NEW PATIENT CONSULT · phone and tablet app for a NEW PATIENT CONSULT will also be coming soon. P AT I E N T U P L O AD Ap p l i c a ti o n - Patients who need to provide documents

NEW PATIENT CONSULT

Our Warmest Welcome

as you embark with the best individualized care for your pain from our friendly and dedicated team at

specializing in you

A MESSAGE FROM OUR PROVIDERS

Welcome to Pain Specialty Group

"Chronic pain is a terrible thing. We experience a tremendous amount of professional satisfaction when we are able to relieve a patient’s chronic pain, help restore function and improve a person’s quality of life. Many patients in our practice arrive disheartened, hopeless and desperate, because they have been living with chronic pain for so long. It is extremely and tremendously fulfilling for us to provide compassionate care with the most advanced technologies and techniques available. We believe that pain management starts with genuine compassion and ability to not only ‘listen’ but to actually ‘hear’ what our patients are saying! It is our strong belief that there must be a strong connection of trust between the patient and our team, which leads to excellent communication, delineation of goals and management of expectations. Our overwhelming goal is to provide the best possible outcomes. We always strive to restore and maximize the most active lifestyles possible. Our patients and specialists are a team with the common goal of improving function, managing pain and restoring hope. Nothing makes us happier than to see our patients improve with appropriate treatment, care and to see them be able to enjoy life once again. For everyone at Pain Specialty Group, we truly believe that “health is the first wealth" as we “specialize in you.”

Manuel G. Sanchez, MD Interventional Pain Specialist

Ashley E. Phipps, APRN Pain Management Specialist

Anh L. Ngo, MD MBA Interventional Pain Specialist

101 Shattuck Way, Suite 6 Newington, NH 03801

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COVID-19 SAFETY PROTOCOLS


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GENERAL GUIDELINES

We are excited to announce our continued commitment to excellence in patient care by the reinitiation of in-office procedures and services. We are using updated guidelines set by the New Hampshire Hospital Association and the United States Center for Disease Control (CDC) in order to protect you, patients and staff, your families and the health of our community. We have also instituted digital health applications to help with time efficiency, accuracy of medical information, as well as to optimize your care by limiting your exposure to others through the:

What we will be doing for patients:

● We will be limiting patients coming into the office for only procedures and special circumstances at this time.

● We will be performing a screening the day of procedure with a temperature check and short questionnaire.

● We will be screening patients for significant health problems such as immunocompromised status, lung disease, history of transplant, diabetes, severe heart and kidney disease.

● We will be minimizing patient’s contact with each other by having patients immediately brought into an exam room upon entering the office after doing a self check in at the computer station, eliminating time spent in the waiting room.


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● Patients who arrive earlier may also be requested to wait in their vehicles after checking in with us.

● Patients may also call us when they arrive outside our clinic to make sure that the waiting area is clear to enter.

● With our digital health initiative, patients can limit risks while optimizing care with our:

Smartphone and tablet applications coming soon.

● CLINIC VISIT Application - To help with visit efficiency, accuracy of your medical information and to optimize care, we have created digital applications to help patients prepare for any visit. Patients are encouraged to complete the CLINIC VISIT survey (bit.ly/clinicvisit) within 24 hours PRIOR to your appointment. A phone and tablet app for CLINIC VISIT will also be coming soon.


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http://bit.ly/clinicvisit

● NEW PATIENT CONSULT Application - New patients are also able to prepare for their initial

consultation with us digitally through our NEW PATIENT CONSULT survey (bit.ly/new-consult). A phone and tablet app for a NEW PATIENT CONSULT will also be coming soon.

● PATIENT UPLOAD Application - Patients who need to provide documents to our clinic may

digitally submit them securely in our HIPAA compliant form at bit.ly/patient-submit.

● We will be sanitizing patient areas and equipment after each use.

● Staff who are feeling ill will stay home.

● We will continue to offer medication visits, follow up appointments and general office visits virtually through DIGITAL VISITS to reduce the risk of exposure for staff and patients in the office.

What we ask of patients:

● Call the office prior to a patient procedure to report any cough, fever, chills, shortness of breath, and/or exposure to COVID-19 or people known to have been exposed to COVID-19.

● We ask you to wear a mask when entering the office, wash hands frequently, avoid eating and drinking in the office unless there are health reasons such as diabetes.

● Drivers shall remain in their cars.

● Once you arrive and check in, we request that you also wait in the car until we notify you to come into the office to limit the risk of exposure.

● When you enter the office you will have a short screening questionnaire temperature check and self check in on the computer.

● The office will call you to make patient follow up appointments.


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http://bit.ly/new-consult

http://bit.ly/patient-submit

Staff Protocol:

● Each staff member will be screened each shift (questionnaire and temperature check)

● Each staff member will wear appropriate PPE (mask, gloves, face shields, hair caps) when dealing with patients.

● Each staff member will stay 6 feet apart from each other while in the office, except while in the procedure room where close contact is required in which PPE will be worn.

● Staff members who are feeling ill or have been exposed to any person with COVID-19 will stay home.

Screening Questionnaire: All patients are encouraged to perform the Screening Questionnaire online and via phone / tablet app (coming soon), which can be found at: bit.ly/clinicvisit. A paper version will also be available upon request.

● Have you been within 6 feet of a person with confirmed COVID-19 in the past 14 days?

● In the last 48 hours have you had any of the following NEW symptoms?

○ Fever of 100.5 or above ○ Cough ○ Trouble breathing ○ Chills ○ Muscle aches ○ Sore throat ○ Diarrhea ○ Loss of smell or taste ○ Headache

The safety and well being of you, your family, patients and our community is our top priority.


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http://bit.ly/clinicvisit

For non-urgent healthcare matters, please submit your messages through our secure patient portal on our website at painspecialtygroup.com and look for the image:


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https://www.painspecialtygroup.com/

NEW PATIENT CONSULT

DOCUMENT CHECKLIST

DOCUMENT COMPLETED & SIGNED

Document Checklist Certification

Agreement and Consent for Digital Submission and Use of Electronic Signature

Demographic Information

Provided ID and Insurance Card

General Information & Practice Policies

Important Note Regarding After Hours & Weekend Services

Patient Medical Information

Opioid / Narcotic Treatment Agreement

Consent for Opioid Therapy

Authorization and Consent

Billing Policy and Agreement

Notice of Privacy Practices

Notice of Privacy Practices - Acknowledgement of Receipt

Release of Information TO Pain Specialty Group

Release of Information FROM Pain Specialty Group


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DOCUMENT CHECKLIST CERTIFICATION

PLEASE PROVIDE THIS FORM WITH YOUR SIGNATURE TO OUR OFFICE AT INITIAL VISIT (NO PRINTER? NOT TO WORRY. WE CAN PRINT THIS IN OUR OFFICE)

I, ___________________________, hereby certify that all information provided in the forms listed in the Document Checklist have been reviewed, completed, and accepted by me. I have read, understand, completed all requested forms and provided all information truthfully and correctly to the best of my ability and agree with the terms and conditions of the Agreement and Consent for Digital Submission and Use of Electronic Signature, Demographic Information, General Information & Practice Policies, Important Note Regarding After Hours & Weekend Services, Patient Medical Information, Opioid / Narcotic Treatment Agreement, Consent for Opioid Therapy, Authorization and Consent, Billing Policy and Agreement, Notice of Privacy Practices, Notice of Privacy Practices - Acknowledgement of Receipt, Release of Information TO Pain Specialty Group, and Release of Information FROM Pain Specialty Group.

Patient Print Name Patient Signature Date


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AGREEMENT AND CONSENT OF DIGITAL SUBMISSION AND USE OF ELECTRONIC SIGNATURE

I hereby agree and consent that any signature (including any electronic symbol or process attached to, or associated with, this form, contracts, documents or other record and adopted by me with the intent to sign, authenticate or accept such contract or record) hereto or to any other certificate, agreement or document related to this submission, and any contract formation or record-keeping through electronic means shall have the same legal validity and enforceability as a manually executed signature or use of a paper-based record-keeping system to the fullest extent permitted by applicable law, including the Federal Electronic Signatures in Global and National Commerce Act, the New Hampshire 2010 New Hampshire Statutes TITLE XXVII CORPORATIONS, ASSOCIATIONS, AND PROPRIETORS OF COMMON LANDS CHAPTER 294-E UNIFORM ELECTRONIC TRANSACTIONS ACT Section 294-E:7 Legal Recognition of Electronic Records, Electronic Signatures, and Electronic Contracts, or any similar state law based on the Uniform Electronic Transactions Act. I hereby waive any objection to the contrary. I also verify that I will provide complete all requested information and provide all required documents prior to the initial clinic evaluation and management visit with Pain Specialty Group. I HAVE READ, UNDERSTAND AND ACCEPT THE TERMS AND CONDITIONS OF THE AGREEMENT AND CONSENT OF DIGITAL SUBMISSION AND USE OF ELECTRONIC SIGNATURE. <<I HAVE READ, UNDERSTAND AND ACCEPT THE TERMS AND CONDITIONS OF THE AGREEMENT AND CONSENT OF DIGITAL SUBMISSION AND USE OF ELECTRONIC SIGNATURE>> WITH THE STATEMENTS ABOVE AND SIGN WITH MY DIGITAL SIGNATURE BELOW.



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GENERAL INFORMATION & PRACTICE POLICIES

Our Commitment to You

● We will provide you with the most appropriate care in the most time efficient fashion. ● We will treat you with respect and professionalism. ● We will always do our best to keep your scheduled appointment and to minimize any wait time you may incur;

however, due to circumstances beyond our control, there may be times that we must reschedule your appointment with short notice.

● In order to give you as much notice as possible we request a phone contact so that we can reach you in person during the day, such as a business number or cell phone.

● We will do our best to move your appointment to an earlier time or date if we have a cancellation in our office schedule.

● If you have any questions regarding this information, please do not hesitate to ask us. We are here to help you.

General Information

● Our office hours are very limited. It is very important that you keep your appointment. ● If you have an emergency and cannot keep your appointment, you must contact our office no later than 48

hours prior to your scheduled appointment date. ● We may charge a NO SHOW FEE if your appointment is not kept or cancelled 48 hours prior to your scheduled

time. ● In order to treat you effectively and efficiently and within HIPAA guidelines, we require a Registration Form and

several other forms to be completed by you. ● We are sorry, but due to high fax volume, we are NOT able to guarantee acceptance of any of the following

documents via fax. ● Without the completed documents, films, tests, and referral, if appropriate, you may NOT be seen by the doctor

and your appointment will be RESCHEDULED. ○ Referral; if required by the insurance ○ Active valid insurance card ○ Case number or Claim number for Auto insurance or Worker’s Compensation ○ Government issued photo ID ○ MRI films & Reports, CT Scan films & Reports, Bone scan reports ○ EMG reports ○ Primary doctor’s notes, other specialists’ notes (Orthopedic surgeon, neurologist, psychiatrist,

rheumatologist, etc.) ○ List of current medications ○ Auto Insurance policy Declaration Page (PIP Coverage)

Medication Policy

● It is important to your health that you follow the directions carefully on all medications that we prescribe. ● In addition, we must be informed of all other medications, prescription and over-the-counter.


