Authorization For Use / Disclosure Of Health Information

Step 1 of 8

Medical Records Request
First Name*
Last Name*
Date of Birth*
YYYY slash MM slash DD
Authorization for Use/ Disclosure of Information: I voluntarily authorize and direct:
To disclose my health information during the term of this Authorization to:

Pain Relief Solutions
Casey Fisher, MD
Zachary Cohen, MD
3142 Vista way suite 207 Oceanside CA 92056
Phone: (760) 610-0522 Fax: (760) 610-0523
Purpose: I understand that the specific purpose of this Authorization is:
- All of my health information that the provider has in his or her possession, including information relating to any medical history, mental or physical condition and any treatment received by me, including without limitation, x-rays, HIV/AIDS status, genetic testing, psychotherapy notes and other mental health information, drug, alcohol or other controlled substance information, billing information,correspondence, and records from my other healthcare providers that the above- named provider may hold.
- All of my health information described above except for the following:
- Only the following records or types of health information: (insert dates and types or treatment or other designation)
Term: This authorization will remain in effect for one (1) year from the date this authorization is Signed.
Signature of Patient:
Date
YYYY slash MM slash DD
Pain Relief Solutions
Casey Fisher, MD
Zachary Cohen, MD
3142 Vista way suite 207 Oceanside CA 92056
Phone: (760) 610-0522 Fax: (760) 610-0523

Welcome Letter

To Our New Patients:

Welcome to Pain Relief Solutions. Your care and comfort are most important to us. To make your visit with us as pleasant as possible, please sign in at the front desk when you arrive for your appointment and have a seat. In order to better serve our patients, we have adopted the following policies and procedures:

Office Policies

Please Bring The Following Items With You On Your First Appointment:

(i) picture ID card; (ii) insurance card; (iii) authorization form; and (iv) for those patients who are seeing a physician, (a) a list or bottles of all medications the patient is taking, (b) the patient’s x-ray imaging reports, and (c) the patient’s other medical records.

Please Complete And Bring In All Of The Registration Paperwork.

You must complete the paperwork before seeing a provider. If you have not had the opportunity to fill out the paperwork prior to your appointment, please arrive 45 minutes early. Those able to complete their paperwork prior to their appointment, please arrive 15 minutes early.

Please Be On Time.

Like you, we are extremely busy and must budget our time efficiently. If you are late for your appointment, you may have to reschedule your appointment. Patients who fail to cancel an appointment within 24 hours of the appointment time will be subject to a $50.00 fee billed directly to the patient.

You Must Show Your Insurance Card At Each Visit.

We will bill most insurance companies for our patients as a courtesy, provided we have all the necessary information. It is your responsibility to verify with the carrier as to whether the medical services provided to you/the patient (e.g. consults, procedures, tests) are covered by your/the patient’s insurance. Any deductible, copayment, or balance not paid by a patient’s insurance is the patient’s financial responsibility. This applies to all insurances, including Medicare.

Co-Payments And Deductibles Are Due When Services Are Rendered.

If a patient does not have or is unable to pay the patient’s copayment at the time of the patient’s appointment, the patient will have to reschedule the appointment until such time as the patient can pay it. We are sorry, but there can be no exception. Insured patients are responsible for all charges not paid by their insurance within 45 days after the date of service. Payment arrangements can be made on an individual basis at our discretion. We do not accept checks marked with “Payment in Full” or words of similar meaning when the amount of the check is less than the amount charged to the patient. Any deposit of such a check is inadvertent, is not a satisfaction of the full amount owed by the patient, and will be considered a partial payment. We reserve the right to withdraw the extension of credit. There is a service fee of $20 on all returned checks.

Disclosure Of Information.

Disclosure of insurance and other information is necessary in order for services received by a patient to be paid in full. If the patient’s ailment or injury is due to any type of personal injury, accident, or malicious conduct for which the patient is seeking damages, you/the patient must notify us and sign a lien in our favor. Your failure to make necessary disclosures might make the patient personally responsible for all charges incurred by the patient for services rendered by us.

Thank you for taking the time to read this material. Your cooperation is much appreciated.

Agreement.

I agree to be bound by the policies and procedures above, and I agree to pay reasonable attorney’s fees and costs should legal proceedings be necessary to collect any portion of the patient’s bill or to enforce this agreement. CONSENT TO TREATMENT. I hereby consent to the patient’s evaluation and treatment by Pain Relief Solutions (“PRS”) and PRS’s healthcare providers. I authorize PRS and the patient’s physician to (i) consult with any other physician should he/she believe it necessary; and/or (ii) engage the services of another physician if any surgical procedure is to be performed. I agree to pay for such consult and/or services.

Participation In Medical Education Program.

I understand that (i) PRS is a teaching institution; and (ii) the patient may participate as a teaching subject in PRS’s medical education program and may receive treatment from fellows unless PRS is notified to the contrary in writing.
Patient's Signature
Date*
MM slash DD slash YYYY
Patient's Name
Date of Birth*
MM slash DD slash YYYY
Representative's Signature:
Date*
YYYY slash MM slash DD
Representative's Name:
Rel.to Pt.:

