Pain Relief Centre
www.painreliefcentre.net
PALATKA
700 Reid Street Suite A
Palatka, FL 32177
32086 Ph: 386-328-4043
Fax: 386-328-4141
Scott Michaels M.D.
Sonja Navarro PA-C
ST AUGUSTINE
165 Southpark Blvd
Saint Augustine, FL
Ph: 904-823-8833
Fax:904-823-9394
Welcome to Our Office
New Patient Consent Forms
Please complete the following questionnaire. This will become part of your office record and will be held in
strict confidence.
Date _______________
Information on patient
Name (Mr/Mrs/Miss/Dr) _________________________________________________________________
Last name
First name
MI
Nickname _____________________________ Race ________________ Ethnicity_________________
Sex: □ Male □ Female Marital Status ____________________
Home address __________________________________________________________________________
City _____________________________________________ State ___________ ZIP _________________
Home phone ___________________________________ Work phone _____________________________
Date of birth ___________________________________ SS # ___________________________________
Occupation ____________________________________________________________________________
Physician ______________________________________________________________________________
Information on party responsible for payment
□ Check here if this information is the same as in the box above.
Home address __________________________________________________________________________
City _____________________________________________ State ___________ ZIP _________________
Home phone ___________________________________ Work phone _____________________________
Date of birth ___________________________________ SS # ___________________________________
Employer _____________________________________________________________________________
Relationship to patient____________________________________________________________________
Insurance information
______________________________________________________________________________________
1st insurance company
Policy #
Group #
Insured’s name
______________________________________________________________________________________
2nd insurance company
Policy #
Group #
Insured’s name
I agree to be responsible for any charges for services and materials supplied by Pain Relief Centre and its
doctors for the above patient.
_________________________________________________
_______________________
Signature of party responsible for payment
Date
Notice of Privacy Practices Acknowledgment Form HIPAA
Pain Relief Centre
www.painreliefcentre.net
PALATKA
700 Reid Street Suite A
Palatka, FL 32177
32086 Ph: 386-328-4043
Fax: 386-328-4141
Scott Michaels M.D.
Sonja Navarro PA-C
ST AUGUSTINE
165 Southpark Blvd
Saint Augustine, FL
Ph: 904-823-8833
Fax:904-823-9394
I acknowledge that I have received a copy of the Pain Relief Centre Notice of Privacy Practices and have had an
opportunity to review it. I have also been given an opportunity to request restriction on the use and disclosure of my
protected health information, as well as to request confidential treatment of communications relating to my health
information.
1. ______________________________________________________________________
Patient acknowledgement (Signature)
Date
Consent for Purposes of Treatment, Payment and Health Care Operations
I understand that, as a condition to my receiving treatment from Pain Relief Centre. The Pain Relief Centre may use or
disclose my personally identified health information for treatment to obtain payment for the treatment provided and as
otherwise necessary for the operations of Pain Relief Centre. These uses and disclosures are more fully explained in the
Notice of Privacy Practices that has been provided to and reviewed by me.
While I am here, I permit the employees, the doctor and all other persons caring for me to treat me in ways they judge are
beneficial to me. I understand the attending physician will explain to me the nature of my condition, his or her
recommended treatment and any associated risk involved. I also understand that he or she will explain to me other ways
this condition could be treated. I further understand that this care may include diagnostic testing, examinations, and
medical and/or surgical treatment, and that no guarantees have been made to me about the outcome of this care.
“Personally identifiable health information” refers to health and demographic information collected about me by my
physician (or other health care provider, public health authority, health plan, employer, life insurer, school or university, or
health care clearinghouse) that relates to my past, present or future physical or mental health or condition or payment for
provision of health care. The information identifies me, or there is a reasonable basis to believe that the information may
identify me.
I understand that privacy practices described in the Notice of Privacy Practices may change over time and that I have a
right to obtain any revised Privacy Notice by contacting Pain Relief Centre to make such a request. I may receive a
revised Notice of Privacy Practices by calling the office and requesting a revised copy by mail or by asking for one at my
next visit.