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● We WILL NOT refill controlled medications in advance of their refill date. ● We WILL NOT mail prescriptions. ● We WILL NOT prescribe any opioid (narcotic) medications at the first visit. ● They must be given IN PERSON to you at the time of your appointment. ● If there is an unavoidable reason that you cannot make an appointment, we require a 3-day notice for a

medication refill.

Financial Policy

● We are committed to providing you with the best possible care. ● We expect that you have an understanding of your responsibilities under your insurance contract in respect to

referral and pre-authorization requirements, and your deductible, co-pay, and coverage limits. ● In order to achieve your maximum allowable benefits, we need your assistance and your understanding of our

payment policy. ● Payment is due in full at time of service, unless you have made payment arrangements in advance with our

business office. ● If you have insurance coverage with one of the plans we participate with, we will bill your ● insurance company along the guidelines of our contract; however, we require that ALL COPAYS OR

DEDUCTIBLES be paid at the time of service. ● If you have an insurance with which we do not participate, we ask that payment be made at the time services

are rendered and your insurance company will reimburse any amount due to you directly. ● Returned checks will be subject to an additional $35.00 service fee. ● We will gladly discuss your proposed treatment and answer any questions relating to your insurance. Please

realize, however, that your insurance is a contract between you, your employer and the insurance company. We are not a party to that contract.

● While filing of insurance claims is a courtesy we extend to our patients, all charges are the responsibility of the patient from the date the services are rendered.

● You will be required to show a copy of your insurance card at the time of service. ● If you do not have your insurance information or we are unable to verify your coverage, you will be required to

pay for the services rendered to you that day. ● If your insurance coverage terminates or changes, you are responsible for notifying us of this change

immediately so that we can assist you in receiving your maximum reimbursement.

Missed Appointments

● Please help us serve you better by keeping scheduled appointments. ● Unless cancelled at least 48 hours in advance, our policy is to charge a NO SHOW FEE for missed office

appointments. ● Missed appointments for procedures performed at surgery center or on procedure days may incur a fee of

$100. This includes not following instructions; stopping of medications, food/drink restrictions and having a driver.


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I HAVE READ the General Information and Practice Policies. I UNDERSTAND and AGREE to this General Information and Practice Policies, including financial policies and information. I GUARANTEE payment of all charges incurred for the account. I hereby assign benefits to PAIN SPECIALTY GROUP for all claims submitted to my insurance on my behalf. I further agree to pay any and all attorney’s fees, court costs and related collection fees incurred. I HAVE READ, UNDERSTAND AND ACCEPT THE TERMS AND CONDITIONS ON THE GENERAL INFORMATION AND PRACTICE POLICIES.



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IMPORTANT NOTE REGARDING AFTER-HOURS & WEEKEND SERVICES

Pain Specialty Group provides care for chronic problems. As such, our patients are not expected to require urgent care or immediate contact with this practice after hours. If you have an urgent medical problem after regular business hours (8AM to 5PM Monday through Friday) or over the weekend, please do one of the following:

● Contact your primary care physician ● Go to an urgent care center ● Go to the emergency department of the nearest hospital

It is permissible that you obtain medications from these physicians for any acute pain or new injury that you have. It is your responsibility to contact us within the next two business days to inform us of any changes, additions, or deletions made to your narcotic regimen. All non-narcotic changes should be reported at your next office visit. By signing below, you agree that you have read the above notice regarding after-hours and weekend services and that you understand your responsibilities. I HAVE READ, UNDERSTAND AND ACCEPT THE TERMS AND CONDITIONS ON AFTER-HOURS AND WEEKEND SERVICES.



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OPIOID / NARCOTIC TREATMENT AGREEMENT

I understand that in order to receive care for the treatment of pain at Pain Specialty Group, I MUST comply with the following rules: I UNDERSTAND that narcotic and controlled drug prescriptions are MY RESPONSIBILITY once they are placed in my hand. I UNDERSTAND that if anything happens to this prescription (i.e. it is lost, stolen, flushed down the toilet, etc.), I am personally responsible, and physicians, physician’s assistants and/or nurse practitioners WILL NOT rewrite the prescription until the designated time is given. Your narcotic and controlled drug prescription WILL NEVER be refilled after hours or on the weekends. All controlled substances should be obtained at the SAME PHARMACY. Should the need arise to change pharmacies our office must be informed. I WILL take medications at the dose and frequency prescribed. Any changes in the dose or frequency will be discussed with my physician, physician’s assistant and/or nurse practitioner at Pain Specialty Group. If my medications are prescribed on an every eight- hour basis, I WILL take these medications every eight hours. I UNDERSTAND that if I use more than the allowed amount or use up my medication before my appointment date, NO MORE PILLS WILL BE GIVEN. I UNDERSTAND that narcotics and controlled drug prescriptions WILL NOT be phoned into the pharmacy. I MUST appear for my given appointment time. I UNDERSTAND that if I come in at an earlier date for an appointment, my medication WILL NOT be given until the date of the original appointment. I WILL receive prescriptions at the interval determined by physician, physician’s assistant and/or nurse practitioner in Pain Specialty Group. I WILL NOT receive controlled substances for the treatment of pain from any source other physician, physician’s assistant and/or nurse practitioner in Pain Specialty Group. I WILL communicate with my primary physician that I am treated at Pain Specialty Group for the controlled prescribing of pain medications. I understand that Pain Specialty Group has the permission to discuss all diagnostic and treatment details with the dispensing pharmacist or other professionals who provide my health care. I WILL consent to random drug testing. I will NOT drink any alcohol beverages with pain medications. I will NOT use any illegal substances (cocaine, heroin, crystal methamphetamine, PCP, ecstasy, ketamine, etc.) or use any controlled


