minutes before your appointment time and bring with you:

• Insurance card(s) - It is your responsibility to inform our office of ANY insurance changes PRIOR to your visit.
• Driver’s license or photo ID
• ALL medicine bottles (must have with you or appointment will b e rescheduled)
• Completed patient information and clinical history forms
• Co-payment (if required by your plan)

Appointments

Please make any follow-up appointments as you leave.

• Call in advance to make or reschedule office visit appointments
• As a courtesy to other patients and staff, please call the office as soon as possible if you are going to be late or are unable to keep your appointment
• If you will be late, you will need to reschedule your appointment for the next available day and time
• A $25.00 fee will be assessed for missed appointments which were not cancelled
• Due to the large time allotment required, RFTC and RACZ appointments require 24 hours notice to cancel; otherwise, a $100.00 fee will be assessed

Prescriptions

All prescriptions and refills should be obtained during your appointment. We do not call in refills. Please bring all medications and bottles prescribed by us to your appointment or your appointment will be rescheduled.

Financial Policy

• You are financially responsible for all charges incurred.
• Payment of any co-pays, deductibles and co-insurance is expected at time of service.
• We will file your insurance as a courtesy to you. Any remaining balance after 60 days will  become your obligation.
• We accept Cash, Check, Visa, Mastercard, and Discover.
• Please see our “Policies and Procedures” for our complete financial policy.

Insurance

Prior to your appointment, please check your insurance information so you will be informed about referrals, co-payments, and any deductible required at the time of the visit.

• If your insurance requires a referral from your primary care physician, a written referral or authorization number must be in our office prior to your visit.
• Your health insurance contract is between you and your insurance company. Any concerns regarding your coverage or co-payments should be directed to your carrier.
• It is your responsibility to inform our office of ANY insurance changes PRIOR to your visit.

What We Need From You

• To arrive on time for scheduled appointments and cancel the appointment when necessary with a phone call.
• To inform the Medical Practice staff of any pertinent changes in insurance, demographic information, employment, or other care/service givers.
• To notify the Medical Practice of any change in your health status.
• To follow the recommended treatment plan and inform the Medical Practice of any physical or mental impairment requiring special accommodations.
• To ask questions if directions and procedures are not understood.
• To provide payment for services requested and delivered by the Medical Practice not covered by insurance within 90 days of date of service.

What You Should Expect From Us

• To be treated with respect and dignity.
• Professional, timely, and appropriate services.
• To be informed of your care needs in order to make appropriate decisions.
• That teaching materials will be provided in a manner you can understand.
• To be informed of the Medical Practice billing process.
• To have your records kept confidential except when consent has been given or to coordinate health care services for you.
• To communicate your complaints to the Medical Practice Manager and expect to receive follow up without negative repercussions or changes in services.
• To receive care without discrimination due to race, religion, age, sex, disability, or ethnic origin.

This Notice of Privacy Practices is NOT an authorization. This Notice describes how we, our Business Associates, and their subcontractors may use and disclose your protected health information (PHI) to carry out treatment, payment, or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. Protected Health Information includes information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or mental health condition and related health care services.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
Your protected health information may be used and disclosed by your physician, our office staff, and others outside of our office who are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician's practice, and for any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes coordination or management of your health care with a third party. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan.

Healthcare Operations: We may use or disclose, as needed, your protected health information to support the business activities of your physician's practice. These activities include, but are not limited to, quality assessment, employee review, training of medical students, licensing, fundraising, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students who see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment and to inform you about treatment alternatives or other health-related benefits and services that may be of interest to you. If we use or disclose your protected health information for fundraising activities, we will provide you the choice to opt out of those activities. You may also choose to opt back in.

We may use or disclose your protected health information in the following situations without your authorization: These situations include: as required by law, public health issues as required by law, communicable diseases, health oversigh abuse or neglect, food and drug administration requirements, legal proceedings, law enforcement, coroners, funera directors, organ donation, research, criminal activity, military activity and national security, workers' compensation inmates, and other required uses and disclosures. Under the law, we must make disclosures to you upon your request Under the law, we must also disclose your protected health information when required by the Secretary of the Departmer of Health and Human Services to investigate or determine our compliance with the requirements under Section 164.500.

