Chronic Pain Management | TN | MS - Midsouth Pain ...



MidSouth Pain Treatment CenterMichael E. Steuer MD PCMidSouth Interventional Pain Institute LLC Southaven Location:122 Airways PlaceSouthaven, MS 38671Phone: 662-349-9990Fax: 662-349-2026Oxford Location:2908 S. Lamar 2nd FloorOxford, MS 38655Phone: 662-236-5442Fax: 662-236-5295Cordova Location:146 Timbercreek, Ste 200Cordova, TN 38018Phone: 901-751-4112Fax: 901-751-9878Jackson Location:2016 Greystone Sq.Jackson, TN 38305Phone: 731-664-1773Fax: 731-664-1751Tupelo Location:609 Brunson DriveTupelo, MS 38801Phone: 662-891-8662Fax: 662-236-5295Michael E. Steuer, MD * Bradley W. Wargo, DOHolly T. Robertson, FNP-BC * Teresa D. Smith, FNP-BC * Christy Egbert, FNP-CSusan D. Smith, CFNP * Ouida Wilkes, APRN, FNP-BCHillary Moss, FNP-C * Amanda Lee, AGACNP-BC* Sheryl Kirk, FNP * Stephanie Cagle, FNP-C Dear New Patient:Thank you for scheduling with MidSouth Pain Treatment Center. Your appointment is as follows:Date_________________________________Time_________________________________am/pm Location_________________________________You should plan to be in the office for approximately two to four hours for your initial visit. The actual amount of time spent in our office will depend upon the complexity of your pain problem(s) and any unavoidable delays as a result of completing the required medical forms. ***If your pain is the results of a work related injury, an automobile accident, or if you have an attorney involved due to litigation, it is very important that you provide us with this information before your appointment date.*** Please be prepared to pay any co-pays or fees your insurance requires at time of service. The physicians and staff look forward to meeting and working with you to manage your pain.**All outpatient procedures are performed in either our Southaven or Germantown surgery center.***Items you will need for your appointment:Photo ID (must have to be seen)Insurance Card(s)Prescription card Copay, co-insurance, or deductible (if applicable) –Cash, money order, credit or debit cards are accepted. WE DO NOT ACCEPT PAYMENT BY CHECK.ALL medications you currently take, in their original bottles.The enclosed paperwork- Paperwork needs to be filled out completely If your insurance requires a referral form from your primary care physician, please make certain we receive the referral form before the day of your appointment*****Failure to provide the items listed above may result in the rescheduling of your appointment.******Please contact our office immediately if you should need to cancel or reschedule your appointment.Michael E. Steuer, MD PCName: __________________________________________________________________ Date: _______________Referred By: _____________________________________________________________Primary Care Physician: ___________________________________________________Chief Complaint (my worst pain is): _________________________________________Other Pain Complaints:Abdominal PainCervical PainFacial PainGroin PainHeadacheHip PainButtock PainLow Back PainShoulder PainThoracic PainRight Arm PainRight Hand PainLeft Arm PainLeft Hand PainRight Leg PainRight Foot PainLeft Leg PainLeft Foot PainRight Knee PainLeft Knee PainWhat is the cause of your pain?_____________________________________________________________________________________________________________________________________________11156951885950057785018859500Gender: Male Female 907415996950019475459969500Age: ________ Right Handed Left HandedHistory of Pain: _____ year(s) _____ month(s) _____ weeks(s)Type of Pain:ConstantIntermittentDullAchingThrobbingBurningSharpStabbingPulsatingTinglingNumbThings that make your pain worse:Prolonged sittingBendingStoopingLiftingProlonged standingArching backTwisting at waistProlonged walkingTurning head rightTurning head leftTilting head rightTilting head leftExtending neckRaising arm rightRaising arm leftNONE of the abovePain LevelCircle the number that best describes your pain on average last month:1 2 3 4 5 6 7 8 9 10 No Unbearable Pain PainPain interferes with sleep _______ nights per week.Things that help relieve your pain:HeatIceHot shower and bathRestPhysical therapyChiropractic treatmentMedicationsNONE of the aboveCurrent Medications: Medication Dosage Frequency/# of tabs left Prescribing DoctorMark the medications you have taken in the PAST: Opioids NSAIDS Tranquilizers Anti-depressants Mem/StabVicodinLorcet PlusPercocetPercodanTyloxFiorinalMethadoneLortabOxycontinDuragesicMS ContinMSIROxyIRActiqNucyntaRoxicodoneDilaudidAdvilMotrinIbuprofenNaprosynRelafenDayproVolatrenOrudisCelebrexBextraMobicValiumAtivanXanaxKlonopinSeroquelBusparElavilAmitriptylineDesyrelPaxilProzacZoloftEffexorSerzoneCelexaWellbutrinZyprexaLexaproAbilifyNeurontinTegretolMexiletineDepakoteGabitrilTrileptalKeppraTopamaxZonegran Muscle Relaxers Other OtherFlexerilNorflexRobaxinSkelaxinSomaZanaflexBaclofenRelpaxAxertMaxaltDHE/ErgotDrugsTylenolUltramUltracetImitrexZomigSuboxone158432525527000Do you have allergies? YES If YES, what are you allergic to? ________________________ ________________________15805152667000 NO ________________________ ______________________Past Medical History:High Blood PressureDiabetesHigh CholesterolHeart ProblemsStrokeSeizuresCongestive Heart FailureEmphysemaAsthmaLung DiseaseHIV/AIDSCancer *if yes, Type? ____________________Prior Radiation TreatmentPrior Chemotherapy TreatmentHepatitisKidney StonesHistory of Bladder/Kidney InfectionsThyroid DiseaseBowel DiseaseScoliosisArthritisStomach RefluxStomach UlcersAnxietyBipolarDepressionSchizophreniaHistory of Sleep Apnea2696845266700023050503048000(Do you use a breathing machine? Yes NoPrevious Pain Treatments:Physical Therapy *If yes, circle belowLow back Mid back Neck HipOther _________________________Chiropractic TherapyTENSAcupunctureLumbar/Cervical BlocksTrigger Point InjectionPeripheral Nerve BlockBack BraceSpinal Cord StimulatorOther ___________________________Past Surgical History:NoneLumbar LaminectomyCervical LaminectomyTonsillectomyAppendectomyGallbladder SurgeryTubal LigationHysterectomy/OvariesHemorrhoidsHerniaCataractsCardiac CatheterizationCardiac BypassKnee Surgery *If yes, L or ROther ____________________________Social History:3558540406400030365703683000Are there any substance abuse issues in your household? Yes No539877040640004531995444500037191954064000305371540640009404354064000Marital Status: Married (how many years? ______) Single Divorced Widowed Separated445325543180003006725393700020567654318000111125043180004718054699000Lives: Alone with Family with Spouse with Significant Other with RoommateNumber of Children _______ Number of Grandchildren _______3999230361950034918653619500Type of Work ______________________________ Disabled? Yes No18072104191000Pain had a significant impact on: General Lifestyle18135604762500 Social Lifestyle18192755334000 Sexual LifestyleSubstance Utilization History:3725545412750042418004508500133223053340008255005334000Cigarettes ? Yes No Alcohol? Yes NoPacks per day? _________ # of Drinks per week: ________151066548895009766304508500Quit Smoking? Yes No # of DUI: ________5085080463550045802555016500 History of Alcohol Abuse? Yes No5838190349250053447954064000 History of Recreational Substance Abuse? Yes No5850255495300053505104953000 History of Prescription Substance Abuse? Yes