New Patient NF part 3 | Broadway Accident

New Patient NF (cont.)

DG Pain Management

73-24 195 St.

Fresh Meadows, NY, 11366

Ph: 718-690-2572

Fax: 718-886-1868

To Attorney:

Full Name

Patient:

Full Name

Date of Accident:

Date of Accident

MEDICAL LIEN

I do hereby authorize

to furnish you, my attorney, with a full

report of his examination, diagnosis, treatment, prognosis, etc... of myself in regard to the accident in which I was recently involved.

I hereby authorize and direct you, my attorney, to pay directly to said doctor/medical facility such sums as may be due and owing said doctor/medical facility for medical services rendered to me both by reason of this accident and by reason of any other bills that are due his office and to withhold such sums from any settlement, judgment or verdict as may be necessary to adequately protect said doctor/medical history. I further give a lien on my case to said doctor/medical facility against any and all proceeds of my settlement, judgment or verdict which may be paid to you, my attorney, or myself, as the result of the injuries for which I have been treated or injuries in connection therewith.

I fully understand that I am directly and fully responsible to said doctor/medical facility for all medical bills submitted by doctor/medical facility for services rendered to me and that this agreement is made solely for said doctor/medical facility's additional protection and in consideration of said doctor/medical facility awaiting payment. I further understand that such payment is not contingent on any settlement, judgment or verdict from which I may eventually recover said fee.

In the case of automobile accidents, where no-fault regulations govern the medical reimbursement, this lien will be effective only to the extent of those applicable no-fault regulations.

Dated:

Date

Patient's Signature

The undersigned being attorney for the above patient does hereby agree to observe all the terms of the above and agrees to withhold such sums from any settlement, judgment or verdict, as may be necessary to adequately protect said doctor above-named.

Dated:

Date

Attorney's Signature

DG Pain Management

Assignment of Benefits and LTD Power of Attorney

I hereby assign benefits and authorize payment directly to DG Pain Management and/or its staff (hereinafter collectively "You") of any insurance benefits made as a payment to me (or a minor for whom I am the guardian) for their services provided to me (or a minor for whom I am the guardian) for their services. I agree to immediately forward to this office any insurance payments which are made directly to me.

irrevocably assign to you, DG Pain Management, my medical provider, all of my right and benefits under my Insurance contract for payment for services rendered to me. I authorize you to file insurance claims on my behalf for services rendered to me and this specifically included filling arbitration /litigation In your name on my behalf for collection of your bills. I direct that all reimbursable medical payments go directly to you, my medical provider. I authorize you to act on my behalf. I consent to your acting on my behalf in this regard and in regard to my general health insurance coverage pursuant to the "benefit denial appeals process" set forth in the NY Administrative code. I request that the insurance carrier consent to my assignment of benefits within 10 days of receipt otherwise it is deemed consented to.

As a medical provider I agree to attempt to reasonably comply with the PIP carrier's decision point review/pre certification plan and to hold the patient harmless if I fail to comply with same, in consideration for the carrier's consent to this assignment.

In the even the insurance carrier responsible for making medical payments in this matter does not accept my assignment, or my assignment is challenged or deemed invalid. I execute this limited/special power of attorney and appoint and authorize your collection attorney as my agent and attorney to collect payment for your medical services directly against the carrier in this case in my name or in your name as a medical provider rendering services to me and designate your collection agency as my attorney in fact. I further grant limited power of attorney to you as my medical provider to receive and collect directly from the insurance carrier money due you for services rendered to me in this matter and hereby instruct the insurance carrier to pay you directly any monies due you for medical services you rendered to me.

I authorize you and your attorney to obtain medical information regarding my physical condition from any other health care provider, including hospitals, diagnostic centers, etc., and I specifically authorize such health care provider(s) to release call such information to you about me, including medical reports, X-ray reports, narrative reports, and any other report or information regarding my physical condition.

I understand that I am responsible for all fees charged, whether they are covered by insurance or not. Also, I am aware it is my personal responsibility to monitor insurance payments and maximums. If I receive any payment in trust for:

and I also agree to send such payment to:

within one week after receipt of same. I also agree to pay attorney's fees equal to 33 1/3% of the outstanding balance, plus court costs, in the event the account is turned over to an attorney for collection.

Patient's Signature

Date

Patient's Name (printed)

DG Pain Management

Acknowledgement of Patient Rights and Privacy Practices

By signing below, I acknowledge that I have been provided a copy of this Notice of Privacy Practices and have therefore been advised of how health information about me may be used and disclosed by our practice listed at the beginning of this notice, and how I may obtain access to and control this information.

Patient's Signature

Date

Patient's Name (printed)

DG Pain Management

This letter will authorize you to provide a copy, summary, or narrative of my medical records (as indicated by the check mark(s) below) or to otherwise release confidential information.