I also understand that I have the right to request Pain Relief Centre to restrict how my health information is used or
disclosed. Pain Relief Centre does not have to agree to my request for the restriction, but if Pain Relief Centre does
agree, Pain Relief Centre is bound to abide by the restriction as agreed. Finally, I understand that I have the right to
revoke/withdraw this consent, in writing, at any time. My revocation/withdrawal will be effective except to the extent that
Pain Relief Centre has taken action in reliance on my consent for use or disclosure of my health information. Provision of
future treatment maybe withdrawn if I withdraw my consent.
2.______________________________________________________________________
Signature
Date
Medicare lifetime consent & Medicaid: I certify that the information given by me in applying under Title XVII of the
Social Security Act is correct, and I authorize any holder of medical or other information about me to release it to the
Social Security Administration or its intermediaries or carriers as needed for this or a related Medicare claim. I assign the
benefits payable for the physician services to the physician or organization furnishing the services or authorize such
physician or organization to submit a claim to Medicare for payment to me.
3. ______________________________________________________________________
Signature
Date
Pain Relief Centre
www.painreliefcentre.net
PALATKA
700 Reid Street Suite A
Palatka, FL 32177
32086 Ph: 386-328-4043
Fax: 386-328-4141
Scott Michaels M.D.
Sonja Navarro PA-C
ST AUGUSTINE
165 Southpark Blvd
Saint Augustine, FL
Ph: 904-823-8833
Fax:904-823-9394
Controlled Substance/Opioid Prescription Utilization Agreement
(Narcotic prescription contract)
Patient name ______________________________________________ Chart # _____________________
The purpose of this agreement is to give the patient information about the medications he or she will be taking
for pain management and to ensure that the patient and physician comply with all state and federal regulations
concerning the prescribing of controlled substances such as opioids. The physician’s goal is for the patient to
have the best quality of life possible given the reality of his or her clinical condition. The success of treatment
depends on mutual trust and honesty in the physician-patient relationship and full agreement and understanding
of the risks of using opioids to treat pain.
1. A trial of opioid therapy with adjunctive analgesics can be considered for moderate to severe pain to reduce
the patient’s pain and increase function to give the patient the best quality life possible in view of his or her
clinical condition.
2. The patient should be informed of the risks of opioid therapy, which include but are not limited to the
following side effects: skin rash, constipation, sexual dysfunction, sleeping abnormalities, sweating, edema,
sedation, or the possibility of impaired cognitive (mental status) and/or motor ability. Overuse of opioids can
cause decreased respiration (breathing).
3. The patient should also be informed that opioid medication causes physical dependence. This means that if
the opioid medication is abruptly stopped or not taken as directed, withdrawal symptoms can occur. This is a
normal physiological response. A patient’s withdrawal response may include but is not limited to the following
symptoms: sweating, nervousness, abdominal cramps, diarrhea, goose bumps and mood alterations.
4. It should be noted that the physical dependence caused by opioid medication is not the same as addiction.
Similarly, a patient can be dependent on insulin to treat diabetes or prednisone (steroids) to treat asthma but not
be addicted to the insulin or prednisone. Unlike dependence, addiction is a primary, chronic neurobiologic
disease with genetic, psychosocial and environmental factors influencing its development and manifestation. It
is characterized by behavior that includes one or more of the following: impaired control over drug use,
compulsive use, continued use despite harm, and cravings. Patients who have a history of addiction should
notify the physician of since the treatment of opioids for pain may increase the possibility of relapse. A history
of addiction does not disqualify a patient for opioid pain treatment, but it does require the patient to start or
continue a recovery program.
5. Tolerance, which refers to a state of adaptation in which exposure to the drug results in the diminishing of one
or more of the drug’s effects over time, can occur with opioid medication. When long-term opioid use is
appropriate, persons who take long-acting formulations of these medications are less likely to become tolerant
than those who take short-acting formulations. To produce maximum function for the patient, the dose of the
opioid may need to be titrated up or down as necessary.
6. Only one physician should be responsible for prescribing all opioid medications and adjunctive analgesics to
the patient, and only one pharmacy should be used to obtain all opioid prescriptions and adjunctive analgesics
prescribed by the physician. The patient, on this covenant, must put the name and phone number of the
pharmacy he or she is going to use: Pharmacy ___________________________ Phone ___________________.