No158940534925002323465374650032556453683000399351545085005097145425450059289954572000 Which Drugs? Alcohol Barbiturates Cocaine Amphetamines Marijuana OtherFamily HistoryHigh Blood Pressure CancerMigrainesDiabetesLung DiseaseAlcohol AbuseHeart DiseaseStrokeSubstance AbuseList family members or friends that are patients here: ____________________________________________________General/ConstitutionalFeverChillsWeight ChangeFatigueGenitourinaryUncomfortable UrinationUrinary FrequencyUrinary UrgencyUrinary HesitancyUrinary incontinenceEyesBlurry VisionDouble VisionLoss of VisionEye PainMusculoskeletalBack PainJoint PainNeck PainMuscle AchesMuscle WeaknessEar/Nose/ThroatTinnitus (ringing in the ears)Hearing LossSwallowing DifficultiesSkinBruisingChange in SkinEasy BruisingNon-healing SorePersistent RashCardiovascularChest PainPalpitationsDyspnea on ExertionOrthopnea (Shortness of breath lying down)PND (shortness of breath during sleep)Peripheral EdemaRapid HeartbeatIrregular HeartbeatClaudication (leg pain when walking)NeurologicBowel ProblemsDizzinessFallingHeadachesInvoluntary MovementsImbalanceLoss of ConsciousnessMemory LossRestless LegsSeizuresSensory Loss (numbness)Sleep DisturbanceSpeech DifficultySyncopeTinglingTremorsWeaknessRespiratoryLung ProblemsChronic CoughShortness of BreathUncomfortable BreathingExcessive SputumWheezingPsychiatricAnxietyDepressionDifficulty ConcentratingHallucinationsPanic AttacksParanoiaSevere Mood SwingsSuicidal ThoughtsTrouble SleepingGastrointestinalGI SymptomsAbdominal PainFrequent DiarrheaFrequent ConstipationNauseaVomitingEndocrineDiabetesThyroid DiseaseHeat IntoleranceCold IntoleranceLarge Volumes of UrineHematologic/LymphaticExcessive BleedingEasy BruisingAllergic/Immunologic HivesHay FeverHIV ExposureOther (describe): MidSouth Pain Treatment Center, LLCSOAPP-RPatient Name: _____________________________________________ Date: ____________________________The following are some questions given to patients who are on or being considered for medication for their pain. Please answer each question as honestly as possible. There are no right or wrong answers.Never0Seldom1Sometimes2Often3Very Often4How often do you have mood swings?How often have you felt a need for higher doses of medication to treat your pain?How often have you felt impatient with doctors?How often have you felt that things are just too overwhelming that you can't handle them?How often is there tension in the home?How often have you counted pain pills to see how many are remaining?How often have you been concerned that people will judge you for taking pain medication?How often do you feel bored?How often have you taken more pain medication than you were supposed to?How often have you worried about being left alone?How often have you felt a craving for medication?How often have others expressed concern over your use of medication?How often have any of your close friends had a problem with alcohol or drugs?How often have others said you had a bad temper?How often have you felt consumed by the need to get pain medication?How often have you run out of pain medication early?How often have others kept you from getting what you deserve?How often, in your lifetime, have you had legal problems or been arrested?How often have you attended an AA or NA meeting?How often have you been in an argument that was so out of control that someone got hurt?How often have you been sexually abused?How often have others suggested that you have a drug or alcohol problem?How often have you had to borrow pain medication from your family or friends?How often have you been treated for an alcohol or drug problem?SCORE:_________________________MACRA Patient Name ________________________________________ Date ____________________Over the last 2 weeks, how often have you been bothered by any of the following problems?Read each item carefully and circle your response.Little interest or pleasure in doing thingsNot at all Several days More than half the days Nearly every dayFeeling down, depressed, or hopelessNot at all Several days More than half the days Nearly every dayTrouble falling asleep, staying asleep, or sleeping to muchNot at all Several days More than half the days Nearly every dayFeeling tired or having little energyNot at all Several days More than half the days Nearly every dayPoor appetite or overeatingNot at all Several days More than half the days Nearly every dayFeeling bad about yourself, feeling that you are a failure, or feeling that you have let yourself or your family downNot at all Several days More than half the days Nearly every dayTrouble concentrating on things such as reading the newspaper or watching televisionNot at all Several days More than half the days Nearly every dayMoving or speaking so slowly that other people could have noticed, or being so fidgety or restless that you have been moving around a lot more than usualNot at all Several days More than half the days Nearly every dayThinking that you would be better off dead or that you want to hurt yourself in some wayNot at all Several days More than half the days Nearly every dayIf you checked off any problem on the questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?Not Difficult at All Somewhat Difficult Very Difficult Extremely DifficultMidSouth Pain Treatment has made a commitment to promote the health of its members and provide education regarding preventive health measures that you can take to maintain a healthy lifestyle. As a health care provider, it is important that comprehensive healthcare is considered for you, including preventive health screenings. Please assist us in making sure our records are up to date so we can best assist you in your care. In order to gain a better idea as to how best to assist you, kindly take a few minutes to answer the following questions:Would you like to join our patient portal in order to send and receive secure messages from your provider? Y / N If yes, what is your email address so we can send you an invitation to join? __________________________________Would you like to receive reminder texts for your appointments? Y / NIf yes, what cell phone number would you like to be used for the reminder texts? ____________________________Lifestyle:Smoking status: Do you consider yourself as any of the following:Current every day smoker: Y / NCurrent some day smoker (every so often): Y / NHeavy tobacco smoker: Y / NLight tobacco smoker: Y / NI never smoked: Y / NWhen did you start smoking? Date: ______________________How much do you smoke (packs per day): ?, ?, 1, 2, 3, or 4Regarding previous smoking status:I previously smoke but no longer smoke: Y / N Length of time since you quit? _______Days/Months/YearsHow much did you smoke? (packs per day) ?, ?, 1, 2, 3, or 4If you currently smoke, do you wish to be provided with tobacco cessation information or learn more about the health effects of tobacco use? Y / NDo you use smokeless tobacco? Y / NNote: Tobacco use is a leading cause of many preventable diseases. IF YOU ARE A SMOKER, it is highly and strongly encouraged that you quit.Are you interested in receiving information and/or counseling to promote sustained weight loss? Y / NNote: The NSH suggested BMI (body mass index) range is 22-30Flu season is September through March. It is important to get your annual flu shot.When did you receive your last flu shot? Date:___________ Where