At this time, I am requesting the following:

Compete Record

Records of care from: (mark the checkbox to open the date fields)

From:

To:

Records of care concerning the following conditions: (mark the checbox to open the conditions field)

Conditions (separate conditions using a comma)

Other: (Please Specifiy)

Confer with other person orally about information in my medical record to the following person(s): (mark the checkbox to open the text field)

Name

Street

City

State

ZIP

The reasons or purposed for this release of information are:

I understand that you will provide this information within 15 business days from receipt of request, and you may charge a fee for preparing and furnishing this information.

The fee is waived because the records are to be used for supporting an application for disability or other benefits or assistance under Aid to Families with Dependent Children, Medicare, Supplemental Security Income, and Federal Old-Age and Survivors Insurance. I have attached a statement which confirms that such an application or appeal has been filed or is pending.

Patient's Signature

Date

DG Pain Management

Controlled Substance Agreement Contract

I understand there are risks involved with chronic controlled substance (narcotics, pain killers, sleeping pills, nerve pills) administration including, but not limited to dependence, addiction, sleep and appetite changes; constipation and even bowel obstruction; and change in sexual desire and performance. I understand that the inappropriate use of medications such as mixing with another substance can cause death.

Please check the box on each item and sign below:

I understand that the reason I am being I am being prescribed controlled substances is to improve my ability to function and reduce my pain. Alternative forms of treatment have been offered t me, and I have chosen to be treated with controlled substances for pain control. If I find these medications hinder my ability to function in my job or interpersonal relationships, I will inform Dr. Gamburg so he can address these Issues and make appropriate changes. I agree to comply with Dr. Gamburg's treatment plan including, if appropriate, weight loss, smoking cessation and alcohol cessation, I will use care when driving or operating machinery. I understand that only through following a healthier lifestyle can I have the most successful outcome to my treatment.

I have never been involved in the illegal sale, possession, diversion or transport of controlled substances.

I am not currently abusing illicit non-prescription drugs, and I am not undergoing treatment for substance dependence or abuse.

I understand that stopping these medications suddenly can lead to rebound pain and withdrawal symptoms, and I have been informed not to stop my controlled substances suddenly. Controlled substances can react with certain medications; the most important of which is alcohol. I have been informed of the risks of mixing alcohol with controlled substances and will inform Dr. Gamburg of my alcohol consumption. I will also inform Dr. Gamburg of all over the counter and prescription medications am taking.

I understand to minimize the risks involved with controlled substances and assure adequate supervision, I agree to report any change in my mental status or drug reactions. I agree to have any lab test he advises, including blood and urine drug screens. I also agree to go for any consultation he deems necessary.

I agree not to obtain any controlled substances from any other physicians unless Dr. Gamburg 's office is notified.

I agree that I may not discard any medication given by this office unless witnessed by our staff.

I will not use any other narcotic medication or sedatives or street drugs such as heroin or cocaine or other substances; since the use of these can result in serious injury or death.

l agree to take the medication at the dosage and frequency prescribed. If I feel I must stop my medication or change the dose, I will call dr. Gamburg during office hours before making changes. Any change in the dose or frequency will be at the direction of Dr. Gamburg.

I understand controlled substance medications are my responsibility and twill protect their safety, Should they be lost, destroyed or used up for any reason, I will not receive a new prescription until my next regular refill, no matter the circumstance, I agree to report any stolen medications to the police, and produce, such documentation, at which time Dr. Gamburg will make a decision regarding the replacement of the stole medications, I will not give any medications to another person.

I will give 5 business days' notice of my need for refill, if my medication is scheduled to run out before my next scheduled appointment. I will not request a refill at any other time other than office hours (including evenings, holidays and weekends). I will be required to pick up my prescription at the office during office hours as no prescriptions are called in or mailed. I agree to obtaqin controlled substances from only the pharmacy, and will inform the office if I change pharmacies.

I have read this contact and Dr. Gamburg and or his staff has explained it to me. All my questions and concerns about treatment have been adequately answered.

I understand that if I do not follow this contract, Dr. Gamburg may taper and stop my controlled substances and refer me elsewhere for care. A copy of this document has been given to me.

I give permission for DG Pain Management to search electronically for my medical history, including but not limited to Prescriptions and Radiology reports.

Please indicate your pharmacy name

Patient's Signature

Pharmacy Phone Number

Date

New Patient NF (cont.)

DG Pain Management

Assignment of Benefits and LTD Power of Attorney

DG Pain Management

Acknowledgement of Patient Rights and Privacy Practices

DG Pain Management

DG Pain Management

Controlled Substance Agreement Contract

Please check the box on each item and sign below:

CRP - Controlled Substance