CINCINNATI PAIN PHYSICIANS, LLC (CPP) ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES By signing below, I acknowledge that I have received a copy of CPP s Notice of Privacy Practices. The Notice describes who my health information may be used or disclosed to. I understand that I should read it carefully. I am aware that the Notice may be changed at any time and that I may obtain a revised copy of the Notice by calling CPP, by visiting CPP s website at www.cincypain.com, or by requesting one at CPP s offices. The person listed below has the authority to confirm, make or change an appointments and we can also release emergency medical information to them if necessary. Please note: no one except the patient can pick up medical records of any sort. The patient must be present and show ID. If you are the POA (power of attorney) for the patient, you must show the POA paperwork to receive printed medical records. The name listed below should be your emergency contact or POA.Please fill out completely. Name: Relationship to Patient: Address: Telephone: OKAY TO RELEASE MEDICAL (emergency) INFORMATION THIS PERSON ABOVE IS MY P.O.A. (Must turn in POA paperwork for this to be valid in chart) PATIENT SIGNATURE: DOB: Date: *Please furnish a copy of any conservator/guardianship papers with this form. (POA forms) Cincinnati Pain Physicians, LLC New Patient Intake Form - Revised December 19, 2017 Page 1
This form will need to be completed every calendar year. Please complete the following forms to the best of your ability so that we can assist in your continual monitored care. If you have any questions regarding these forms, please ask. WELCOME TO CINCINNATI PAIN PHYSICIANS Dr. Gururau Sudarshan Dr. Atul Chandoke NEW PATIENT INTAKE FORM Today s Date: Referring Physician Name: Name: DOB: Male Female Address: City: State: Zip Code: Social Security #: Preferred Primary Phone Number: Home Cell Work Relative Primary Insurance Payer: (Ex: Medicare, Humana, BCBS, etc) Plan: (HMO, PPO, HSA, etc) ID#: Group#: MUST FILL THIS OUT: Policy Holder: Self Spouse Parent Other Policy Holder Name: DOB: Secondary Insurance Payer: (Ex: Medicaid, Medicare, etc) Plan: (HMO, PPO, etc) ID#: Group#: MUST FILL THIS OUT: Policy Holder: Self Spouse Parent Other Policy Holder Name: DOB: Workers Compensation Claim BWC Claim #: Date of Injury: Workers Comp Company Agent Name/MCO: Employer: Allowed DX codes: MCO Phone Number: Cincinnati Pain Physicians, LLC New Patient Intake Form - Revised December 19, 2017 Page 2
THIS SHEET IS FOR BILLING AND INSURANCE PURPOSES **I certify that the above information regarding my insurance is accurate, complete and true. This information must be updated and correct for billing purposes. It is the duty of the patient to inform the office when your insurance changes. CPP reserves the right to verify and check the validity of insurance at any time. I hereby assign all medical and surgical benefits, to which I am entitled to CINCINNATI PAIN PHYSICIANS. This assignment remains in effect until revoked by me in writing. A photocopy of this assignment is to be considered valid as an original. I hereby authorize said assignee to release all information necessary to secure payment. I consent to the release of information by CINCINNAI PAIN PHYSICIANS and my health insurance and/or payer to CINCINNATI PAIN PHYSICIANS and its employees/representatives to facilitate peer review and of my treatment including utilization and quality management. I understand that I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES WHETHER OR NOT PAID BY SAID INSURANCE. I understand that my medical insurance is a contract between myself and the insurance company and/or my employer. CINCINNATI PAIN PHYSICIANS is not a party said to contract. I understand that I am responsible for legal and/or collection fees necessary to settle my account, should it become delinquent** Patient Name: Date: Patient Signature: PHARMACY INFORMATION: Cincinnati Pain Physicians, LLC New Patient Intake Form - Revised December 19, 2017 Page 3
PHARMACY INFORMATION For the easy of filling your medications, we ask that you choose one Pharmacy to fill at. This allows for seamless communication verbally and through our medical records system regarding your medications. If at any point, your preferred pharmacy location changes, you must let us know. If you do not tell us, it can cause delay in ordering or picking up your medications. Pharmacy Name: Phone Number: Address: City/State: Zip Code: We do need ALL of the above information completed. *** Cincinnati Pain Physicians, LLC New Patient Intake Form - Revised December 19, 2017 Page 4
THIS SHEET IS FOR ON-GOING MEDICAL DOCUMENTATION NEEDS FOR CPP Please circle and fill in your answers Have you had your Pneumonia vaccine for last calendar year (2017)? Yes No If Yes, when: Have you had a Flu shot for last calendar year (2017)? Yes No If Yes, when: Cincinnati Pain Physicians, LLC New Patient Intake Form - Revised December 19, 2017 Page 5
2018 Opioid Contract Office Care Guidelines The following is an agreement between the patient and Cincinnati Pain Physicians concerning the use of narcotic pain medication as well as office guidelines for continued care. By signing this form, you are agreeing to follow the guidelines set forth by this practice. Failure to comply can result in termination of the patient-provider relationship through Cincinnati Pain Physicians and possible notification to Federal, State, or Local Law Enforcement authorities if a crime is believed to have been committed with your failure to comply with this agreement. PLEASE INITIAL ALL AREAS. Your initials certify that you agree to all policies of the office. Non-compliance will result in the discontinuation of care at our facility. 1. I understand that narcotic medication prescribed by CPP is for my use only. I will not share my medication with any other person. 2. I understand that selling my medications is illegal. 3. I understand that I cannot use an illegal drug, drink alcohol, or use another s prescribed medications while I am a patient at CPP. 4. I understand that if I lose or misplace my medication, it will not be replaced. 