HIPPA guidelines require that we handle your medical records in a
safe and secure manor. The of ice policy concerning this is readily
available in our lobby and a copy will be offered to you upon request.
By signing this form you acknowledge that you have received or have
been offered a copy of the Notice of Privacy Practices for North Lakes
Please list persons, other than medical professionals, that you allow to have access to your records. This includes
persons that will come with you and/or pick up items for you at this office.
This is an agreement between North Lakes Pain Consultants (NLPC), as creditor, and the
Patient/Debtor named on this form. In this agreement the words “you,” “your,” and
“yours” mean the Patient/Debtor. The word “account” means the account that has been
established in your name to which charges are made and payments credited. The words
“we,” “us” and “our” refer to NLPC. By executing this agreement, you are agreeing to pay
for all services rendered.
CO-PAYMENTS REQUIRED BY AN INSURANCE COMPANY MUST BE PAID AT THE TIME OF SERVICE.
THIS IS AN INSURANCE REQUIREMENT; WE CANNOT BILL YOU.
Contracted Insurance: NLPC must comply with our contracts and any requirements
set there in. It is the insurance company that makes the final determination of your
eligibility/benefits. If your insurance company requires a referral and/or
preauthorization, you are responsible for obtaining it. Failure to obtain the referral
and/or preauthorization may result in no payment or a lower payment from the insurance
company. If your insurance company states that your policy has been cancelled and you no
longer have coverage the bill will be due in full by the patient. Ultimately, you are
responsible for unpaid amounts.
Non-contracted Insurance: Your insurance coverage is a contract between you and
your insurance company. We are NOT a party to this contract, in most cases. We will bill
your primary insurance company as a courtesy to you. Although we may estimate what your
insurance company may pay, it is the insurance company that makes the final
determination of your eligibility/benefits. If your insurance company requires a
referral and/or preauthorization, you are responsible for obtaining it. Failure to
obtain the referral and/or preauthorization may result in no payment or a lower payment
from the insurance company. You agree to pay any portion of the charges not paid by your
insurance. You may choose to file your own insurance.
In most cases payment options may be available upon request once your account is
No Insurance: This office will accept patients that do not have health insurance.
The patient is responsible for all charges. A patient with no insurance is eligible for
a cash pay discount rate. To be eligible for the cash pay discount rate full payment
must be received on the date of service. If for any reason full payment of the
discounted rate is not received on the date of service, the cash pay discount rate will
not apply. The bill will then revert back to the original charged amount. The cash pay
discount rate does not apply to payment plans.
Workers Compensation(WC): Complete WC information is required. The required
information includes but is not limited to your employer, date of injury, claim #,
adjuster, WC Carrier and all necessary contact phone numbers. We require written
approval/authorization by your worker’s compensation carrier prior to your visit. Once
your claim is determined to be finally adjudicated you must provide updated billing
information such as private health insurance.
Letters of Protection(LOP): LOPs are only accepted from local attorneys. You are
required to provide private health insurance information when you have coverage. We will
file all charges to your health insurance plan first then all remaining balances are
forwarded to the local attorney for payment when a settlement is reached.
Account Statement: If you have a balance on your account larger than $10, we will
send you a statement. It will show separately the previous balance, any new charges to
the account and payments or credits applied to your account during the month. Unless
other arrangements are approved by us in writing, the balance is due when your statement
is issued, and is past due if not paid by the end of the month.
Charges to Account: We shall have the right to cancel your privilege to make
charges against your account at any time. Future visits would then need to be paid at
the time of service.
Past due accounts: If your account becomes past due, we will take necessary steps
to collect this debt. If your account is referred to a collection agency, you agree to
pay all of the collection costs which are incurred.
Returned checks: A $25 fee will be incurred for any checks returned for
non-sufficient funds by the bank. The patient’s account will then be marked/flagged, and
no more checks are to be accepted as payment on the account.
Medical Records: Patients may obtain a copy of their medical record upon request.
The first copy of your medical record is free, if picked up from one of our office
locations. If you would like your medical record mailed you are required to pay for
postage prior to the records being sent. There will be a $15 charge for each additional
medical record request.