Pain Relief Centre
www.painreliefcentre.net
PALATKA
700 Reid Street Suite A
Palatka, FL 32177
32086 Ph: 386-328-4043
Fax: 386-328-4141
Scott Michaels M.D.
Sonja Navarro PA-C
ST AUGUSTINE
165 Southpark Blvd
Saint Augustine, FL
Ph: 904-823-8833
Fax:904-823-9394
7. The patient must inform the physician of all medications he or she is taking, since opioid medications can
interact with over-the-counter and prescribed medications.
8. The patient should be seen on a regular basis and given prescriptions for enough medication to last from one
appointment to the next (with only two or three days’ worth of extra medication). The extra medication is not to
be used without the explicit permission of the prescribing physician unless an emergency requires the patient’s
appointment to be deferred by one or two days.
9. At each visit, the patient must return all opioid and adjunctive medications prescribed by the physician in the
original bottles, as well as any other medications prescribed by a physician.
10. The patient must agree that any prescription refills (including those for pain medication) will only be
handled during the visit or other regular office hours. No refills will be handled during the evenings or on
weekends.
11. If the patient shows any evidence of hoarding drugs, acquiring any opioid medication or adjunctive analgesic
from other physicians (including from emergency rooms), using another patient’s medications, increasing or
decreasing the dosage without physician involvement, losing prescriptions, or failing to follow the agreed-upon
covenant, the physician may taper off all medications and possibly discontinue the physician-patient relationship
completely.
12. The patient may not use any illegal controlled substances, such as cocaine and marijuana. Doing so may
result in the possible discontinuation of the physician-patient relationship.
13. The physician reserves the right to perform random or unannounced urine toxicology testing. The presence
of a nonprescribed drug(s) or illicit drug(s) in the urine may result in termination of the physician-patient
relationship.
14. At all visits (initial and follow-up), the patient must fully communicate his or her pain level and functional
activity. This information allows the physician to choose the right medication and dose for the patient.
15. The patient must waive his or her right of privacy so that the physician can contact any health care provider,
pharmacy, legal authority or regulatory agency to obtain or provide information about the patient’s care or
actions.
The above agreement has been explained to me by _______________________________ and I agree to its
terms so that ____________________________ can provide quality pain management using opioid therapy to
decrease my pain and increase my function.
________________________________________________________________________
Patient signature
Date
________________________________________________________________________
Witness signature
Date
Pain Relief Centre
www.painreliefcentre.net
PALATKA
700 Reid Street Suite A
Palatka, FL 32177
32086 Ph: 386-328-4043
Fax: 386-328-4141
Scott Michaels M.D.
Sonja Navarro PA-C
ST AUGUSTINE
165 Southpark Blvd
Saint Augustine, FL
Ph: 904-823-8833
Fax:904-823-9394
Personal Representative Designation
The purpose of this form is to designate a patient’s Personal Representative(s) for discussion and disclosure of Personal
Health Information. The designation is voluntary and in no way affects benefits, claims processing and payment, or
eligibility status.
Patient information
Patient name:
Date of birth:
Policy #:
Type of information
Pain Relief Centre may discuss or release Personal Health Information to the Personal Representative(s) regarding the
following information: eligibility, billing, payment status, benefits, claims, medical information used to make payment
decisions, providers, appeals, and complaints about my health insurance coverage through Pain Relief Centre.
Authorized use and/or disclosure
I authorize Pain Relief Centre to release Personal Health Information to the person(s) named as my Personal
Representative for the purpose of assisting with, or facilitating, the coordination or payment of my health plan benefits. I
also understand that if my Personal Representative is not a health care provider or other person subject to federal privacy
laws, my Personal Health Information may no longer be protected by those privacy laws and may be subject to
redisclosure by my Personal Representative. Pain Relief Centre is not responsible should my Personal Representative
further disclose my protected Personal Health Information. I further understand that I have the right to limit the
information that you release under this authorization. Limitations for disclosure are identified below. By leaving this
section blank, I am creating a “no limitation” on disclosure of Personal Health Information.
Disclosure limitations:
________________________________________________________________________
________________________________________________________________________
Expiration and revocation
The authorization to release information to my Personal Representative(s) will automatically expire 365 days following
the termination of my health plan enrollment. I understand that I may revoke this authorization at any time by giving
written notice to the Plan Administrator. Revocation will not affect any action that Pain relief Centre has taken or any
information that has already been released based upon prior authorizations.
Designation of personal representatives(s)
Name of authorized person:
Relationship to patient:
SS#:
Name of authorized person:
Relationship to patient:
SS#:
Name of authorized person:
Relationship to patient:
SS#:
Signature and authorization
I, the undersigned, do hereby swear that I am the above-mentioned patient or an authorized legal representative of the
above-mentioned patient. I have read and understand the content of this Personal Representative Form. My signed
authorization is voluntary and I acknowledge that the information released may include protected and individually
identifiable information about me.
________________________________________________________________________
Signature of patient/legal representative
Date
________________________________________________________________________
Pain Relief Centre
www.painreliefcentre.net
PALATKA
700 Reid Street Suite A
Palatka, FL 32177
32086 Ph: 386-328-4043
Fax: 386-328-4141
Printed name of legal representative
Scott Michaels M.D.
Sonja Navarro PA-C
ST AUGUSTINE
165 Southpark Blvd
Saint Augustine, FL
Ph: 904-823-8833
Fax:904-823-9394
Description of legal representative relationship to patient
HIPAA Privacy Policy:
Acknowledgement of Receipt
Patient’s acknowledgement of receipt
The Pain Relief Centre Notice of Privacy Practices provides a thorough explanation of how we may use and
disclose your protected health information, as well as your rights as a patient.
I, __________________________________ , have received a copy of the Pain Relief Centre Notice of Privacy
Practices.
I choose to designate the individuals listed below as my primary contacts. Pain Relief Centre personnel may
share information with these primary contacts that is consistent with the Notice of Privacy Practices.
Patient’s name _______________________________ Patient’s DOB _______________
#1 Contact name ______________________________ Relationship ________________
Contact phone ________________________________
#2 Contact name ______________________________ Relationship ________________
Contact phone ________________________________
Signature ____________________________________ Date _______________________
(patient, parent, authorized representative)
************************************************
Inability to obtain acknowledgement
To be completed by Pain Relief Centre representative ___________________________
It was not possible to obtain the individual’s acknowledgement for the following reason(s):
_____ Emergency situation
_____ Patient physically unable to sign
_____ Patient refused
_____ Patient left office prior to obtaining signature
_____ Other reasons (list below)
____________________________________________________
Patient name ____________________________________________________________
Comments ______________________________________________________________
Signature of representative _____________________________ Date ________________
Pain Relief Centre
www.painreliefcentre.net
PALATKA
Scott Michaels M.D.
Sonja Navarro PA-C
700 Reid Street Suite A
Palatka, FL 32177
32086 Ph: 386-328-4043
Fax: 386-328-4141
ST AUGUSTINE
165 Southpark Blvd
Saint Augustine, FL
Ph: 904-823-8833
Fax:904-823-9394
Medical Records Release
To ensure that your medical records are held in the utmost confidentiality, please be as explicit as possible as to
where you want them sent.
Name __________________________________________________________________
Address ________________________________________________________________
Street
City
State
ZIP
Home phone _________________________ Work phone _______________________
Date of birth _________________________
Please transfer my medical records* as follows:
From:
_________________________
To: __________________________
_________________________
__________________________
_________________________
__________________________
_________________________
__________________________
*Records to be released:
__ Annual exam and Pap smear / Prostate
__ Labs/Xray
__ Birth control
__ Abortion care
__ All medical records
__ Other _____________________________________
I understand that my medical records are protected under state and federal confidentiality regulations.
Disclosure of information regarding drug and/or alcohol abuse and treatment, confirmed sexually transmitted
infections (including testing or treatment for HIV/AIDS), and diagnosis of mental illness or psychiatric care
cannot be released without my written consent.
Please initial below if you DO NOT want any of the following records released. All applicable records will be
released if nothing is marked.
_____ Drug and/or alcohol abuse, diagnosis or treatment
_____ HIV/AIDS testing and/or treatment
_____ Psychiatric care and/or mental illness
_____ Confirmed sexually transmitted infection test results and/or treatment
This consent can be revoked by me at any time unless action has been taken in reliance on it. If not previously
revoked, this consent will terminate in 90 days.