Patient Demographics
Patient Name*
Date of Birth*
MM slash DD slash YYYY
Sex*
- Male
- Female
SSN
Marital Status
DL/ID#
Occupation:
Ethnicity & Race
Preferred Language
Employer Name
Employer Phone
Employer Address
Primary Insurance*
Policy#
Secondary Insurance
Policy#
Home / Mobile / WorkPhone*
Home / Mobile / WorkPhone
I consent to receive communication at the numbers above from Pain Relief Solutions (“PRS”) regarding (i) the patient’s appointments; (ii) the patient’s healthcare; and (iii) the collection of the patient’s unpaid medical bills and other debts. I understand and agree that such communication may (i) include calls, voicemail and/or text messages, and pages; (ii) contain confidential information; (iii) involve charges by my phone service provider; and (iv) be generated by an automated dialing system or an automatic telephone dialing system and may use a prerecorded message. I understand that cellular/mobile/wireless communication is not a secure form of communication.
Mailing Address*
Email*
I consent to receive communication at the addresses provided above from PRS. I understand that (i) while PRS will use the minimum necessary information, PRS will not encrypt any information I request to be sent by e-mail; (ii) unencrypted e-mail is not a secure form of communication; and (iii) the risks include an unauthorized third-party accessing my/the patient’s e-mail and/or the disclosure or misdirection to, or interception by, an unauthorized third-party of the confidential or sensitive information that may be contained in an unencrypted e-mail. I wish to receive written communication in envelopes / e-mails marked “CONFIDENTIAL.”

PRS may communicate with the following persons about the patient’s healthcare, billing/insurance information, and appointments:

Name Rel. to pat. Address Phone Emergencies only
Name
Rel. to pat.
Address
Phone
Emergencies only
- Yes
- No
Name
Rel. to pat.
Address
Phone
Emergencies only
- Yes
- No
I understand and agree that (i) PRS cannot guarantee the security and confidentiality of phone and e-mail communication; (ii) PRS is not liable for improper disclosure of information received by and/or stored in devices and/or accounts associated with the phone numbers and/or e-mail addresses provided above; (iii) I may contact PRS in writing to request a restriction on communications as stated in PRS’s Notice of Privacy Practices; (iv) I will notify PRS whenever the information above changes; and (v) a copy of this form will be provided to me upon my request.

I Hereby Consent To The Communications Described Herein.
Patient’s Signature:
Date
MM slash DD slash YYYY
Patient’s Name
Date Of Birth
MM slash DD slash YYYY
ASSIGNMENT OF INSURANCE BENEFITS. I hereby irrevocably assign to Pain Relief Solutions (“PRS”) all of the patient’s rights and benefits under the patient’s insurance contract/policy for payment for services rendered to the patient at/by PRS. I hereby authorize PRS to (i) file insurance claims on the patient’s behalf for services rendered to the patient at/by PRS; and (ii) release any information that may be necessary for processing applications for financial benefit. I further authorize payment of insurance benefits to be paid directly to PRS.
Patient’s Signature
Date
MM slash DD slash YYYY
Patient’s Name
Date of Birth

Consent Form

Consent To The Use And Disclosure Of Health Information For Treatment, Payment, And Healthcare Operations
Patient’s Name*
I understand that as part of Patient’s healthcare, Pain Relief Solutions (“Healthcare Provider”) originates and maintains paper and/or electronic records describing Patient’s health history, symptoms, examination and test results, diagnoses, treatment, any plan for future care or treatment, and other information relating to Patient’s healthcare. | understand that this information serves the following purposes:
- A basis for planning Patient care and treatment
- A means of communication among the health professionals contributing to Patient’s care
- A source of information for applying Patient’s information to Patient’s bill
- A means by which a third-party payer can verify the services provided and
- A tool for healthcare operations such as assessing quality and staff competence.
I understand that as part of Healthcare Provider’s treatment, payment, and healthcare operations, it may be necessary to disclose Patient’s health information to another person or entity.

I hereby consent to the foregoing uses and disclosures, including disclosures in electronic format.

I acknowledge receipt of Healthcare Provider’s Notice of Privacy Practices (the “Notice”) that provides a detailed description of the uses and disclosures of Patient’s protected health information. I understand the rights and privileges described on the Notice.

I understand that Healthcare Provider reserves the right to change the content of the Notice and their privacy practices and to apply such changes to protected health information that was created or received prior to the issuance of a revised Notice, in accordance with Federal Regulations. Should Healthcare Provider make such changes, I understand that the revised Notice will be made available at Healthcare Provider’s website at www.caseyfishermd.com, at their office, and to me — upon my request — by mail / electronic(Circle one) transmission.
I wish to have the following restrictions on the use and/or disclosure of Patient’s information:
I understand that Healthcare Provider is not required to agree to the requested restrictions, except as specified on the Notice. I understand that I may revoke this consent in writing, except to the extent that Healthcare Provider has already taken action in reliance thereon. I understand that by refusing to give consent or revoking this consent, Healthcare Provider may refuse to treat Patient as permitted by Federal Regulations.

I acknowledge receipt of the Notice, and I fully understand and accept / decline (circle one) the terms of this consent.
Patient's Signature:
Date
MM slash DD slash YYYY
Patient's Name
Date of Birth*
MM slash DD slash YYYY
Representative's Signature
Date
MM slash DD slash YYYY
Representative's Name
Rel.to.Pt

Authorization For Use / Disclosure Of Health Information

Step 1 of 8

Medical Records Request

Welcome Letter

To Our New Patients:

Office Policies

Please Complete And Bring In All Of The Registration Paperwork.

Please Be On Time.

You Must Show Your Insurance Card At Each Visit.

Co-Payments And Deductibles Are Due When Services Are Rendered.

Disclosure Of Information.

Agreement.

Participation In Medical Education Program.

Patient Demographics

I Hereby Consent To The Communications Described Herein.

Consent Form

Consent To The Use And Disclosure Of Health Information For Treatment, Payment, And Healthcare Operations

Pain Assessment

Pain Assessment

Medications / Therapies / Imaging

General Health History

Social History

Oswestry Disability Questionnaire

Tops Questionnaire

The Corrado-Gottlieb TOPS

Please mark one response for each of the following questions or statements: