Pain Management Associates, Inc.

Interventional Spine Center, Inc

PATIENT ATTESTATION

PLEASE READ THIS SECTION CAREFULLY ALONG WITH THE DOCUMENTS THAT GOES WITH IT.

Thank you for choosing Pain Management Associates, Inc. (PMA) and Interventional Spine Center, Inc. (ISC). Please make sure that our staff has given you all the documents listed below. It is extremely important that you carefully read and review these documents that were given to you before your initial consultation with our pain management Physician. Please initial your name once you have read, understood, and agreed with each of the documents completely. The documents listed below are used for your benefit to inform you in regards to PMA & ISC company’s policies & procedures. **THIS FIRST SHEET (pg. 1) IS FOR THE OFFICE TO KEEP AND PAGES 2 TO 4 ARE FOR YOU TO KEEP.

1. Patient’s Rights and Responsibilities

By initialing after the dotted line, I was given and have read, understood, and agreed with PMA & ISC patient’s rights and responsibilities. I was also given a list of contact information regarding where and whom I may be able to express my concerns, complaints, and/or grievances to……………………………………….……………………………………..Initials ______

2. Statement of Financial Responsibilities

By initialing after the dotted line, I understood and agreed with the Statement of Financial Responsibilities given to me by PMA & ISC. Any questions, concerns, and/or disagreements to these terms will be held responsible upon me to bring attention to with PMA & ISC staff. (**PLEASE BE AWARE THAT AFTER 60 DAYS OF OUTSTANDING BALANCE, 18% INTEREST WILL BE ADDED TO YOUR BALANCE EACH MONTH) ……………..……………………………………..Initials ______

3. Opioid Contract

By initialing after the dotted line, I was given, understood, and agreed that if I was to violate any of the condition(s) written in the Opioid Contract, given to me by PMA & ISC, that it may result in dismissal from this practice and the discontinuation of getting any narcotics/controlled substances prescribed to me ……………………….....Initials ______

4. Policy Concerning Advance Directives

By initialing after the dotted line, I was given information about PMA & ISC Advance Directives policy. Any questions, concerns, and/or disagreements to these terms will be held responsible upon me to bring attention to with PMA & ISC staff …………………………………………………………..………………………………………………………………………..Initials ______

5. Disclosure of Physician Ownership

By initialing after the dotted line, I was given information about PMA & ISC Ownership. Any questions and/or concerns will be held responsible upon me to bring attention to with PMA & ISC staff………………………………....Initials ______

I certify that I have received written documentation of the following items list above, prior to my scheduled initial consultation and/or my procedure date. By signing below, I understood and agreed to the above documents, in regards to Pain Management Associates, Inc. and Interventional Spine Center, Inc. policies and procedures. I am also validating that the each initials next to the corresponding documents, listed above, were written by me. Furthermore, I have understood that should I have any questions regarding its content, I should contact Pain Management Associates, Inc. and/or Interventional Spine Center, Inc. staff for any clarification.

Patient Name: ______Date: ______

Signature: ______

PATIENT’S RIGHTS

Below is a summary of a Bill of Rights that was adopted by the U.S. Advisory Commission on Consumer Protection and Quality in the Health Care Industry in 1998.

Information Disclosure: You have the right to accurate and easily-understood information about your health plan, health care professionals, and health care facilities. If you speak another language, have a physical or mental disability, or just don’t understand something, help should be provided so you can make informed health care decisions.

Participation in Treatment Decisions: You have the right to know your treatment options and to take part in decisions about your care. Parents, guardians, family members, or others that you select can represent you if you cannot make your own decisions.

Respect and Non-discrimination: You have a right to considerate, respectful care from your doctors, health plan representatives, and other health care providers.

Confidentiality of Health Information: You have the right to talk privately with health care providers and to have your health care information protected. You also have the right to read and copy your own medical records.

PATIENT’S RESPONSIBILITIES

- The patient has the responsibility to participate in his/her own health care decisions, and to obtain necessary information from his/her doctor to make informed choices.

- The patient has the responsibility to be as accurate and complete as possible when providing medical history and treatment information. The patient is responsible for reporting perceived risks in their care and changes in their condition.

- The patient has the responsibility to inform his/her doctor or nurse if he/she has questions or concerns regarding treatment. The patient has the responsibility to follow his/her doctor's advice regarding health care requirements.

- The patient has the responsibility to cooperate with the office by providing complete, timely insurance information and making payment arrangements on any balances.

You may contact the following entities to express all health care related concerns, complaints, and/or grievances you may have:

OFFICE MANAGER / Email:
Phone: 949-588-7246 / Fax: 949-272-3746
CALIFORNIA HEALTH DEPARTMENT / Hotline: 800-822-6222
Email:
Online Form:
MEDICAL LICENSE BOARD / Online Form:
Mailing Address:
Medical Board of California – Central Complaint Unit
2005 Evergreen Street, Suite 1200, Sacramento, CA94815
Phone: 800-633-2322 / 2nd Phone: 916-263-2382 / Fax: 916-263-2435
MEDICARE OMBUDSMAN / Website:
2nd link:
Phone: 800-HHS-TIPS (800-447-8477) / Fax: 800-223-8164
Email:
Accreditation Association for Ambulatory Health Care (AAAHC) / Phone: 847-853-6060 / Fax: 847-853-9028
Email:

ADVISEMENT OF PHYSICIAN OWNERSHIP

The physician(s) listed below is/may be a partner in Pain Management Associates, Inc. and/or Interventional Spine Center, Inc.; which was developed between local physicians to provide a cost-effective alternative to hospital based surgical care. We are committed to providing quality outpatient surgical services, pain management care, and is also accredited by the Accreditation Association of Ambulatory Health Care.

