TERMS AND AGREEMENTS
**PLEASE SCROLL TO THE BOTTOM OF THE PAGE AND sign your name and email address TO AGREE to our service policies.**
**Before we SCHEDULE YOUR APPOINTMENT, PLEASE READ ALL TERMS AND AGREEMENTS.**
IMPORTANT MEDICATION POLICIES AND PROCEDURES
Our practice focuses on the treatment of patients with mild to moderate pain. Some patients are in need of treatment for EXCRUCIATING/SEVERE PAIN. These patients may require large doses of DANGEROUS NARCOTICS. We feel that these patients are better served, by being treated by highly trained specialists that are affiliated with tertiary hospitals.
For that reason, we abstain from treating these very difficult cases. Because of this, we have a strict, inflexible policy of limiting the amount of narcotic medication prescribed to no more than Percocet 10/325 or Oxycodone 10 MG, 3 times per day. This is our MAXIMUM DOSAGE for any of our patients. Of course, a large percentage of our patients will be prescribed lower doses and quantities.
**In the past, some patients have been foolish enough to try to convince us to break this well entrenched policy. As you may have guessed, this has resulted in a wasting of OUR TIME and YOUR MONEY. If you feel that you may need more narcotic medication than our doctor will prescribe, then we implore you to seek another physicians who will be willing to write for these higher doses.**
PLEASE ARRIVE WITH THE FOLLOWING DOCUMENTS:
- PHOTO IDENTIFICATION CARD
- INSURANCE CARD
- PHARMACEUTICAL BENEFITS CARD
- MEDICAL RECORDS
While we would like you to bring as many records as possible, below is a listing of the more essential records
- PAPER REPORT OF YOUR MRI AND/OR X-RAY.
- WE WILL NOT ACCEPT ANY CD'S OR FILMS OF YOUR MRI OR X-RAY.
- SURGERY REPORT IF APPLICABLE
- PROCEDURAL NOTES
- HOSPITALIZATION REPORTS IF APPLICABLE
- CONSULTATIVE REPORTS
- PREVIOUS PAIN MANAGEMENT NOTES
Pharmacy Print Out
IF YOU HAVE RECENTLY BEEN ON ANY MEDICATION THAT IS A CONTROLLED SUBSTANCE,
PLEASE PROVIDE US THE PRINT OUT OF THE LAST 6 MONTHS OF YOUR PHARMACY RECORDS.
(This can be obtained by going to your current pharmacy and asking for 6 months of your pharmacy records.)
“SHOULD YOU BRING INSUFFICIENT RECORDS WE WILL NOT BE ABLE TO SEE YOU.
IN THIS EVENT, THERE WILL BE A $25 RESCHEDULING FEE.
PAYMENT AND INSURANCE INFORMATION
- 1st Visit: $185
- 2nd Visit and ever subsequent visit: $175
We accept CASH, CREDIT, and DEBIT
URINE DRUG SCREENING
Each Visit, all patients will be required to give a urine drug screen, prior to being seen by the doctor.
- To monitor the types of medications our patients are taking (Combining certain medications can cause dangerous health complications)
- To assess compliance with our treatment regimen
- To assure that patients are not using the medications for illicit purposes
Patients should be aware that inconsistent drug screens (presence of an illegal substance, presence of a substance not prescribed, and/or absence of substance that should be present in a drug screen) are grounds for dismissal.
**Patients who are unable to urinate will experience a delay to see the doctor and there will be a $20 charge as the urine test will to be replaced with an oral swab test.**
If you miss or cancel your scheduled appointment, you will be charged a $25 fee.
What qualifies as a "missed or cancelled appointment"?
- Notifying our office of a cancellation with less than 48 hour notice.
- Not showing up at your scheduled appointment time.
- Coming to your appointment after our office has closed for the day.
- Not seeing the Doctor on your scheduled appointment date and time
- If you come late and the doctor is no longer there
If your appointment is scheduled within the last half hour of our session times you must have your phone available.
Please make note and be aware of our office session hours. We may call our patients to come in earlier than their scheduled appointment. If your phone IS NOT available, and there has been a change of your appointment for an earlier time, this may result in a missed appointment fee.