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substances which are not prescribed in our practice while being treated with controlled substances at Pain Specialty Group. Refusal of such testing or positive results will result in prompt termination of care from Pain Specialty Group. I WILL safeguard my prescribed medications. I understand that these medications may be lethal or hazardous to a person that is not tolerant to its effects, especially a child. I WILL comply with my scheduled appointments. I UNDERSTAND that there is a possibility of impairment of thought processes, especially if this narcotic is combined with a sedative, a sleeping pill, tranquilizer or alcohol. I UNDERSTAND the possible adverse effects and dependencies associated with these medications. Overdose of medication may result in injury or possible death. Other side effects may include, but are not limited to constipation, difficulty in urination, fatigue, drowsiness, nausea, itching, loss of appetite, confusion, sweating, flushing, sexual dysfunction, and or depressed respiration. I UNDERSTAND that if I plan to become pregnant or become pregnant, I have to inform the physician, physician’s assistant and/or nurse practitioner in Pain Specialty Group immediately. I UNDERSTAND that if I become pregnant, a child WILL likely be physically dependent at birth if I continue narcotics. You are expected to INFORM OUR OFFICE of any new medications or medical conditions, and of any adverse effects you experience from any of the medications that you take. I UNDERSTAND that changing date, quantity or strength of medication or altering a prescription in any way, shape or form is against the law. Forged signatures are also against the law. If there is a violation this will be reported to the patient’s pharmacy, local authorities and DEA. I realize that it is MY RESPONSIBILITY to keep others and myself from harm, including safety of driving and the operation of machinery. I UNDERSTAND that if I violate this contract, all medications from Pain Specialty Group WILL thereafter CEASE. I UNDERSTAND this mode of treatment will be stopped if any of the following occurs: * I giveaway, sell, or misuse the drugs or use other people’s drugs or illegal substances; * I am noncompliant with any of the terms of this agreement; * I disrespect or harass any Pain Specialty Group personnel; * I do not follow up regularly or as requested by my physician, physician’s assistant and/or nurse practitioner.


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YOU ARE INFORMED that you have the right and power to sign and be bound by this agreement, and that you have read, understand and accept all of its terms. I HAVE READ, UNDERSTAND AND ACCEPT THE TERMS AND CONDITIONS ON THE OPIOID / NARCOTIC TREATMENT AGREEMENT.



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CONSENT FOR OPIOID THERAPY

I understand that the treatment with opioid pain medication is being carefully evaluated and recommended because my pain complaints are moderate to severe and other treatments have not sufficiently helped my pain. I understand that many medications can have interactions with opioids that can either increase or decrease their effect. Therefore, I have told the medical providers (physicians, nurse practitioners and/or physician assistants) at Pain Specialty Group about all other medicines and treatments that I am receiving – and that I will promptly advise the medical provider at Pain Specialty Group if I start to take any new medications or have new treatments. Likewise, I have told the medical providers at Pain Specialty Group about my complete personal drug history and that of my family. I have been informed by the medical providers at Pain Specialty Group that the initiation of a narcotic/opioid medication is a trial. Continuation of the medication is based on evidence of benefit to me from, associated side effects of, and compliance with instructions on, use of medication. I have also been informed by the medical providers at Pain Specialty Group that continuation and any changes in dosage of the medication will be determined by pain relief, functional improvement, side effects, and adherence to usage restrictions. IT HAS BEEN EXPLAINED TO ME THAT TAKING NARCOTIC/OPIOID MEDICATION HAS CERTAIN RISKS ASSOCIATED WITH IT. THESE INCLUDE, BUT ARE NOT LIMITED TO, THE FOLLOWING: • Allergic reactions • Slowing of breathing rate, slowing of reflexes or reaction time, sleepiness, drowsiness, dizziness, and/or confusion • Impaired judgment and inability to operate machines or drive motor vehicles • Nausea, vomiting, and/or constipation, itching • Overdose (which could result in harm or even death) • Addiction • Physical dependence or tolerance to the pain relieving properties of the medication (This means that if my medication is stopped, reduced in dose, or rendered less effective by other medications I may be taking, I may experience runny nose, yawning, large pupils, goosebumps, abdominal pain and cramping, diarrhea, irritability, aches throughout my body, and a flu-like feeling. These can be very painful but are generally not life-threatening.)