did you received it? ______________________Note: Influenza vaccination has been shown to decrease hospitalizations for influenza, especially for those with risk factors. However, annual influenza vaccinations remain low.When did you receive your last pneumonia vaccine (pneumovax)? Date: _______________Where did you receive it? ___________________________________Michael E. Steuer, MD PC PATIENT REGISTRATIONINFORMATION ---- Please complete all sectionsFirst Name____________________________________ MI __________ Last Name _______________________________________333184514668500292989014668500Date of Birth _______ / _______ / _______ Sex M F SSN _______-_______-______________Mailing Address ________________________________________________________________________________________________2019304318000 City / State / Zip_________________________________________________________________________________________Physical Address ________________________________________________________________________________________________2019304064000 City / State / Zip ________________________________________________________________________________________(If different than mailing address)County___________________________ Home # ( ) ________ - __________ Cell # ( ) ________ - __________Email Address _________________________________________________________________________________________________Emergency Contact ________________________________________________________ Phone ( ) ________ - __________2019303556000 Relationship to Patient _____________________________________________Marital StatusSingleMarriedDivorcedWidowedOtherSeparatedLife PartnerLanguageEnglishFrench GermanVietnameseItalianMandarinSpanishRace Hispanic Other Asian Undetermined Caucasian Chinese Pacific Islander Filipino Black or African American Japanese Native American Native Hawaiian American Indian or Alaska Native MultiracialEthnicityHispanic or LatinoNon-Hispanic or LatinoOther or UndeterminedEmployer ________________________________________________________ Work # ( ) ________ - __________Employer Address _________________________________________________ City / State / Zip ________________ Referring Physician ________________________________________ Physician Phone # ( ) ________ - __________Referring Physician Address __________________________________________ City / State / Zip ________________ Primary Insurance ______________________________ Policy ID # ____________________ Group # ___________468884016256000587057515049500521144515049500Policy Holder __________________________________ Relation to Patient Self Spouse OtherPolicy Holder SS # (if different from patient)_______ - _______ - ______________ DOB _______ / _______ / _______Primary Insurance Address _______________________________________ City / State / Zip ___________________ Secondary Insurance ____________________________ Policy ID # ____________________ Group # ___________468884016256000587057515049500521144515049500Policy Holder __________________________________ Relation to Patient Self Spouse OtherPolicy Holder SS # (if different form patient)_______ - _______ - ______________ DOB _______ / _______ / _______Secondary Insurance Address _____________________________________ City / State / Zip ____________________Michael E. Steuer, MD PC PATIENT REGISTRATIONAUTHORIZATION OF PAYMENT & RELEASE --- I hereby authorize (a) payment of insurance benefits due to me to be made directly to Michael E. Steuer, MD, PC/MidSouth Interventional Pain Institute, LLC, (b) release of information including protected health information to insurance companies as needed to file for payment for services incurred, (c) Michael E. Steuer, MD, PC/MidSouth Interventional Pain Institute, LLC to obtain records from other sources as may be necessary in the diagnosis or treatment, and (d) understand that I am financially responsible for payment to Michael E. Steuer, MD, PC/MidSouth Interventional Pain Institute, LLC, for charges related to services provided or incurred by me or my dependents.I am aware that my insurance carrier may determine that certain procedure(s) may be a Investigational Service, may not be a covered service or may not be medically necessary or medically appropriate as those terms defined in my member healthcare benefits plan, I acknowledge that my insurance carrier may not pay for the service(s) and I will be responsible to pay for all costs associated with the service(s), including, by not limited to, practitioner costs, facility cost, ancillary charges and any other related expenses at an established standard fee. I also understand that Michael E. Steuer, MD, PC/MidSouth Interventional Pain Institute, LLC, verifies my insurance specialist benefits and files my insurance claims as a courtesy.Patient Signature __________________________________________________________________________ Date ______________________________PATIENT CONTRACTI, ______________________________________________, a new patient of Michael E. Steuer, MD, PC/MidSouth Interventional Pain Institute, LLC verify and confirm that I have no current association with any other pain treatment facility and I am aware that a certain level of bilateral trust must be developed between my doctors and me as a patient within this practice.Accordingly, I understand that the payment I am making today is compensation to Michael E. Steuer, MD, PC/MidSouth Interventional Pain Institute, LLC, for my initial medical evaluation only. I have not been promised any particular medication(s) by any provider or associate in exchange for this fee (quid pro quo). Additionally, no other doctor has represented to me that such medication would be prescribed for me in exchange for this fee. I further understand that if any provider or associate within Michael E. Steuer, MD, PC/MidSouth Interventional Pain Institute, LLC deems that I am currently not a candidate for strong pain medications, no such medication will be prescribed.In addition, a urine specimen will be collected today as is standard for every new patient consultation. Urine drug screen will be conducted randomly throughout my course of treatment within Michael E. Steuer, MD, PC/MidSouth Interventional Pain Institute, LLC. I understand that I will be responsible for any resulting outstanding balances from charges incurred through an independent lab regardless of insurance coverage and/or payment.Patient Signature __________________________________________________________________________ Date ______________________________MICHAEL E. STEUER, MD, PCACCIDENT INFORMATION & ASSIGNMENTIs this appointment related to one of the following? (answer each question)4420235247650035045652349500A workman’s comp injuryYESNOPlace of employment and address where injury occurred: ________________________________________________________4420235133350035045652540000A motor vehicle accidentYESNO[If yes, please describe how and when the accident occurred]____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________4432300209550035045652095500Any other type of injury (such as slip and fall in a store, etc.)YESNO[If yes, please describe how and when the accident occurred]____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________4432300165100035166301651000Are you involved in a lawsuit?YESNOI hereby authorize all rights, benefits and interest in all plans of health insurance, cases