New Patient Paperwork

Patient Name *
Patient Name
Date of Birth *
Date of Birth
Home Address *
Home Address
Home Phone Number
Home Phone Number
Employer Information
Employer Address
Employer Address
Work Phone
Work Phone
Spouse Info
Spouse Name
Spouse Name
Spouse's Phone Number
Spouse's Phone Number
Emergency Contact Info
Name of Emergency Contact not living with you *
Name of Emergency Contact not living with you
Emergency Contact Phone Number *
Emergency Contact Phone Number
Primary Insurance Information
Policyholder Name
Policyholder Name
Policyholder DOB
Policyholder DOB
Secondary Insurance Information
Policyholder Name
Policyholder Name
Policyholder DOB
Policyholder DOB
Worker's Comp Insurance Information
Assignment of Benefits
I certify that the information given by me is correct. I hereby authorize payments directly to Consultants in Pain Management of the insurance benefits otherwise payable to me. I understand I am financially responsible to Consultants in Pain Management for any charges not covered by this authorization. *
Medicare Patients
I hereby authorize Medicare to furnish Consultants in Pain Management any information regarding my Medicare claims under “Title XVIII” of the Social Security Act. I also request payment of authorized benefits be made on my behalf to Consultants in Pain Management for any services furnished to me. I Authorize any holder of medical information about me to release the MEDIGAP INSURER on the opposite page any information needed to determine these benefits or the benefits payable for related services.
Financial Responsibility Agreement
FOR AND IN CONSIDERATION of health care and health care related services and treatment rendered or to be rendered to the patient identified below, and the extension of credit to the patient according to the Financial Policies of Consultants in Pain Management, PC I/WE, promise and agree to pay in full to Consultants in Pain Management upon demand, all charges incurred on the account of the patient hospitalization or treatment (including out-patient or clinic services) at our offices, hospitals, of other locations. Payments received from insurance of other third-party payers for services and treatments rendered, be applied to the patient account and the balance, if any, shall be and remain my/our responsibility. I/WE represent that I/WE have read this Financial Agreement, understand its terms and conditions, and sign the agreement voluntarily for the purposes stated in this agreement. *
Photography
I hereby authorize any personal at Consultants in Pain Management to take photographs necessary to document my physical condition. The photograph can/will be used for educational and of therapeutic purposes only. *
Privacy
May we leave a voicemail on your home phone regarding your appointments? *
May we leave a voicemail on your cell phone regarding your appointments? *
May we speak with or leave a message with a family member or other individual concerning your appointments? *
May we leave a message when returning your calls? *
May we speak with and/or leave a message with a family member or other individual when returning your call? *
Who may we speak to regarding your care, messages, and appointments? *
This question broadly pertains to anything that we may need to contact you about. If you answer, "The authorized persons listed below", provide each authorized person's information in the following questions.
Name of Authorized Person #1
Name of Authorized Person #1
Name of Authorized Person #2
Name of Authorized Person #2
Authorized Person #3
Authorized Person #3
Patient Policies
I agree to the patient policies below *
CPM considers you as a No Show for your scheduled appointment if you cancel after 3pm the prior business day. We have reserved this appointment for you and without proper notice we are unable to offer the appointment to anyone else. If you reschedule or cancel any appointment with CPM please remember that no medications will be given. It is the policy of CPM that in order to receive any narcotic medication; you must be seen by a provider. CPM requires that you present your medications in the correct bottles at each visit. All narcotic prescriptions must be filled in Tennessee. Failure to comply with these policies may result in your dismissal from CPM.