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• Failure to provide pain relief • Changes in sexual function (This is generally caused by reduced testosterone levels. Such reduced levels may affect mood, stamina, sexual desire and physical and sexual performance.) • Changes in hormonal levels • Use of these medications poses special risks to women who are pregnant or may become pregnant. If I plan to become pregnant or believe that I have become pregnant while taking this pain medicine, I will immediately call my obstetrician and this office to inform them. I have been advised that, should I carry a baby to delivery while taking this medication, the baby will be physically dependent upon opioids. I also understand that birth defects can occur whether or not the mother is on medicines and there is always the possibility that my child will have a birth defect while I am taking an opioid. Furthermore, I recognize that the long-term consequence on a child’s development who was exposed to opioids is not understood. IT HAS BEEN EXPLAINED TO ME THAT THERE ARE OTHER TREATMENTS THAT DO NOT INVOLVE USE OF NARCOTIC/OPIOID MEDICATIONS. HAVING BEEN INFORMED OF THESE RISKS AND POTENTIAL BENEFITS BOTH OF SUCH MEDICATIONS AND POSSIBLE ALTERNATIVES TREATMENTS, I HAVE FREELY CONSENTED TO TAKING THE NARCOTIC/OPIOID MEDICATION. I would note that I have been given the opportunity to ask any questions that I may have – and that any questions that I have raised have been discussed to my satisfaction. I will take this/these medication(s) only as prescribed and I will not change the amount or dosing frequency without authorization from the medical providers at Pain Specialty Group. I understand that unauthorized changes may result in my running out of medications early, and early refills may not be allowed. I also understand that if I do not take the medication correctly, I may have withdrawal reactions that may include stomach pain, sweating, anxiety, nausea, vomiting and general discomfort. I will obtain all opioid prescriptions from my physician or, during his or her absence, by the covering physician. I will not request medications outside of normal business hours. I will obtain all scheduled medications from one pharmacy. I will notify my physician if I change pharmacies. I hereby authorize the physicians, nurse practitioners and physician assistants at Pain Specialty Group to discuss all diagnostic and treatment details of my condition with the pharmacists at the dispensing pharmacy. I will submit to random urine and/or blood drug tests as requested by the medical providers at Pain Specialty Group to monitor my treatment. I understand that the presence of any unauthorized substances in my urine or blood may prompt referral for assessment of addiction or chemical dependency and could result in discontinuation of further opioid prescriptions.


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I also understand that failure to follow these rules may lead to my no longer being treated by the medical providers at Pain Specialty Group. I will not share, sell or otherwise permit others to have access to these medications. I HAVE READ THIS FORM OR HAVE HAD IT READ TO ME. I UNDERSTAND ALL OF IT. I HAVE HAD A CHANCE TO HAVE ALL OF MY QUESTIONS REGARDING THIS TREATMENT ANSWERED TO MY SATISFACTION. BY SIGNING THIS FORM VOLUNTARILY, I GIVE MY CONSENT FOR THE TREATMENT OF MY PAIN WITH OPIOID PAIN MEDICINES. I UNDERSTAND AND AGREE THAT FAILURE TO ADHERE TO THESE POLICIES WILL BE CONSIDERED NONCOMPLIANCE AND MAY RESULT IN CESSATION OF OPIOID PRESCRIBING AND POSSIBLE DISMISSAL FROM PAIN SPECIALTY GROUP I HAVE READ, UNDERSTAND AND ACCEPT THE TERMS AND CONDITIONS ON THE CONSENT FOR OPIOID / NARCOTIC THERAPY.



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AUTHORIZATION AND CONSENT

I request that payment of authorized Medicare Benefits be made on my behalf to Pain Specialty Group for any services furnished me by Pain Specialty Group and its associates. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents or any information needed to determine these benefits or the benefits payable to related services. I permit a copy of this authorization to be used in place of the original and request payment of medical insurance benefits to myself or to the party who accepts the assignment. I request that payment of authorized Medigap and Insurance Benefits be made on my behalf to Pain Specialty Group for any services furnished to me by Pain Specialty Group . I authorize any holder of medical information about me to release to my insurance carrier or any information needed to determine the benefits payable for related services. AUTHORIZATION to release information and payment request. I certify that the service(s) covered by this claim have been received and I request that payment for these services be made on my behalf. I authorize any holder of medical or other information about me to release to the Division of Medical Assistance and Health Services or its authorized agents any information needed for this or a related claim. ASSIGNMENT OF INSURANCE BENEFITS: I irrevocably assign all payments to Pain Specialty Group for medical insurance benefits including any Major Medical Benefits otherwise payable to me under the terms of my policy but not to exceed the balance due to Pain Specialty Group for services performed during this period of treatment. In making this assignment, I understand and agree that I am financially responsible to the above party for charges not paid under this insurance policy. I permit a copy of this authorization to be used in place of the original. RELEASE OF INFORMATION: Pain Specialty Group may disclose any or all parts of the clinical record to me, my insurance company(s) or employer(s) for purposes of satisfying charges billed by Pain Specialty Group. I further understand that it may be necessary for Pain Specialty Group to contact my past or present employer(s) in regards to this claim. This authorization does not cover 3rd party liability claims. GUARANTEE OF ACCOUNT: Pain Specialty Group, for and in consideration of services rendered by Pain Specialty Group to the below named patient, the undersigned (jointly and severally, if more than one) guarantees payment of all charges incurred for said patient in accordance with the policy of payment of such bills. There will also be added 35% collection and reasonable attorney fee if your account goes to a collection agency. This guarantee is made for the purpose of insuring that Pain Specialty Group and its associates receive complete reimbursement for services rendered. I also agree that in the event of nonpayment, this amount would include all late charges, collection fees charged to Pain Specialty Group and its associates and any attorney fees awarded as a result of legal action being taken to recover said amount.


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THE UNDERSIGNED CERTIFIES THAT EACH HAS READ AND UNDERSTANDS THE ABOVE TERMS AND CONDITIONS. I HAVE READ, UNDERSTAND AND ACCEPT THE TERMS AND CONDITIONS OF THE AUTHORIZATION AND CONSENT.