No Show Policy: A No Show is failure to attend a scheduled appointment without
calling to cancel the appointment at least 24 hours in advance, unless due to emergency.
Schedule II Prescriptions: Due to increased work load and time spent processing
prescriptions, as of November 6, 2014 we will charge a $10.00 processing fee for ALL
CII prescriptions that have to be written and picked up at the office. This will
not be billed to your insurance. The money will be due when the prescription is
picked up. (Per state regulations Medicaid and Workers compensation patients are
In each of the preceding scenarios, as the patient, you are ultimately
responsible for all liable amounts.
Wavier of confidentiality: You understand received treatment at our office may
become a matter of public record, if this account is submitted to an attorney or
collection agency, if we have to litigate in court, or if your past due status is
reported to a credit reporting agency.
Disclosure of Physician Ownership: We treat all of our patients the way we would
expect to be treated and will work hard to improve your pain and life. Today’s
medical business climate is very complicated, and physicians have little negotiation
power with insurance companies. Because of this, we will sometimes need to refer
your care to a facility that we may have a financial interest. Some of these are
participating in-network facilities and some are out-of-network. If you have
concerns or questions, please ask the office staff or treating physician. If you
have strong enough concerns about one of our facilities, we are happy to refer your
care to a facility that you are comfortable. Many physicians today have multiple
investments in medical businesses and we are no different. Most of these investments
will likely not involve your care, but some may. The office has a list of all of our
medical business investments that can be provided and there are posted lists within
Effective Date: Once you have signed this agreement, you agree to all of the
terms and conditions contained herein and the agreement will be in full force and
I understand that, as set forth in the North Lakes Pain Consultants’ Privacy Notice, I have the right to revoke this authorization, in writing, at any time by sending written notification to:
North Lakes Pain Consultants
133 Medical Park Lane, Ste B
Huntsville, TX 77340
I understand that I have a right to:
In order for us to obtain a complete medical history, it is necessary for you to
fill out this form. It is important for your
doctor to know that you have carefully reviewed every area of this form. Please fill
out every item, and remember to
sign and date page 4. This information will be entered into our system and you are
welcomed to a copy upon request.
This information will assist us in treating your pain.
Thank you for your cooperation.
TO THE PATIENT: As a patient, you have the right to be informed about your condition and the recommended medical or diagnostic procedure or drug therapy to be used, so that you may make the informed decision whether or not to take the drug after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you, but rather it is an effort to make you better informed so that you may give or withhold your consent/permission to use the drug(s) recommended to you by me, as your physician. For the purpose of this agreement the use of the word “physician” is defined to include not only my physician but also my physician’s authorized associates, technical assistants, nurses, staff, and other health care providers as might be necessary or advisable to treat my condition.
CONSENT TO TREATMENT AND/OR DRUG THERAPY: I voluntarily request my physician (name at bottom of agreement) to treat my condition which has been explained to me as chronic pain. I hereby authorize and give my voluntary consent for my physician to administer or write prescription(s) for dangerous and/or controlled drugs (medications) as an element in the treatment of my chronic pain.
It has been explained to me that these medication(s) include opioid/narcotic drug(s), which can be harmful if taken without medical supervision. I further understand that these medication(s) may lead to physical dependence and/or addiction and may, like other drugs used in the practice of medicine, produce adverse side effects or results. The alternative methods of treatment, the possible risks involved, and the possibilities of complications have been explained to me as listed below. I understand that this listing is not complete, and that it only describes the most common side effects or reactions, and that death is also a possibility as a result from taking these medication(s).
THE SPECIFIC MEDICATION(S) THAT MY PHYSICIAN PLANS TO PRESCRIBE WILL BE DESCRIBED AND DOCUMENTED SEPARATE FROM THIS AGREEMENT. THIS INCLUDES THE USE OF MEDICATIONS FOR PURPOSES DIFFERENT THAN WHAT HAVE BEEN APPROVED BY THE DRUG COMPANY AND THE GOVERNMENT (THIS IS SOMETIMES REFERRED TO AS “OFF-LABEL” PRESCRIBING). MY DOCTOR WILL EXPLAIN HIS TREATMENT PLAN(S) FOR ME AND DOCUMENT IT IN MY MEDICAL CHART.