or claims arising from my condition, whether against an insurance company, corporation, individual or any other entity, to Michael Steuer, MD, PC and MidSouth Interventional Pain Institute, LLC. Furthermore, I have been advised that Michael Steuer, MD, PC and MidSouth Interventional Pain Institute, LLC are unable to file charges resulting in an automobile or accident injury (a third party is involved) to my personal insurance carrier. I understand that I am ultimately responsible for payment of all charges if not otherwise paid (unless prohibited by law or plan contract). I further understand that any amount paid in excess of the regular charges will be refunded as appropriate to the third party payer or to the patient or guarantor. However, in cases where the patient or guarantor has other outstanding charges, the overpayment will be applied to those charges.Patient Signature (Responsible Party) _______________________________________________________ Date ______________________________Michael E. Steuer, MD PC ?MidSouth Interventional Pain InstituteAuthorization of Use of Disclosure of Protected Health InformationPerson(s) Authorized to Receive Information:Health Information collected or received by the facilities listed above about you may be disclosed to the following person/persons:________________________________________ ________________________________________Name of Person Relationship Name of Person RelationshipUses and Disclosures of Information:I authorize the healthcare professional(s) deemed necessary by the above listed facilities to receive all health information about appointments, treatment and/or other information pertinent to my healthcare and/or payment for my healthcare provided at these facilities.I authorize to communicate (verbally/written) and/or send records to my treating physician(s) to better coordinate my care so all my providers are aware of my healthcare needs.I acknowledge Michael E. Steuer, MD PC/MidSouth Interventional Pain Institute, LLC will access my state prescription monitoring report on a regular basis which will become part of my permanent record.Authorization:This authorization is effective throughout the course of medical treatment received at the above facilities unless revoked or terminated in writing by the patient or patient’s personal representative.Right to Terminate or Revoke Authorization:You may revoke or terminate this authorization by submitting a written revocation to the facilities listed above.Potential for Re-disclosure:The person(s) or organization(s) to which health information is sent may repeatedly disclose health information that is identified by this authorization. The privacy of this information may not be protected under the federal privacy regulations.Other Uses and Disclosures:Disclosure of your health information or its use for any purpose other than those listed in the “Notice of Privacy Policies and Practices” brochure and/or consent will require your specific written authorization. If you change your mind after authorizing a use or disclosure of your information, you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision. You have the right to request restrictions on use and disclosure of your health information.I would like the following restriction regarding the use and disclosure of my health information:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________I acknowledge that I have received a copy of the Notice of Privacy & Practices.___________________________________________ ___________________________________________Print Patient Name Date___________________________________________ ___________________________________________Patient Signature Staff Witness___________________________________________ ___________________________________________Patient Representative RelationshipMichael E. Steuer, MD PC MidSouth Interventional Pain Institute, LLC365760257175PATIENT/RESPONSIBLE PARTY FINANCIAL POLICY00PATIENT/RESPONSIBLE PARTY FINANCIAL POLICYPatient Name:___________________________________ DOB: ______________ Age: ______ Gender: _____ Date: _____________In order to establish a complete understanding of the financial responsibilities associated with the care provided by the facilities listed above, the financial policies outlined herein are provided for your review. If you have any questions, please feel free to ask one of our Billing Department Representatives for clarification.It is our desire that you receive the maximum benefit possible from your health insurance. In order to achieve this, we need your assistance in providing complete and accurate personal and insurance information requested on our Patient Registration Form. Please complete this form in its entirety and provide your insurance card to be copied.We have verified your insurance coverage as a courtesy to you. We will also submit any claims to your insurance company as a courtesy. When coming in for an office visit, your co-payment/co-insurance is due at the time of service. Insurance companies will not tell us exactly what your portion will be until they receive the claim and review it; therefore, the payment you make will apply to your balance for that specific date of service. Then you will be responsible for only the remaining balance. Financial arrangements are available for outpatient procedures only. We accept cash, money orders, Care Credit, and Visa, MasterCard, Discover and American Express. WE NO LONGER ACCEPT CHECKS!!..NO EXCEPTIONS. All services rendered are the responsibility of the patient or guarantor regardless of insurance. ________ InitialsIf your insurance company considers our Physician or Surgery Center out-of-network, we will inform you. Most insurance carriers do have out of network coverage. A billing department representative is available to discuss payment arrangements. ________ InitialsIf payment is issued to you by your insurance carrier due to the carrier being out-of-network, it is your financial responsibility to issue payment to this facility for services that were provided. ________ InitialsIn the event that a patient’s account is turned over to a collection agency for further collection actions, the patient will be responsible for all collection, legal, and court costs related to the patient’s account and unpaid balances. ________ InitialsPatient PolicyPrescriptions: Prescriptions required between scheduled office visits may be provided at the discretion of your provider at a charge of $25.00 per month and is due at the time the prescription is picked-up. This charge is a maintenance fee charged directly to you, the patient, as the prescription pick-up requires staff time for receiving and placing calls, input of prescription information, as well as ensuring the integrity of the patient prescription pick-up process. ________ InitialsCancelled Appointments: Cancellation of an office visit must be made 48 hours in advance or a $75.00 cancellation fee will be charged to the patient. Cancellation of a procedure must be made 48 hours in advance or a $100.00 cancellation fee will be charged to the patient. ________ InitialsWorker’s Comp: All workman’s compensation cases must be approved by the workman’s compensation carrier. If your workman’s compensation case closes/settles during your treatment at our facility, you must notify our office immediately. You will be