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BILLING POLICY AND AGREEMENT

INSURANCE INFORMATION AND BILLING POLICY:

Pain Specialty Group participates with Aetna, Anthem-BCBS of NH, Cigna of NH, Healthcare Value Management HCVM/First Health/Coventry, Harvard Pilgrim, Medicare, RR Medicare, Martin's Point, MVP, PHCS, Tricare, Tufts, United Healthcare-UHC and Workers Compensation as well as some other insurances not listed on this form. For these participating carriers Pain Specialty Group will submit all claims and necessary supporting documentation on your behalf. Any co-payment required by your plan will be collected up-front at the time of your office visit. After the final payment has been received from your insurance company, you will be billed for any remaining patient due balance, as specified by your carrier. If deductibles have not been met, you are responsible for payments. If your insurance company is not listed here or if you did not receive written confirmation from your insurance company that we accept your insurance policy, we will consider you a self-pay patient. If you are new to Pain Specialty Group, you will be required to pay in full up-front at time of service by either cash or credit card. Established patients will be required to pay fifty (50%) of the balance up-front at time of service. Pain Specialty Group will, as a courtesy to you, submit your claim to your insurance carrier. However, you will immediately become responsible for payment of the balance of your account. Please note: For those insurance carriers that Pain Specialty Group does not participate with the claim check may be mailed directly to you. In these cases, please sign and forward the check to our office as you will be responsible for full payment of services rendered. You will be responsible for ensuring we have all necessary referrals or pre-certifications prior to your scheduled appointment. If you do not have a referral or pre-certification in place when you arrive for your visit you will be held responsible for payment of your office visit or procedure or your appointment may need to be rescheduled. A picture ID is required, and a picture will be taken for your medical records file for security purposes. Failure to comply may result in refusal of treatment.

WORKERS COMPENSATION:

Pain Specialty Group will submit “open” claims only, on your behalf, unless we are aware in advance that the claim will be denied. It is your responsibility to provide the office staff with complete insurance information, as well as your current case management contact and phone number. Pain Specialty Group will bill your primary health insurance in cases where worker’s compensation denies the claim for whatever reason. Any balance not paid by the worker’s compensation carrier or primary health plan will be your responsibility.


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MOTOR VEHICLE ACCIDENT (MVA) AND LITIGATION CASES:

Pain Specialty Group does not recognize MVA or Litigation claims. As such, you will be classified as a self-pay patient unless you have active health insurance coverage as specified above, in which case we will submit all claims to your health insurance carrier.

SELF-PAY POLICY:

All self-pay patients (no insurance, non-participating insurance carrier, motor vehicle accident (MVA) or litigation claimants) will receive a 40% discount off our current rates for paying at the time of service. Otherwise, you will be required to pay at least 50% of the office visit or procedure up-front at the time of service and will be billed for the remaining balance. New patients who are self-pay must pay for their initial visit up-front at the time of visit in cash, by credit card (Discover, Visa and MasterCard) or money order (personal checks will not be accepted).

CANCELLATION POLICY:

A 48-hour notice is required for cancelled appointments. A $50 cancellation fee will be imposed for any appointment not cancelled with a 48-hour notice. Repeatedly not showing for your scheduled appointment may result in discharge from the practice.

RETURNED CHECKS:

A fee of $35.00 will be charged to your account for any/all returned check(s). All future payments must be made in cash, charge, money order or bank check.

PAST DUE BALANCES:

To avoid interruption in provided care, all past due balances are expected to be paid in full prior to future treatment, unless you have made payment arrangements prior to your appointment.


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THE UNDERSIGNED CERTIFIES THAT EACH HAS READ AND UNDERSTANDS THE ABOVE TERMS AND CONDITIONS. I HAVE READ, UNDERSTAND AND ACCEPT THE TERMS AND CONDITIONS FOR BILLING POLICY AND AGREEMENT.



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NOTICE OF PRIVACY PRACTICES

This notice is issued by Pain Specialty Group PLLC. If you have any questions about this notice, please contact our Privacy Officer. Protected Health Information (“PHI”) is information, including demographic information, that may identify you and that relates to health care services provided to you, the payment of health care services provided to you, or your physical or mental health or condition, in the past, present or future. This Notice of Privacy Practices describes how we may use and disclose your PHI. It also describes your rights to access and control your PHI. As a provider of healthcare, we are required by Federal and state law to maintain the privacy of PHI. We are also required to notify you following a breach of the privacy of your PHI. We are required to provide you with this notice of our legal duties and privacy practices. We are required to abide by the terms of this Notice of Privacy Practices, but reserve the right to change the Notice at any time. Any change in the terms of this Notice will be effective for all PHI that we are maintaining at that time. We will provide you with any revised Notice of Privacy Practices upon request; you may either call the office and request that a revised copy be sent to you in the mail or ask for one at the time of your next appointment. We will also promptly post the revised Notice of Privacy Practices in our reception area.