Financial Policy
I agree to the financial policies below *
The objective of this office is to provide you with the highest quality health care in the most cost effective manner. However, the ability of Consultants in Pain Management, P.C. to achieve this objective depends greatly on your understanding of our financial policy. IF YOU HAVE MEDICAL INSURANCE, WE WILL FILE INSURANCE CLAIMS ON YOUR BEHALF. This is done as a courtesy to our patients. We are glad to help you receive the maximum allowable benefits from your insurance. Even though we will file the insurance claim for you, at times we will need your active participation in the insurance claims process. MEDICARE PATIENTS: As a participating provider of Medicare Part B (physician services), Consultants in Pain Management, P.C. will bill you for your Medicare Co-insurance, deductible or any services rendered, but not covered by Medicare prior to these services being rendered. NOTE: You will be informed of services not covered by Medicare prior to these services being rendered. Your signature on the appropriate Medicare waiver form (Advance Beneficiary Notice) represents your authorization for the physician to perform such services and your acceptance of the financial responsibility. PAYMENT FOR SERVICES NOT COVERED BY MEDICARE ARE TO BE PAID THE DAY SERVICE IS PERFORMED. For covered services, you will be responsible for paying your 20% co-insurance amount at the time of service if you do not have a secondary insurance. If you have Medicare Part A only, the services you receive from our practice will not be covered by Medicare and payment is due at the time of service. COMMERICAL INSURANCE: While we are happy to file your insurance, your insurance contract is between you and your insurance company. If your insurance pays only part of your bill, or rejects your claim, you are financially responsible for the balance. CPM IS REQUIRED BY YOUR INSURANCE COMPANY TO COLLECT CO-PAYS, DEDUCTIBLES OR CO-INSURANCES AT THE TIME OF SERVICE. YOU SHOULD BE PREPARED TO PAY YOUR COPAY OR 20% OF YOUR BILL AT THE TIME OF SERVICE. THERE WILL BE A $12.00 PROCESSING FEE ADDED FOR CO-PAYS THAT ARE NOT PAID AT THE TIME OF SERVICE. HMO AND OR MANAGED CARE INSURANCE PATIENTS: Many HMO, PPO, or Managed Cared Plans require that you obtain a referral from your assigned primary care provider in order to receive care from a specialist. IT IS YOUR RESPONSIBILITY TO OBTAIN THIS REFERRAL IF REQUIRED. Unauthorized services will be the financial responsibility of the patient. You will be asked to sign a waiver before being seen by the physician. PLEASE HAVE YOUR REFERRAL FORM AND MEMBERSHIP CARD WITH YOU WHEN YOU CHECK IN.... YOU WILL BE REQUIRED TO PAY THE CO-PAYMENT FOR AUTHORIZED SERVICES AT THE TIME OF SERVICE AND THE COMMERICAL INSURANCE POLICY APPLIES. COLLECTION COSTS: In the event that you do not make any payment for which you are financially responsible, as stated above, and Consultants in Pain Management institutes collection processing against you, you agree to pay all of Consultants in Pain Management, PC’s costs of collection, including but not limited to its reasonable attorney’s fees. PATIENTS WITH NO INSURANCE: Those who pay in full at the time of service may be eligible for a discount. If payment can not be paid the day of service full charges will apply and you will need to contact our billing department for special payment arrangements. (423-648-8480 x 3401) TELEPHONE CONTACT: By signing below, you agree to allow Consultants in Pain Management, or its representatives, to contact you at any of the telephone numbers you have provided to Consultants in Pain Management concerning the collection of any balance you owe. PATIENTS WHO CANCEL APPOINTMENTS WITH LESS THAN 24 HOURS NOTICE OR DO NOT COME FOR THEIR APPOINTMENT MAY BE SUBJECT TO A $25.00 FEE. THIS FEE MAY BE HIGHER FOR PROCEDURES VISITS. Return Check Fee: Consultants in Pain Management, PC will charge to the patient a $30.00 fee for any returned check.
Initial Evaluation
Date of first appointment
Date of first appointment
Are you currently in physical therapy?
Do you use a TENS unit or stimulator?
How intense is your pain? (Scale of 1-10, 1 is no pain, 10 is excruciating pain)
Pharmacy Phone Number
Pharmacy Phone Number
Choose the words that best describe your pain
Episodes of pain are best described as
What makes your pain worse?
My medication works
Are you experiencing any side effects from your current pain reliever?
Adverse Effects
Mark overall severity of any side effects you are experiencing
Affect
Is pain affecting your sleep?
Which, if any, of the following has your pain affected?