considered a Self-pay patient unless you provide our office with your personal insurance information. ________ InitialsMotor Vehicle Accident: WE DO NOT FILE ANY MVA CASES TO YOUR HEALTH INSURANCE!! If you are in a lawsuit or become involved in a lawsuit, you must notify our office immediately with your attorney’s information. ________ InitialsPhone Calls: If a representative is unavailable to take your call, please leave a detailed message with a working phone number. Your call will be returned as a staff member becomes available: multiple calls per day will not be tolerated. There is no after hour number. If you are having urgent problems after hours, on the weekends, or on holidays, you should go to the nearest ER or outpatient emergency walk-in clinic for evaluation. ________ InitialsNurse/Medication Calls: Your call will be returned by a nurse the same day if received before 4:00 p.m. Monday through Thursday. You must give our office a working phone number and be available to answer when the nurse returns your call. There is no after hours number. If you are having urgent problems after hours, on the weekends, or on holidays, you should go to the nearest ER or outpatient emergency walk-in clinic for evaluation. ________ InitialsAppointments: There are no walk-in appointments. Do not walk into the clinic demanding to be seen if your do not have a scheduled appointment. ________ InitialsPrimary Care Doctor: You are required to have a primary care doctor that treats all your non-pain problems. Should you be involved in an accident, a fall or other injury, you must have this evaluated by your primary care doctor or go to the ER for evaluation. We do not treat new injuries or acute pain. Your pain doctor does not admit to the hospital. All chronic pain is treated on an outpatient basis. ________ InitialsMedical Forms and Letters: This office charges for filling out forms and writing letters. This charge must be paid prior to the forms being filled out or the letter being written. Our physicians are not certified to give disability ratings or fill out functional capacity evaluation (FCE) forms. Please DO NOT have your lawyer or workmen’s compensation carrier send forms requesting this information. ________ InitialsPatient Behavior: No firearms are allowed in the clinic. Your doctor will not see you is you have a firearm with you. We do not tolerate abusive behavior in the clinic or over the phone. We expect our patients to be pleasant and cooperative. Inappropriate or abusive behavior may result in our inability to continue your care in this practice. ________ InitialsRight to Refuse: Providers have the right to refuse treatment or to give prescription(s) if a patient is non-compliant with their treatment regimen designed specifically for each patient’s pain management needs. ________ InitialsI have read, understand, and have been given a copy of the patient policy guidelines. By signing below, I am agreeing to follow these policies.___________________________________________________ _________________________Print Name Date___________________________________________________Patient/Guardian SignatureMidSouth Pain Treatment CenterMichael E. Steuer, MD, PC122 Airways Place, Southaven, MS 38671 - Ph: 662-349-9990 Fx: 662-349-2620146 Timbercreek, Ste 200, Cordova, TN 38018 - Ph: 901-751-4112 Fx: 901-751-98782908 S. Lamar 2nd Floor, Oxford, MS 38655 - Ph: 662-236-5442 Fx: 662-236-52952016 Greystone Sq., Jackson, TN 38305 - Ph: 731-664-1773 Fx: 731-664-1751609 Brunson Dr., Tupelo, MS 38801 - Ph: 662-891-8662 Fx: 662-269-1771ADVANCE DIRECTIVES FOR MEDICAL CAREUnder the Federal Patient Self Determination Act, we as healthcare providers are obliged to inform you that, as a competent adult or as the parent/legal guardian/patient representative, you have the right to make advance decisions regarding your healthcare.In the event of a life-threatening emergency, it is the policy of the MidSouth Pain Treatment Center to perform Cardiopulmonary Resuscitation (CPR) as necessary to stabilize our patients for transfer to an acute healthcare facility.In order to fulfill our obligation we must ask the following questions:1. Do you have an Advance Directive? ( ) Yes ( ) No2. If yes, what type of Advance Directive do you have? (Do Not Resuscitate form (DNR), Living Will, etc.)___________________________________________________________________________________________________3. Did you bring a copy with you? ( ) Yes ( ) No4. Where is the original document? ______________________________________________________________________________________________________________________________________________________________________I am stating that I have read the above and understand my rights in the making of advance healthcare decisions. I further understand that, if I have a Living Will or any form of Advance Directives, I must inform the MidSouth Pain Treatment Center of the same, and it is my responsibility to present them a copy.Patient Name: ___________________________________________________ Date: ___________________Patient Signature: ________________________________________________Patient Representative Signature: ___________________________________Witness (Staff): __________________________________________________ Date: ___________________General Consent for Care and Treatment ConsentTO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s). This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at this office or any other satellite office under common ownership. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services. You have the right to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions. I voluntarily request a physician, and/or mid-level provider (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist), and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s). I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents. ___________________________________________________________________Signature of Patient or Personal Representative Date: ____________________________________________________________________Printed Name of Patient or Personal Representative Relationship to Patient ____________________________________________________________________Printed Name of Witness Employee Job Title _____________________________________________________________________Signature of Witness DateConsent to Obtain Patient Medication HistoryPatient medication history is a list of prescription medicines that our practice providers, or other providers, have prescribed for you. A variety of sources, including pharmacies and health insurers, contribute to the collection of this history.The collected information is stored in the practice electronic medical records system (EHR/EMR) and becomes part of your personal medical record. Medication history is very important in helping healthcare providers treat your symptoms and/or illness properly and in avoiding potentially dangerous drug interactions.It is very important that you and your provider discuss all your medications to ensure that your recorded mediation history is 100% accurate. Some pharmacies do not make drug history information available, and your drug history might not include drugs purchased without using your health insurance. Also, over-the-counter drugs, supplements, or herbal remedies that patients take on their own may not be included. I give m permission to allow my healthcare provider to obtain my medication history from my pharmacy, m health plans, and my other healthcare providers.