PERMITTED USES AND DISCLOSURES

General Rules

Federal law allows a health care provider to use or disclose PHI as follows: You. We will disclose your PHI to you, as the covered individual, at your request. Authorization. We will disclose your PHI pursuant to the terms of an authorization signed by you. Personal representative. We will disclose your PHI to a personal representative designated by law such as the parent or legal guardian of a child, attorney-in-fact under a durable power of attorney for health care, representative of the estate of a deceased individual, or, in certain circumstances, your surviving spouse. Treatment. We will use and disclose your PHI to provide, coordinate, or manage your health care and any related services. Treatment refers to the provision and coordination or management of healthcare and related services by one or more health care providers, including consultation or referral. For example, we may disclose your PHI from time-to-time


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to another physician or health care provider (e.g., a specialist laboratory or pharmacy) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment. Payment. We may use and disclose your PHI in order to bill and collect payment for the treatment and services provided to you. Payment refers to the collection of premiums, reimbursements, coverage, determinations, billing, claims management, medical necessity determinations, utilization review, and pre-authorization services. For example, we may provide portions of your PHI to our billing company and your health plan to get paid for the health care services we provided to you. We may also disclose your PHI to another health care provider for its payment activities if it received your PHI for treatment purposes. Health care operations. We may disclose your PHI in order to operate this practice. Health care operations refer to specified administrative support activities by or for a health care provider, including quality assessment and improvement, peer review, training and credentialing of providers, and legal and auditing functions. For example, we may use your PHI in order to evaluate the quality of health care services that you received or to evaluate the performance of the health care professionals who provided health care services to you. Appointment reminders and other notifications. We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment. We may use or disclose your PHI, as necessary, to provide you with information about treatment alternatives. Business associates. We will share your PHI with third party “business associates” that perform various activities (for example, billing or transcription services) for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your PHI, we have a written contract that contains legally required terms that will protect the privacy of your PHI. Other uses and disclosures. 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.

USES AND DISCLOSURES ALLOWED WITHOUT AUTHORIZATION OR OPPORTUNITY TO AGREE OR OBJECT

Federal law also allows a healthcare provider to use and disclose PHI, without your consent or authorization, or opportunity to agree or object, in the following ways: As required by law. When a disclosure is required by Federal, state, or local law, judicial or administrative proceedings, or by law enforcement. For example, we make disclosures when a law requires that we report information to government agencies and law enforcement personnel about victims of abuse, neglect, or domestic violence; when dealing with gunshot and other wounds; or when ordered in a judicial or administrative proceeding. For public health activities. For example, we report information about births, deaths, and various diseases to government officials in charge of collecting that information, and we may provide coroners, medical examiners, and funeral directors necessary information relating to an individual’s death.


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For health oversight activities. For example, we will provide information to assist the government when it conducts an investigation or inspection of a health care provider or organization. For purposes of organ donation. We may notify organ procurement organizations to assist them in organ, eye, or tissue donation and transplants. For research purposes. In certain circumstances, we may provide PHI in order to conduct medical research. To avoid harm. In order to avoid a serious threat to the health or safety of a person or the public, we may provide PHI to law enforcement personnel or persons able to prevent or lessen such harm. For specific government functions. We may disclose PHI of military personnel and veterans in certain situations. And we may disclose PHI for national security purposes. For workers’ compensation purposes. We may provide PHI in order to comply with workers’ compensation laws. The examples of permitted uses and disclosures listed above are not provided as an all-inclusive list of the ways in which PHI may be used. They are provided to describe in general the types of uses and disclosures that may be made.

PERMITTED AND REQUIRED USES AND DISCLOSURES THAT MAY BE MADE WITH YOUR AUTHORIZATION OR OPPORTUNITY TO OBJECT

We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your PHI. If you are not present or able to agree or object to the use or disclosure of the PHI, then your physician may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the PHI that is relevant to your health care will be disclosed. Others involved in your health care. If you agree or do not object, we may disclose to a member of your family, a relative, a close personal friend or any other person you identify, your PHI that directly relates to that person’s involvement in your health care or payment for your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We also may use or disclose your PHI to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care. Following your death. After your death, we may disclose to a member of your family, a relative, a close personal friend or any other person you identify, your PHI that directly relates to that person’s involvement in your health care or payment for your health care prior to your death. We may not make such disclosures to the extent you inform us, prior to your death, that you object to some or all such disclosures.

ALL OTHER USES AND DISCLOSURES REQUIRE YOUR PRIOR WRITTEN AUTHORIZATION

In any other situation not described in this Notice, we will ask for your written authorization before using or disclosing any of your PHI. If you choose to sign an authorization to disclose your PHI, you can later revoke that authorization in writing


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to stop any future uses and disclosures (to the extent that we haven’t already taken any action relying on the authorization). Specific examples of uses or disclosures that require authorization include: Marketing. Uses and disclosure of your PHI for marketing require your written authorization. Marketing is a communication that encourages you to purchase or use a product or service. However, it is not marketing if we communicate with you about health-related products or services that we offer, as long as we are not paid by a third party for making the communication. Nor is your written authorization required for us to communicate with you face-to-face or for us to give you a gift of nominal value. Sale. We may not sell your PHI without your written authorization, except as permitted by law.