I HAVE BEEN INFORMED AND understand that I will undergo medical tests and examinations before and during my treatment. Those tests include random unannounced checks for drugs and psychological evaluations if and when it is deemed necessary, and I hereby give permission to perform the tests or my refusal may lead to termination of treatment. The presence of unauthorized substances may result in my being discharged from your care.
For female patients only:
All of the above possible effects of medication(s) have been fully explained to me and I understand that, at present, there have not been enough studies conducted on the long-term use of many medication(s) i.e. opioids/narcotics to assure complete safety to my unborn child(ren). With full knowledge of this, I consent to its use and hold my physician harmless for injuries to the embryo/ fetus / baby.
I UNDERSTAND THAT THE MOST COMMON SIDE EFFECTS THAT COULD OCCUR IN THE USE OF THE DRUGS USED IN MY TREATMENT INCLUDE BUT ARE NOT LIMITED TO THE FOLLOWING: constipation, nausea, vomiting, excessive drowsiness, itching, urinary retention (inability to urinate), orthostatic hypotension (low blood pressure), arrhythmias (irregular heartbeat), insomnia, depression, impairment of reasoning and judgment, respiratory depression (slow or no breathing), impotence, tolerance to medication(s), physical and emotional dependence or even addiction, and death. I understand that I may be impaired during all activities, including work.
I understand I should NOT drive a vehicle or operate (heavy) machinery while using (this) these medications.
The alternative methods of treatment, the possible risks involved, and the possibilities of complications have been explained to me, and I still desire to receive medication(s) for the treatment of my chronic pain.
The goal of this treatment is to help me gain control of my chronic pain in order to live a more productive and active life. I realize that I may have a chronic illness and there is a limited chance for complete cure, but the goal of taking medication(s) on a regular basis is to reduce (but probably not eliminate) my pain so that I can enjoy an improved quality of life. I realize that the treatment for some will require prolonged or continuous use of medication(s), but an appropriate treatment goal may also mean the eventual withdrawal from the use of all medication(s). My treatment plan will be tailored specifically for me. I understand that I may withdraw from this treatment plan and discontinue the use of the medication(s) at any time and that I will notify my physician of any discontinued use. I further understand that I will be provided medical supervision if needed when discontinuing medication use.
I understand that no warranty or guarantee has been made to me as to the results of any drug therapy or cure of any condition. The long-term use of medications to treat chronic pain is controversial because of the uncertainty regarding the extent to which they provide long-term benefit. I have been given the opportunity to ask questions about my condition and treatment, risks of non-treatment and the drug therapy, medical treatment or diagnostic procedure(s) to be used to treat my condition, and the risks and hazards of such drug therapy, treatment and procedure(s), and I believe that I have sufficient information to give this informed consent.
I UNDERSTAND AND AGREE TO THE FOLLOWING:
That this pain management agreement relates to my use of any and all medication(s) (i.e., opioids, also called ‘narcotics, painkillers’, and other prescription medications, etc.) for chronic pain prescribed by my physician. I understand that there are federal and state laws, regulations and policies regarding the use and prescribing of controlled substance(s). Therefore, medication(s) will only be provided so long as I follow the rules specified in this Agreement.
My physician may at any time choose to discontinue the medication(s). Failure to comply with any of the following guidelines and/or conditions may cause discontinuation of medication(s) and/or my discharge from care and treatment. Discharge may be immediate for any criminal behavior:
I certify and agree to the following:
The following are some questions given to all patients at North Lakes Pain Consultants who are on or being considered for opioids for their pain. Please answer each question as honestly as possible. This information is for our records and will remain confidential. Your answers alone will not determine your treatment. Thank you.
Please answer the questions below using the following scale: (Circle your answers)
0 = Never 1 = Seldom 2 = Sometimes 3 = Often 4 = Very Often
Conroe Ambulatory Anesthesia
1517 17th Street / Denver, CO 80124
Account: --, ending in --
Amount Due: $