Keyvan Zavarei, M.D.

Amir Pouradib, M.D.

STATEMENT OF FINANCIAL RESPONSIBILITIES

**Please be aware that after 60 days of outstanding balance, 18% interest will be added to your balance each month.

It is the policy of Pain Management Associates, Inc. & Interventional Spine Center, Inc. to collect any office co-payment or other service charges that are not covered by your Insurance Company, at the time of your visit.Our office will assist you by billing your Insurance Company; however we will offer services based on the assumption that your charges will be paid by your insurance company. It is your responsibility to inform our office of any changes in your insurance benefits.

All professional services rendered are charged to the patient. Necessary forms will be completed to help expedite insurance carrier payments. However, the patient is responsible for all fees, regardless of insurance coverage. It is also customary to pay for services when rendered unless other arrangements have been made in advance with our billing department. Patient agrees to notify us of any changes in the above information within 7 days.

  • I request that payment of authorized Medicare/other insurance company benefits be made to Pain Management Associates, Inc. and/ Interventional Spine Center, Inc. for any services furnished me by Pain Management Associates, Inc. and/ Interventional Spine Center, Inc. Regulations pertaining to Medicare assignment of benefits apply.
  • I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carrier or any other insurance company any information needed for this or a related Medicare/other insurance company claim.
  • I authorize Pain Management Associates, Inc. and/ Interventional Spine Center, Inc. to release medical information or records to other physicians or medical facilities that Pain Management Associates, Inc. and/ Interventional Spine Center, Inc. refers me to for further medical evaluation or treatment.
  • I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claims. If item 9 of the HCFA-1500 claim form is completed, my signature authorizes releasing of the information to the insurer or agency responsible for all co-payments, co-insurances deductibles and non-covered services.
  • I also understand that failure to pay my portion of financial debt may lead to action in civil small claims court or collection proceedings.

INFORMATION REGARDING ADVANCE DIRECTIVES

Advance Directives are legal documents that allow you to convey your decisions about end-of life care ahead of time. They provide a way for you to communicate your wishes to family, friends and health care professionals, and to avoid confusion.

  • A living will communicates your wishes in regard to how you fell about care intended to sustain life. You can accept or refuse medical care.
  • A durable power of attorney for healthcare is a document that names your health care proxy. Your proxy is some you trust to make healthcare decisions if you are unable to do so.
  • While all these documents play a very important role as to how healthcare decisions are made on your behalf, it is the policy of Pain Management Associates, Inc. & Interventional Spine Center, Inc. that we DO NOT honor Advance Directives at this facility.
  • If you have an Advance Directive, please bring it with you on the day of surgery, we will place it in your medical record for reference in the unlikely event you are transferred to the hospital.

If you do not have an Advance Directive and would like more information, you can log on to

OPIOID CONTRACT

Controlled substances, such as narcotics, tranquilizers, and barbiturates are very useful, but have high potential for misuse. They are intended to relieve pain specifically to improve function and/or ability to work, not simply to feel good. Please carefully read and sign at the end of this form that you have agreed with the following conditions that Pain Management Associates, Inc. and/or Interventional Spine Center, Inc. have listed below.

  1. I am responsible for my controlled substance medication. If the prescription is lost, misplaced, stolen, or if I have used it up sooner than prescribed, I understand that it will not be replaced.
  2. I will not request or accept controlled substance medication from any other Physician or individual while I am receiving medication(s) from Pain Management Associates, Inc. and/or Interventional Spine Center, Inc.
  3. There will be no early refills. Prescription for refills will be written at my next office visit. They will not be made if I run out early for any reason including if I lose a prescription or spill/misplace the medication.
  4. I understand that it is the policy of Pain management Associates, Inc. and Interventional Spine Center, Inc. to refill my medication(s) at the time of my scheduled office visit and that there will not be any medication(s) that shall be called into the pharmacy.
  5. I agree to comply with random urine, blood, or breathing test to document the proper uses of the medication(s).
  6. I understand that if I am told that I am impaired by certified personnel, that I will not drive a motor vehicle or operate any other heavy machinery.
  7. I further understand that driving a motor vehicle may not be allowed at times while taking controlled substances. It is my responsibility to comply with the laws of the state while taking these medications.
  8. I agree to waive any applicable privilege or right of privacy or confidentiality with respect of prescribing my pain medication.
  9. I understand that side effects of sedation, itching, nausea, vomiting, difficulty urinating, constipation and other side effects are possible. I further understand that a possibility of addiction and the probability of physical dependence exist and I consent to all of these risks.
  10. I understand that suddenly stopping this medication may result in an abstinence syndrome. I also understand that in addition to the side effects listed above, a possibility of respiratory depression and even death exists from these medications. If I feel very sleepy, I will not overtake these medications, even if my pain level or other problems are very great.
  11. I understand that violating any of the conditions of this agreement may result in dismissal from this practice. Violation of this agreement may also result I narcotics no longer being prescribed.
  12. I further agree that my narcotics prescription may be stopped or decreased at any time for nay reason by my physician or any other Pain Management Associates, Inc. and/ Interventional Spine Center, Inc. physician.

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