YOUR RIGHTS IN RELATION TO PROTECTED HEALTH INFORMATION

You have the following rights with respect to your PHI: Limit Uses. You have the right to ask that we limit how we use and disclose your PHI. We will consider your request, but, except as specified below, we are not legally required to agree to it. If we agree to your request, we will put any limits in writing and abide by them except in emergency situations. You may not limit the uses and disclosures that we are legally required or allowed to use. However, in the event that you pay in full for the services we have provided and request that we not disclose to your health plan PHI pertaining solely to the provision of those services, we will honor that request. Alternative Modes of Communication. You have the right to ask that we send PHI to you to at an alternate address (for example, sending information to your work address rather than your home address) or by alternate means (for example, e-mail instead of regular mail). We will agree to your request so long as we can easily provide it in the format that you requested. Access. In most cases, you have the right to look at or get copies of your PHI that we have, but you must make the request in writing. You also have the right to have us provide a copy of your PHI directly to another person whom you designate by providing us with a completed authorization form. You are also entitled to an electronic copy of your Electronic Health Record (“HER”), if one exists. We will respond to you within 30 days after receiving your written request. In certain situations, we may deny your request. If we do, we will tell you, in writing, our reasons for the denial and explain your right to have the denial reviewed. Copies. If you request copies of your PHI, we will charge you a reasonable, cost-based fee for the labor and supplies associated with making the copy, whether requested in paper or in electronic form. For copies in electronic form, you may be charged the cost of any portable media device on which the copy is provided. Instead of providing the PHI you requested, we may provide you with a summary or explanation of the PHI as long as you agree to that and to the cost in advance. Accounting of Disclosures. You have the right to get a list of instances in which we have disclosed your PHI for a period of up to six years prior to the date of the request, except for disclosures that you have authorized.


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We will respond within 60 days of receiving your request. The list we will give you will include disclosures made in the last six years unless you request a shorter time. The list will include the date of the disclosure, to whom PHI was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure. We will provide the list to you at no charge, but if you make more than one request in the same year, we will charge you a reasonable fee for each additional request. Amendment of Records. If you believe that there is a mistake in your PHI or that a piece of important information is missing, you have the right to request that we correct the existing information or add the missing information. You must provide the request and your reason for the request in writing. We will respond within 60 days of receiving your request. We may deny your request in writing if the PHI is (i) correct and complete, (ii) not created by us, (iii) not allowed to be disclosed, or (iv) not part of our records. Our written denial will state the reasons for the denial and explain your right to file a written statement of disagreement with the denial. If you don’t file one, you have the right to request that your request and our denial be attached to all future disclosures of your PHI. If we approve your request, we will make the change to your PHI, tell you that we have done it, and notify others that need to know about the change to your PHI. Notice by Email. You have the right to get a copy of this notice by email. Even if you have agreed to receive notice via email, you also have the right to request a paper copy of this notice. Pain Specialty Group’s Privacy Officer may be reached by phone or mail at: Privacy Officer Pain Specialty Group 101 Shattuck Way, Suite 6 Newington, NH 03801 (603) 778-9921

COMPLAINTS

You may file a complaint with us by notifying our Privacy Officer of your complaint. We will not retaliate against you for filing a complaint. You may contact our Privacy Officer at (603) 778-9921 for further information about the complaint process. You may complain to us or to the Secretary of the U.S. Department of Health and Human Services if you believe your privacy rights have been violated by us by sending a letter to 200 Independence Avenue, S.W., Washington, DC 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

EFFECTIVE DATE OF NOTICE

This notice was published and became effective on December 1, 2017. You may also find a copy of our privacy policy online at www.painspecialtygroup.com/contents/patients/forms.


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http://www.painspecialtygroup.com/contents/patients/forms

THE UNDERSIGNED CERTIFIES THAT EACH HAS READ AND UNDERSTANDS THE ABOVE TERMS AND CONDITIONS. I HAVE READ, UNDERSTAND AND ACCEPT THE NOTICE OF PRIVACY PRACTICES.



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ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION

I acknowledge receipt of the Notice of Privacy Practices from Pain Specialty Group PLLC (“the Practice”). I understand this Notice contains important information about how my protected health information may be used and disclosed and how I can get access to this information. I understand that the Practice has the right to change this Notice at any time and that I may obtain a current copy upon request. I HAVE READ, UNDERSTAND AND ACCEPT THE ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION.



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RELEASE OF INFORMATION TO PAIN SPECIALTY GROUP

I, ___________________________, date of birth _______________________, authorize and request that you release to Pain Specialty Group PLLC, copies of my medical records, including x-rays, laboratory reports, and any other relevant medical data. I understand that I can revoke this consent at any time with a written statement provided by myself to Pain Specialty Group. I HAVE READ, UNDERSTAND AND ACCEPT THE RELEASE OF INFORMATION TO PAIN SPECIALTY GROUP.



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AUTHORIZATION FOR RELEASE OF INFORMATION FROM PAIN SPECIALTY GROUP

Pain Specialty Group is authorized to release protected health information about the above-named patient to the entities named below. The purpose is to inform the patient or others in keeping with the patient’s instructions. The following person(s) and entity are authorized to receive my protected health information:

Authorized Voicemail at:

Authorized Spouse - NAME AND PHONE NUMBER(S)

Authorized Parent(s) - NAME AND PHONE NUMBER(S)

Authorized Other Individual(s) - NAME AND PHONE NUMBER(S)

I understand that I have the right to revoke this authorization at any time and that I have the right to inspect or copy the protected health information to be disclosed as described in this document. I understand that a revocation is not effective in cases where the information has already been disclosed, but will be effective going forward. I understand that information used or disclosed as a result of this arbitration may be subject to redisclosure by the recipient and may no longer be protected by federal or state law. I understand that I have the right to refuse this authorization and that my treatment will not be conditioned on signing. THIS AUTHORIZATION SHALL BE IN EFFECT UNTIL REVOKED BY THE PATIENT BY WRITTEN STATEMENT PROVIDED TO PAIN SPECIALTY GROUP. I HAVE READ, UNDERSTAND AND ACCEPT THE RELEASE OF INFORMATION FROM PAIN SPECIALTY GROUP.



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specializing in you


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Documents

NEW PATIENT CONSULT · phone and tablet app for a NEW PATIENT CONSULT will also be coming soon. P AT I E N T U P L O AD Ap p l i c a ti o n - Patients who need to provide documents