5. I will safeguard my medication from theft by using a lockbox at my home, this protects myself and others around me. 6. I understand that my narcotic prescriptions can only be filled at ONE pharmacy in the state of OHIO. 7. I understand that I CANNOT obtain a narcotic medication from any other physician/hospital/urgent care/ provider outside of Cincinnati Pain Physicians without the permission of Cincinnati Pain Physicians. I understand that in the event of an emergency, this practice should be contacted as soon as possible and the problem will be discussed with the emergency room or other treating physician. 8. I understand that my narcotic prescriptions can ONLY be refilled during an office visit appointment only, not in interventional procedure days, by telephone, or after normal office hours. 9. I understand that CPP ONLY fills 30 day prescriptions. You will not be allowed to fill a narcotic prescription any earlier than 30 days from the last fill date. Medications will not be allowed to be filled early. 10. I will take my medications as prescribed by the provider who prescribed the medication. 11. I will not dispose of my medication myself. Disposal of medication can only be done by a medical representative at our facility. 12. **I understand that if I am going out of town, I must schedule my travel times around my medication refill dates. ** Again, we cannot allow early refills. 13. I understand that I am subject to random urine drug screen tests and/or pills counts at my physician s request and that I MUST comply in order to obtain my monthly prescription. Cincinnati Pain Physicians, LLC New Patient Intake Form - Revised December 19, 2017 Page 6
14. I understand that my treatment at CPP is private and I will not share my plan of care or medication information with other patients. 15. I understand that it is my responsibility to make my medication appointment for my next medication refill before I leave the office. CPP will not call me to make this appointment. 16. I understand that if I miss my medication refill appointment, that the office will only be able to offer their first available appointment. I may be without medication for a short period of time. 17. I will immediately report to the staff of CPP if I am arrested or charged with any crime related to the abuse and\or selling of any prescribed or illegal drug. 18. I understand that honesty is the part of the foundation of a good doctor-patient relationship in order to receive the best care possible at CPP. I will always be completely honest with CPP staff. I understand that failure to be honest with CPP staff will be considered a breakdown in the doctor-patient relationship and may result in my discontinuation of care. PLEASE INITIAL ACCORDING TO GENDER: Females: If I am within child bearing age, I certify that I am not pregnant and will take appropriate measures to prevent pregnancy during the course of treatment. If I become pregnant, I will notify my provider at CPP immediately. Males: I am aware that chronic opiate use has been associated with low testosterone levels in males. This may affect my mood, stamina, sexual desire and physical and sexual performance. I understand that my doctor may do a blood test to check my testosterone level during my care at CPP. I have read and understand all of the above information. By signing this agreement, I am fully aware that the above opioid contract and office policies are set in place to assist with my safety and monitoring for my well-being. I am willing to comply with the plan of care given by all providers at Cincinnati Pain Physicians. I understand that this contract will be re-signed yearly to continue care with this facility. Cincinnati Pain Physicians, LLC New Patient Intake Form - Revised December 19, 2017 Page 7
Additional Compliance Topics: PLEASE READ AND INITIAL 1. I understand that my narcotic medications can be discontinued if If I test positive for an illegal substance on a urine drug screen test If I test negative for any prescribed medications on a urine drug test If I do not show up or have the correct medication count at mandatory pill count appointments If I NO SHOW or continually cancel an office visit appointments or scheduled interventional procedures If I do not comply with treatment suggested by my provider If I do not cooperate in a civil manner with the staff or providers 2. I understand that I have to have active medical insurance to be seen and obtain medications. I must show my insurance card if requested by the check in clerk. A government issued picture identification needs to be brought to all visits and procedures and may be asked for at random. CPP has the right to verify active insurance through the insurance company before your visit If I have a co-pay to see a specialist, it MUST be paid in order to be seen. I understand that CPP does not accept co-payments by check. Cash or credit card accepted for payment only. 3. I understand physical dependence is a normal expected outcome of using long term opiate medications I am aware that the tolerance to analgesia means that I may require more medicine to get the same amount of pain relief. CPP reserves the right to intervene with medication treatments by using therapeutic methods to help lower the narcotic dose. I understand that there is a risk that opiate addiction may occur. This means that I may become psychologically dependent on the medication. If this occurs, the medication will be stopped and I will be referred to appropriate treatment. I understand that the risks and side effects of opiate medications are: -Sedation, drowsiness, feeling sleepy -Confusion, change of ability to think clear -Difficulty with balance DO NOT operate heavy equipment or drive motor vehicles -Constipation, nausea, vomiting -Decrease in respiration or breathing. Printed Patient Name: Date: Patients Signature: CPP Staff Witness: CPP Provider Signature: Cincinnati Pain Physicians, LLC New Patient Intake Form - Revised December 19, 2017 Page 8