USES AND DISCLOSURES THAT REQUIRE YOUR AUTHORIZATION
Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization, or opportunity to object unless required by law. Without your authorization, we are expressly prohibited to use or disclose your protected health information for marketing purposes. We may not sell your protected health information without your authorization. We may not use or disclose most psychotherapy notes contained in your protected health information. We will not use or disclose any of your protected health information that contains genetic information that will be used for underwriting purposes.

You may revoke the authorization, at any time, in writing, except to the extent that your physician or the physician's practice has taken an action in reliance on the use or disclosure indicated in the authorization.

YOUR RIGHTS

The following are statements of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information (fees may apply) - Pursuant to your written request, you have the right to inspect or copy your protected health information whether in paper or electronic format. Under federal law, however, you may not inspect or copy the following records: Psychotherapy notes, information compiled in reasonable anticipation of, or used in, a civil, criminal, or administrative action or proceeding, protected health information restricted by law, information that is related to medical research in which you have agreed to participate, information whose disclosure may result in harm or injury to you or to another person, or information that was obtained under a promise of confidentiality.

You have the right to request a restriction of your protected health information - This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to your requested restriction except if you request that the physician not disclose protected health information to your health plan with respect to healthcare for which you have paid in full out of pocket.

You have the right to request to receive confidential communications - You have the right to request confidential communication from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively, i.e. electronically.

You have the right to request an amendment to your protected health information - If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures - You have the right to receive an accounting of disclosures, paper or electronic, except for disclosures: pursuant to an authorization, for purposes of treatment, payment, healthcare operations; required by law, that occurred prior to April 14, 2003, or six years prior to the date of the request.

You have the right to receive notice of a breach - We will notify you if your unsecured protected health information has been breached.

You have the right to obtain a paper copy of this notice from us even if you have agreed to receive the notice electronically. We reserve the right to change the terms of this notice and we will notify you of such changes on the following appointment. We will also make available copies of our new notice if you wish to obtain one.

COMPLAINTS

You may complain to us or to the Secretary of Health and Human Services if you believe your  privacy rights have been violated by us. You may file a complaint with us by notifying our Compliance Officer of your complaint. We will not retaliate against you for filing a complaint.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. We are also required to abide by the terms of the notice currently in effect. If you have any questions in reference to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number. Please sign the accompanying "Acknowledgment" form. Please note that by signing the Acknowledgment form you are only acknowledging that you have received or been given the opportunity to receive a copy of our Notice of Privacy Practices.

Primary Insurance:

I hereby assign payment of medical benefits due to me to be paid directly to:

James R. Nunley, D.O., P.C./Interventional Spine and Pain Center

and I authorize the release of any health information needed to determine these benefits or the benefits payable for related services to the insurance company/companies that I have supplied you with. I understand that filing my claims for services rendered is a service to me provided by Interventional Spine and Pain Center and this assignment does not relieve me of my primary obligation to pay my bill to: James R. Nunley, D.O., P.C./Interventional Spine and Pain Center.

I stand responsible for payment.

Medicare (One-Time Authorization)

I request that payment of authorized Medicare benefits be made on my behalf to:

James R. Nunley, D.O., P.C./Interventional Spine and Pain Center

for any services furnished me by that provider. I authorize any holder of medical or other information about me to release to the Social Security Administration and Center for Medicare and Medicaid Services (CMS) or its intermediaries or carriers any information needed for this or a related Medicare claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits to the party who accepts assignment. I understand it is mandatory to notify the health care provider of any other party who may be responsible for paying for my treatment. (Section 1128B of the Social Security Act and 31 U.S.C. 3801-3812 provides penalties for withholding this information.) Regulations pertaining to Medicare assignment of benefits also apply.

MEDIGAP or any Secondary Insurance (Signature on File Statement):

I request that payment o f authorized benefits be made on my behalf to:

James R. Nunley, D.O., P.C./Interventional Spine and Pain Center

for any services furnished me by that provider. I authorize any holder of my personal medical information to release any information needed to determine these benefits payable for related services.

I hereby acknowledge that I have received or have been given the opportunity to receive a copy of Interventional Spine and Pain Center’s Notice of Privacy Practices. By signing below, I am only giving acknowledgement that I have received or have had the opportunity to receive the Notice of our Privacy Practices.

Interventional Spine and Pain Center is pleased to offer our in-house clinical laboratory services. Your medical provider has requested to perform testing on a specimen you provided. ISPC will conduct urine drug screens (UDS) per Palmetto CMS guidelines, which includes an initial screening and confirmation test (at the discretion of your provider). All laboratory services rendered by ISPC are charged to the patient. Our billing department will file a claim and send a statement to you (the patient) if the insurance carrier has determined a deductible, co-payment, and/or co-insurance amount applies. After a claim is filed you will see an E.O.B. (explanation of benefits) which is not a bill but will outline how much of your benefits were applied.

Medicare and Medicaid: ISPC is currently in network with both. However, we are only providing services to Medicare patients. Medicaid will only be billed as a secondary if a patient carries both.
The patient is responsible for any deductible, co-payment, and/or co-insurance amount.

Third Party Insurance Carrier: ISPC is in network with many commercial insurance carriers.
The patient is responsible for any deductible, co-payment, and/or co-insurance amount.

Secondary Insurance: If the patient has secondary insurance that supplements primary coverage, ISPC will file a claim with the secondary when provided with the necessary information.

Self-Pay Patients: The patient will be responsible for payment and will receive an invoice from our billing department. The front office staff will provide the self-pay prices for the testing; payment in full is due at the time of visit.

Statement of Financial Responsibility:
A copy of this Statement of Financial Responsibility and any other billing policies and procedures will be provided to me upon request. I understand I am responsible for co-pays, deductibles, and/or co-insurance, as well as amounts not covered by insurance, litigation, or third-party liability. I am authorizing ISPC to submit claims and acknowledging that payment(s) of authorized insurance benefits or attorney settlements, including but not limited to Medicare, Medicaid, third-party insurance, other benefits and/or payments shall be made on my behalf to Interventional Spine and Pain Center for the services provided to me pursuant to a Laboratory Request, a copy of which will be provided to me upon request, and I will pay for amounts not covered by other sources, if applicable.

Please indicate who we may give your Protected Health Information (PHI) to.

Messages: On your answering machine or voice mail, may we leave messages regarding:

Emergency Contacts: Please list two people that DO NOT live with you and indicate if we may give them your Protected Health Information.

I understand that my healthcare information is protected. I understand that for Interventional Spine and Pain Center and its representatives to leave messages containing my specific health information on my voice mail, cell phone (text), or answering machine, I need to give permission to do so.

Check the appropriate response:

Please fill out the following questions prior to your appointment.

Please select or complete the items in each section below that pertain to your current problem(s).

As you may know, there are several legal, medical, ethical, and social issues associated with pain medicine. Because pain is subjective and cannot be proven, the medical community has developed several questionnaires and forms to help evaluate pain.

OPIOID RISK TOOL:

Many patients are rightfully concerned about the risk of addiction to their pain medications. The risk of addiction actually is quite low when the medications are used properly for pain. Sometimes, a patient already has an addiction disorder. This does not mean that the patient is not deserving of pain control, but it does mean that we need to use extra caution so as to provide the pain control without worsening the addictive disorder. This questionnaire was developed for this purpose and can help us determine your risk of addiction with medications.

Please complete the ORT below honestly, and we can then discuss your level of risk of becoming addicted or having an addictive disorder. This questionnaire is not meant to be a judgment of you as a human being.

Please note if you are female or male.

This questionnaire has been designed to give your physician information as to how your pain has affected your ability to manage in everyday life. Please answer every question by placing a mark in the one box in each section that best describes your condition today. We realize you may feel that two of the statements may describe your condition, but please mark only the box which most closely describes your current condition.

Select the answer that most closely describes you today.