______________________________________________________________________Patient/Parent/Guardian SignatureDateBy signing this consent form you are giving your healthcare provider permission to collect and giving your pharmacy and your health insurer permission to disclose information about your prescriptions that have been filled at any pharmacy or covered by any health insurance plan. This includes prescription medicines to treat AIDS/HIV and medicines used to treat mental health issues such as depression. Appointment No-ShowsIt is the policy of the Practice to monitor and manage appointment no-shows. Any patient who fails to arrive for a scheduled appointment without canceling the appointment less than 48 (Monday through Thursday prior to 4:00 p.m.) hours prior to the scheduled time is considered a “no-show”. A no-show patient is charged a fee (Clinic- $75, ASC- $100), as established by the Practice, for failure to no-show. A patient who consistently fails to present themselves for scheduled appointments is considered a chronic no-show. A patient who is a no-show more than three times is dismissed from the Practice. By giving the Practice 48 hour’s prior notice, the Practice is able to schedule another patient needing to be seen._________________________________Patient Name_________________________________ ____________________Patient Signature DateLEAVE BLANKADVANCE DIRECTIVE INFORMATIONPOLICY:The Center shall provide each adult individual the choice to formulate Advance Directives with respect to the patient’s rights of self-determination.OBJECTIVE:To enable this Center to protect each adult patient’s right to participate in healthcare decision making to the maximum extent of his or her ability.PROCEDURE:The Center shall provide the patient, or as appropriate, the patient’s representative in advance of the date of the procedure, with information concerning the Center’s policies regarding the right to make healthcare decisions and to formulate Advance Directives, and the way such decisions and directives will be implemented in the Center.This Center shall provide upon request, written information describing:An individual’s rights under applicable statutes.Official state advance directive formsThe Center shall document in the individual’s medical record whether or not the individual has executed an Advance Directive. For purposes of this policy, an Advance Directive means a written instruction that related to the provision of healthcare when the individual is incapacitated, such as a Durable Power of Attorney for Healthcare, a Declaration pursuant to the National Death Act, or a Living Will.This Center shall comply with applicable statutes and court decisions regarding Advanced Directives.This Center shall not condition the provision of care or otherwise discriminate against an individual based on whether or not the individual has executed an Advance Directive.This Center shall provide education to staff on issues that concern Advance Directives.Educational information about Advance Directive and the Center’s policy and procedure regarding Advance Directives will be provided to the medical and nursing staff.For purposes of this policy, the following terms shall be interpreted in accordance with their respective definitions as set forth below:Medical Decision Making: authorization for treatment, the withholding of treatment, or the withdrawing of treatment (including life-sustaining treatment) obtained from the patient or, in the event of the patient’s incapacity, from the patient’s surrogate decision maker.Life-Sustaining Treatment: any medical intervention, including the administration of fluids and nutrition by artificial means that sustains life for a particular patient.Advance Directive: a written instruction, such as a Living Will, Durable Power of Attorney for Healthcare, or other documentary evidence recognized by the courts of this state, relating to the provision of medical care when the author is incapacitated.Surrogate Decision Maker: an individual other than the patient to whom healthcare providers appropriately look for medical decision making regarding the patient’s care when the patient is incapacitated. This individual may be formally appointed (e.g., by the patient in a Durable Power of Attorney for Healthcare, or by a court in a conservatorship of guardianship proceedings) or, in the absence of a formal appointment, may be informally authorized by virtue of a relationship with the patient (e.g., the patient’s next of kin or, in the absence of next of kin, close friend).Incapacitated: a condition of the patient where the capacity to make informed decisions regarding care is temporarily lost (e.g., due to unconsciousness, being under the influence of mind-altering substances, or otherwise suffering from treatable mental disability), is permanently lost (e.g., irreversible coma, persistent vegetative state, or untreatable brain injury, rendering understanding by the patient impossible), or never existed (e.g., congenital retardation rendering understanding by the patient impossible or severe brain injury as a child).Michael E. Steuer, MD PCMidSouth Pain Treatment Center, LLCMidSouth Interventional Pain Institute, LLCNOTICE OF PRIVACY PRACTICESEffective Date: January 1, 2015This notice was most recently revised on: January 1, 2015THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE OR IF YOU NEED MORE INFORMATION, PLEASE CONTACT OUR PRIVACY OFFICER:Privacy Officer: Holly RobertsonMailing Address: 122 Airways Place Southaven, MS 38671Telephone: 662-349-9990Fax: 662-349-2620E-mail: hrobertson@About this NoticeWe are required by law to maintain the privacy of Protected Health Information (PHI) and to give you this Notice explaining our privacy practices with regard to that information. You have certain rights – and we have certain legal obligations – regarding the privacy of you PHI, and this Notice also explains your rights and our obligations. We are required to abide by the terms of the current version of this Notice.What is Protected Health Information (PHI)?Protected Health Information (PHI) is information that individually identifies you and that we create or get from you or from another health care provider, a health plan, your employer, or a health care clearinghouse and that relates to (1) your past, present, or future physical or mental health or conditions, (2) the provision of health care to you, or (3) the past, present, or future payment for your health care.How we may use and disclose your PHIWe may use and disclose your PHI in the following circumstances:For Treatment. We may use your PHI to give you medical treatment or services and to manage and coordinate your medical care. For example, we may disclose your PHI to doctors, nurses, technicians, or other personnel who are involved in taking care of you, including people outside our practice, such as referring or specialist physicians.For Payment. We may use and disclose PHI so that we can bill for the treatment and services you get from us and can collect payment from you, an insurance company, or another third party. For example, we may need to give your health plan information about your treatment