____________________________________________
Signature
____________________________________________
Witness
____________________________________________
Interpreter, if necessary
____________________________________________
Date
Pain Relief Centre
www.painreliefcentre.net
PALATKA
700 Reid Street Suite A
Palatka, FL 32177
32086 Ph: 386-328-4043
Fax: 386-328-4141
ST AUGUSTINE
Scott Michaels M.D.
Sonja Navarro PA-C
165 Southpark Blvd
Saint Augustine, FL
Ph: 904-823-8833
Fax:904-823-9394
Financial Policy
Thank you for choosing Pain Relief Centre as your health care provider. We are committed to quality patient
care at the lowest possible cost. The following is a statement of our financial policy that we require you to read
and sign prior to any services being rendered.
Please be aware that some, and perhaps all, of the services provided may be noncovered services that are
not considered reasonable and necessary by your insurance carrier.
Participating insurance plans
For those plans with which we are participating providers, all co-pays and deductibles are due at the time of
service. To properly bill your insurance company and avoid untimely delays, we require that you provide us
with accurate insurance information and allow us to maintain a copy of your insurance card on file. In the event
that your insurance coverage changes to a plan with which we do not participate, refer to the following
paragraph.
Nonparticipating plans
For those plans with which we do not participate, we do not accept assignment of insurance benefits and we do
not bill your insurance company. Payment is expected at the time services are rendered. Your policy is a
contract between you and your insurance company.
Minors
A minor must be accompanied by a guarantor for his or her account (the parent or guardian of the minor or other
adult accompanying the minor during each visit). An unaccompanied minor will be denied non-emergency
treatment unless charges have been pre-authorized to an approved credit plan or insurance plan.
Authorization to pay benefits to physician/clinic
I hereby assign payment directly to Pain Relief Centre for medical and/or surgical benefits, if any, otherwise
payable to me for services provided at the clinic (not to exceed my indebtedness to the clinic for those services).
I understand that I am financially responsible for charges not covered by my insurance.
Authorization to release information
I hereby authorize Pain relief Centre to release any information acquired in the course of my examination or
treatment to my referring physician and/or my insurance company.
Acknowledgement
I have read and understand the above Financial Policy and Benefit Authorization and agree to all provisions
outlined herein.
________________________________________________________________________
Signature of patient or responsible party
Date
Pain Relief Centre
www.painreliefcentre.net
PALATKA
700 Reid Street Suite A
Palatka, FL 32177
32086 Ph: 386-328-4043
Fax: 386-328-4141
Scott Michaels M.D.
Sonja Navarro PA-C
ST AUGUSTINE
165 Southpark Blvd
Saint Augustine, FL
Ph: 904-823-8833
Fax:904-823-9394
Surgery and Procedure Consent
Date _______________ Time _______________ am/pm
1. I consent to the performance upon (patient name) _______________________________
the operation or procedure of (technical name) ____________________________________. The reason for this
operation is _____________________________________________ , and it will be performed by
_________________________ and whomever he or she may designate as assistants.
_____ (initials)
2. The nature, purpose, risks and possibilities of complications associated with the operation or procedure have
been explained to me, and my questions have been satisfactorily answered.
_____ (initials)
3. It has been explained to me that, while a satisfactory result is expected, the following complications or side
effects may occur: bleeding, infection, damage to adjacent tissues or organs, swelling, pain, suture reaction,
delayed healing, scarring, anesthesia or medication reaction, recurrence, additional operations, and, in rare cases,
paralysis or death.
Additional risks, if any _____________________________________________________
_____ (initials)
4. No guarantee has been given by anyone as to the results of this surgery or procedure.
_____ (initials)
5. I consent to the doctors performing different or additional operations or procedures that they deem necessary
or advisable during the course of the operation or procedure.
_____ (initials)
6. I consent to the administration of such anesthetics and drugs as may be considered necessary or advisable for
this operation or procedure except for the following:
________________________________________________________________________
_____ (initials)
7. I am not known to be allergic and do not have intolerance to anything except the following:
________________________________________________________________________
_____ (initials)
8. I understand that I am encouraged and invited to ask any questions I may have, and all of my questions have
been answered to my satisfaction.
_____ (initials)
I have read and understood what this form contains.
____________________________________ __________________________________
Patient, parent or person authorized to sign for patient
Witness to signing
____________________________________________
Physicians’ signature
Pain Relief Centre
www.painreliefcentre.net
PALATKA
700 Reid Street Suite A
Palatka, FL 32177
32086 Ph: 386-328-4043
Fax: 386-328-4141
Scott Michaels M.D.
Sonja Navarro PA-C
PAST MEDICAL HISTORY: Please check if you have ever had any of the following: o Diabetes o Rheumatoid o COPD o PMS o Obesity Arthritis o Emphysema o Urinary Tract o Over Weight o Lupus o Asthma infections o High Blood o Scleroderm
o Pleurisy o Fibroids Pressure a o Pulmonary o Endometriosi
o Heart Disease o Reflux Fibrosis s o High Disease o Empyema o Back Pain Cholesterol o Peptic o Rib o Cystic o Hyperlipidemi
Ulcers Fractures Fibrosis a o Crohns o Hemorrhoid
o SLE Lupus o Coronary Disease s o Scleroderma Artery o Ulcerative o HIV o Psoriasis Disease Colitis o AIDS o Eczema o Hepatitis A o Kidney o Hepatitis B o Bells’ Palsy o Tuberculosis Stones or C o Stoke o Blood o Kidney o Preeclampsi
o TIA Disorder Disease a o Normal o Thalassemia o Lung Cancer o Gestational Pressure o Sickle Cell o Stomach Diabetes Hydrocephal
o Turners Cancer o Migraine us Syndrome o Colon Headache o Seizure o Kleinfelders Cancer o Measles Disorder Syndrome o Breast o Mumps o Myasthenia o G6PD Cancer o Rubella Gravis o Congenital o Skin Cancer o Varicella o Cerebral Heart Defect o Leukemia Shingles Palsy o Anemia o Other o Chicken Pox o Temporal o Gastoparesis Cancer o Cushing’s’ /Giant Cell o Raynaud’s disease Arteritis o Sleep Apnea o Conns o Polio o Thyroid disease o Vitamin D Disease o Diabetes Deficiency o Diverticuliti
Insipidius s o Appendiciti s o Gallbladder disease SURGICAL HISTORY: List all operations below Procedure Year ST AUGUSTINE
165 Southpark Blvd
Saint Augustine, FL
Ph: 904-823-8833
Fax:904-823-9394
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Depression Anxiety Bipolar Schizophreni
a Bed Wetting Night Terrors Narcolepsy Alcoholism Drug Addiction Personality Disorder IDD/MR ADD ADHD Parkinson’s Disease ALS Alzheimer’s disease Essential Tremor Brain Injury Pain Relief Centre
www.painreliefcentre.net
PALATKA
700 Reid Street Suite A
Palatka, FL 32177
32086 Ph: 386-328-4043
Fax: 386-328-4141
Scott Michaels M.D.
Sonja Navarro PA-C
ST AUGUSTINE
165 Southpark Blvd
Saint Augustine, FL
Ph: 904-823-8833
Fax:904-823-9394
MEDICATIONS: START date Medication Dose SIG DISP # STOP DATE ALLERGIES: List all allergies and any reactions that you have had Allergy Reaction Hives, Anaphylaxis:, Vomiting, etc SOCIAL HISTORY: TOBACCO # Pks # Years ETOH # Drinks / Day # Years DRUGS JOB FAMILY HISTORY: MOM DAD SIBLINGS MGM PGM 1st Cousin Pain Relief Centre
www.painreliefcentre.net
PALATKA
700 Reid Street Suite A
Palatka, FL 32177
32086 Ph: 386-328-4043
Fax: 386-328-4141
Scott Michaels M.D.
Sonja Navarro PA-C
ST AUGUSTINE
165 Southpark Blvd
Saint Augustine, FL
Ph: 904-823-8833
Fax:904-823-9394
Will you need referral for or require any of the following services? Please Circle all that apply Alcoholism Mental Health Counseling Drug Opioid Dependency Specialist Care Home Health Services Hospice Care Surgical Care Nutritional Services Smoking Cessation Counseling Will you require an Excuse Note for todays office visit? YES NO