Please initial the following statements
Authorization of Treatment
I hereby authorize Basem Hamid, MD PA providers and associates to examine, diagnose, and treat me. I authorize and give them consent to submit specimens (blood, urine, tissue, etc) to the laboratory of choice for analysis and study and to include diagnosis for submission for payment to the insurance carrier for the named patient.
Appointment Cancellation Policy
If I know I will be unable to make my appointment, I will notify the innova Pain Center as soon as possible. I understand that cancellations must be made at least 24 hours before my appointment, or I will be charged $75 for the missed appointment.
Authorization to Release Information
I authorize innova Pain Center to release any and all information contained in my medical and billing records to:
1) my insurance company,
2) government health care insurers (such as Medicare and Medicaid),
3) other persons financially responsible for my care or treatment, and/or
4) federal or state agencies, if required by law or regulations
I understand that I am financially responsible to the innova Pain Center and agree to pay for all services rendered to me. I authorize innova Pain Center to hold in a secure manner credit/debit card information for future financial payments. This may include fees for “no show” visits.
Prescription Refill Requests
I understand that innova Pain Center does NOT refill prescriptions over the phone. Please call your pharmacy and have them send a fax request. Refills received on Friday after 12 noon will be refilled the following Monday.
My initials and signature indicate that I have read and understand all the preceding information.
We are a multidisciplinary, state-of-the-art facility dedicated to the management and relief of pain. Pain relief is our specialty and your pain is our concern. Innova Pain Centers associates specialize in Pain Management and Neurology and are dedicated to the evaluation, diagnosis, and treatment of pain.
As a patient, you have the right to be informed of: your condition, recommended drug therapy, and potential risks of treatment. Physicians and health care providers are required to provide patients undergoing drug therapy information about their treatment plan. The information in this document is not meant to scare or alarm you. It is intended to help you become better informed, so that you may decide whether or not to have drug therapy.
This document also serves as an agreement between you and our health care team for pain management. Your signature below indicates you are consenting and agreeing to the following:
I understand that as a patient of innova Pain Center, I will be evaluated for pain and may receive treatment intended to manage my pain.
I understand that part of the treatment I may receive includes potentially dangerous and/or controlled medications including opioids or narcotic drugs. I recognize that opioid and narcotic drugs may be harmful if taken inappropriately or without medical supervision.
I further understand that opioid and narcotic drugs may lead to physical dependence and/or addiction and, like other drugs used in the practice of medicine, may produce adverse side effects.
Alternative methods of treatment, the possible risks involved, and the possibilities of complications will be explained to me. I have the right to consent to or refuse treatment.
I understand that the drug therapy my physician may prescribe may involve using a drug that has been approved for some purpose, but has not yet been tested by the Food and Drug Administration, specifically for safety or effectiveness related to my type of condition. Current medical literature shows that such off label use may be beneficial to some patients, and I understand that recommended dosages are often exceeded when treating chronic pain, in order to balance the benefit and risk to the patient.
I understand that if I choose to be treated with opioid or narcotic drugs, I will undergo medical tests and examinations before and during my treatment. If I choose to be treated with opioid or narcotic medications, I may be asked to consent to random, unannounced urine and/or blood screening to check for drugs. I understand that refusal to participate in such checks may lead to termination of my treatment by innova Pain Center. Additionally, I understand that if I am in possession of, or test positive for unauthorized substances, this may also result in the termination of my treatment by the innova Pain Center.
I understand that the most common side effects that occur in the use of opioids and narcotic drugs used in my treatment include, but are not limited to the following: constipation, nausea, vomiting, excessive drowsiness, itching, urinary retention (inability to urinate), low blood pressure, irregular heartbeat, insomnia, depression, impairment of reasoning and judgment, respiratory depression (slow or no breathing), impotence, physical and emotional dependence or addiction to the drugs, and death.
I understand that it may be dangerous for me to operate an automobile or other machinery while using opioids or narcotic medications, and that I may be impaired doing all activities, including work. I understand that the goal of my treatment is to help me gain control of my pain, in order to live a more productive and active life. I realize that I may have chronic pain with a limited chance of complete pain relief, so that I can enjoy and improve my quality of life. I realize that effective treatment may require prolonged or continuous use of medications, but that an appropriate treatment goal may also be the eventual withdrawal from the use of all medications.
I understand that my treatment plan will be tailored specifically for me. I understand that I may withdraw from this treatment plan and discontinue the use of medications at any time. If I do so, I agree to inform my physician immediately. I further understand that I may be offered medical supervision when discontinuing medication use.