in order for your health plan to pay for that treatment. We also may tell your health plan about a treatment you are going to receive to find out if your plan will cover the treatment. If a bill is overdue we may need to give PHI to a collection agency to the extent necessary to help collect the bill, and we may disclose an outstanding debt to credit reporting agencies.For Health Care Operations. We may use and disclose PHI for our health care operations. For example, we may use PHI for our general business management activities, for checking on the performance of our staff in caring for you, for our cost-management activities, for audits, or to get legal services. We may give PHI to other health care entities for their health care operations, for example, to your health insurer for its quality review purposes.Appointment Reminders/Treatment Alternatives/Health-Related Benefits and Services. We may use and disclose PHI to contact you to remind you that you have an appointment for medical care, or to contact you to tell you about possible treatment options or alternatives or health related benefits and services that may be of interest to you.Minors. We may disclose the PHI of minor children to their parents or guardians unless such disclosure is otherwise prohibited by law.Personal Representative. If you have a personal representative, such as a legal guardian (or an executor or administrator of your estate after your death), we will treat that person as if that person were you with respect to disclosures of your PHI.As Required by Law. We will disclose PHI about you when required to do so by international, federal, state, or local law.To Avert a Serious Threat to Health or Safety. We may use and disclose PHI when necessary to prevent a serious threat to your health or safety or to the health or safety of others. But we will only disclose the information to someone who may be able to help prevent the threat.Business Associates. We may disclose PHI to our business associates who perform functions on our behalf or provide us with services if the PHI is necessary for those functions or services. For example, we may use another company to do our billing, or to provide transcription or consulting services for us. All of our business associates are obligated, under contract with us, to protect the privacy of your an and Tissue Donation. If you are an organ or tissue donor, we may use or disclose your PHI to organizations that handle organ procurement or transplantation – such as an organ donation bank – as necessary to facilitate organ or tissue donation and transplantation.Military and Veterans. If you are a member of the armed forces, we may release PHI as required by military command authorities, we also may release PHI to the appropriate foreign military authority if you are a member of a foreign military.Workers’ Compensation. We may use or disclose PHI for workers’ compensation or similar programs that provide benefits for work-related injuries or illness.Public Health Risks. We may disclose PHI for public health activities. This includes disclosures to: (1) a person subject to the jurisdiction of the Food and Drug Administration (“FDA”) for purposes related to the quality, safety, or effectiveness of an FDA-regulated product or activity; (2) prevent or control disease, injury or disability; (3) report births and deaths; (4) report child abuse or neglect; (5) report reactions to medications or problems with products; (6) notify people of recalls of products they may be using; (7) a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and (8) the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence and the patient agrees or we are required or authorized by law to make that disclosure.Health Oversight Activities. We may disclose PHI to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, licensure, and similar activities that are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose PHI in response to a court or administrative order. We also may disclose PHI in response to a subpoena, discovery request, or other legal process from someone else involved in the dispute, but only if efforts have been made to tell you about the request or to get an order protecting the information requested. We may also use or disclose your PHI to defend ourselves if you sue us.Law Enforcement. We may release PHI if asked by a law enforcement official for the following reasons: in response to a court order, subpoena, warrant, summons or similar process; to identify or locate a suspect, fugitive, material witness, or missing person; about the victim of a crime if; about a death we believe may be the result of criminal conduct; about criminal conduct on our premises; and in emergency circumstances to report a crime, the location of the crime or victims, or the identity, description, or location of the person who committed the crime.National Security. We may release PHI to authorized federal officials for national security activities authorized by law. For example, we may disclose PHI to those officials so they may protect the President.Coroners, Medical Examiners, and Funeral Directors. We may release PHI to a coroner, medical examiner, or funeral directory so that they can carry out their duties.Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose PHI to the correctional institution or law enforcement official if the disclosure is necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; (3) the safety and security of the correctional institution.Uses and Disclosures That Require Us to Give You an Opportunity to Object and Opt OutIndividuals Involved in Your Care or Payment for Your Care. We may disclose PHI to a person who is involved in your medical care or helps pay for your care, such as a family member or friend, to the extent it is relevant to that person’s involvement in your care or payment related to your care. We will provide you with an opportunity to object to and opt out of such a disclosure whenever we practicably can do so.Disaster Relief. We may disclose your PHI to disaster relief organizations that seek your PHI to coordinate your care, or notify family and friends of your location or condition in a disaster. We will provide you with an opportunity to agree or object to such a disclosure whenever we practicably can do so.Your Written Authorization is Required for Other Uses and DisclosuresUses and disclosures for marketing purposes and disclosures that constitute a sale of PHI can only be made with your written authorization. Other uses and disclosures of PhI not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you do give us an authorization, you may revoke it at any time by submitting a written revocation to our Privacy Officer and we will no longer disclose PHI under the authorization. Disclosures that we made in reliance on your authorization before you revoked it will not be affected by the revocation.Special Protections for HIV, Alcohol and Substance Abuse, Mental Health, and Genetic InformationSpecial privacy protections apply to HIV-related information, alcohol and substance abuse, mental health, and genetic information. Some parts of this general Notice of Privacy Practices may not apply to these kinds of PHI. Please check with our Privacy Officer for information about the special protections that do apply. For example, if we give you a test to determine if you have been exposed to HIV, we will not disclose the fact that you have taken the test to anyone without your written consent unless otherwise required by law.Your Rights Regarding Your PHIYou have the following rights, subject to certain limitations, regarding your PHI:Right to Inspect and Copy. You have the right to inspect and/or receive a copy of PHI that may be used to make decisions about your care or payment for your care. But you do not have a right to inspect or copy psychotherapy notes. We may charge you a fee for the costs of copying, mailing or other supplies associated with your request. We may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state or federal needs-based benefit program. We may deny your request in certain limited circumstances. If we do deny you request, you have the right to have the denial reviewed by a licensed healthcare professional who was not directly involved in the denial of your request, and we will comply with the outcome of the review.Right to an Electronic Copy of Electronic Medical Records. If your PHI is maintained in one or more designated record sets electronically (for example, an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We may charge you a reasonable, cost-based fee for the labor associated with copying or transmitting the electronic PHI. If you chose to have your PHI transmitted electronically, you will need to provide a written request to this office listing the contact information of the individual or entity who should receive your electronic PHI.Right to Receive Notice of Breach. We are required to notify you by first class mail or by e-mail (if you have indicated a preference to receive information by e-mail), of any breach of you Unsecured PHI.Right to Request Amendments. If you feel that PHI we have is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for us. A request for amendment must be made in writing to the Privacy Officer at the address provided at the beginning of this Notice and it must tell us the reason for you request. We may deny your request if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that (1) was not created by us, (2) is not part of the medical information kept by or for us, (3) is not information that you would be permitted to inspect and copy, or (4) is accurate and complete. If we deny your request, you may submit a written statement of disagreement of reasonable length. Your statement of disagreement will be included in your medical record, but we may also include a rebuttal statement.Right to an Accounting of Disclosures. You have the right to ask for an “accounting of disclosures”, which is a list of the disclosures we made of your PHI. We are not required to list certain disclosures, including (1) disclosures made for treatment, payment, and health care operations purposes, (2) disclosures made with your authorization, (3) disclosures made to create a limited data set, and (4) disclosures made directly to you. You must submit your request in writing to our Privacy Officer. Your request must state a time period which may not be longer than 6 years before your request. You request should indicate in what form you would like the accounting (for example, on paper or by e-mail). The first accounting of disclosures you request within any 12-month period will be free. For additional requests within the same period, we may charge you for the reasonable costs of providing the accounting. We will tell you what the costs are, and you may choose to withdraw or modify your request before the costs are incurred.Right to Request Restrictions. You have the right to request a restriction or limitation on the PHI we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the PHI we disclose about you to someone who is involved in you care or the payment for your care, like a family member or friend. We are not required to agree to your request. If we agree, we will comply with your request unless we terminate our agreement or the information is needed to provide you with emergency treatment.Right to Restrict Certain Disclosures to Your Health Plan. You have the right to restrict certain disclosures of PHI to a health plan if the disclosure is for payment or health care operations and pertains to a health care item or service for which you have paid out of pocket in full. We will honor this request unless we are otherwise required by law to disclose this information. This request must be made at the time of service.Right to Request Confidential Communications. You have the right to request that we communicate with you only in certain ways to preserve your privacy. For example, you may request that we contact you by mail at a special address or cal you only at your work number. You must make any such request in writing and you must specify how or where we are to contact you. We will accommodate all reasonable requests. We will not ask you the reason for your request.Right to a Paper Copy of this Notice. You have the right to a paper copy of this Notice, even if you have agreed to receive this Notice electronically. You may request a copy of this Notice at any time. You can get a copy of this Notice at our website to Exercise Your RightsTo exercise your rights described in this Notice, send your request, in writing, to our Privacy Officer at the address listed at the beginning of this Notice. We may ask you to fill out a form that we will supply. To get a paper copy of this Notice, contact our Privacy Officer by phone or mail.Changes to This NoticeThe effective date of the Notice is stated at the beginning. We reserve the right to change this Notice. We reserve the right to make the changed Notice effective for PHI we already have as well as for any PHI we create or receive in the future. A copy of our current Notice is posted in our office and on our plaintsIf you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, contact our Privacy Officer at the address listed at the beginning of this Notice. All complaints must be made in writing and should be submitted within 180 days of when you knew or should have known of the suspected violation. There will be no retaliation against you for filling a complaint.Optional Provisions to be Included as applicable:Medical Residents and Medical Students. Medical residents or medical students may observe or participate in your treatment or use your PHI to assist in their training. You have the right to refuse to be examined, observed, or treated by medical residents or medical students.Newsletters and Other Communications. We may use your PHI to communicate to you by newsletter, mailings, or other means regarding treatment options, health related information, disease management programs, wellness programs, or other community based initiatives or activities in which our practice is participating.Psychotherapy Notes. Under most circumstances, without your written authorization we may not disclose the notes a mental health professional took during a counseling session. However, we may disclose such notes for treatment and payment purposes, for state and federal oversight of the mental health professional, for the purposes of medical examiners and coroners, to avert a serious threat to health or safety, or as otherwise authorized by law. ................
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