I understand that no warranty or guarantee has been made to me as to the results of any drug therapy or the cure of any condition. I also understand that the long-term use of medications to treat chronic pain is controversial because of the uncertainty regarding the extent to which such medications provide long-term benefit.
I understand and agree that this Treatment Agreement relates to my use of all medications including opioids (also called narcotics or painkillers), and other prescription medications, interventions, or other therapies for pain.
I understand that there are federal and state laws, regulations, and policies regarding the use and prescribing of controlled substances and those medications will only be provided to me so long as I comply with this agreement.
My physician may at any time choose to discontinue my medication. I also understand that failure to comply with any of the following guidelines and/or conditions may cause discontinuation of medications and/or my immediate discharge of the care and treatment with innova Pain Center.
My progress will be periodically reviewed and if there is no sufficient evidence that the medication is improving my quality of life, the medication may be discontinued.
I will disclose to my physician all medications that I take at any time, regardless of who prescribes them.
I will use medications prescribed or provided to me exactly as directed by my physician.
I agree not to share, give, or sell these medications. I agree not to permit others, including my family and friends, to have inappropriate access to these medications.
I will not allow or assist in the misuse or diversion of my medications, nor will I give or sell them to anyone else.
All medications should be obtained at one pharmacy, where possible and reasonably practical. Should the need arise to change pharmacies; I agree to inform my physician immediately.
I understand that my medications may be refilled on a regular basis; however, if my medications or prescriptions are lost or stolen, my physician may decide, on a case-by-case basis, not to replace the medications or prescriptions. I understand that in the event that my prescription is stolen, my physician may require a police report stating the circumstances of my loss prior to refilling my medications. Refills, if any, will generally not be permitted before the scheduled refill date. I understand that early refills may be allowed when I am traveling, if I make arrangements in advance of my planned departure date. Otherwise, I understand that I may not receive additional medications prior to the time of my next schedule refill, even if my prescriptions run out.
I understand that I will generally receive pain medications only from innova Pain Center, unless there is an emergency or other extenuating circumstance.
I understand that if I am receiving medications from other healthcare providers and do not appropriately inform my physician of this, it may lead to discontinuation of medications and treatment. I recognize that chronic pain represents a complex problem which may benefit from physical therapy, psychotherapy, alternative medical care, and certain other interventions. I also recognize that my active participation in the management of my pain is extremely important. I agree to actively participate in all aspects of my pain management program recommended by my physician, to achieve increased function and improve quality of life or to discuss questions, concerns or barriers to my participation with my physician.
I agree to inform any healthcare provider who may treat me for any other medical problem that I am enrolled in a pain management program.
I understand that I am to take medications as instructed by my physician. I also understand that if I increase the amount or dose of medication without the authorization of my physician, this may be viewed as a cause for discontinuation of treatment at innova Pain Center. I understand that I have an obligation to keep all follow-up appointments as recommended by my physician or to timely contact innova Pain Center to reschedule if I am unable to keep a scheduled appointment; I understand that failure to do so may result in the discontinuation of treatment at innova Pain Center.
I acknowledge that I am not using illegal drugs or abusing prescription medications, and I am not undergoing treatment for substance dependence (addiction) or abuse at this time. I acknowledge that I am not involved in the sale, illegal possession, misuse/diversion, or transport of controlled substance (such as narcotics, sleeping pills, nerve pills, or painkillers) or illegal substances (marijuana, cocaine, heroin, etc). I understand that if I decide not to comply with innova Pain Center policies or procedures, other hospital rules, my care and/or treatment plan, or this patient care agreement, innova Pain Center may permanently stop providing me with care and treatment.
I understand that this patient care agreement does not change or impact my rights to consent to or refuse other care and treatment.
I understand that this patient care agreement will be signed by members of the healthcare team and me and will be placed in my medical records.
I have been given an opportunity to ask questions about my condition and treatment, risk of non-treatment, and the drug therapy, medical treatment, or procedures to be used to treat my pain, as well as the risks and hazards of such treatment, therapy, treatment, or procedures.
For females: I certify that I am not pregnant now and will notify the physicians at innova Pain Center if I am planning a pregnancy or become pregnant.
I understand that my treatment at innova Pain Center may be terminated if I am in any way hostile, belligerent, aggressive, ornery, or violent toward the physician and/or any of the staff at innova Pain Center. My signature indicates that I have read and understand all of the preceding information
innova Pain Center
, give permission to innova Pain Center to
__use the following protected health information, and/or
__disclose the following protected health information to:
[Name(s) of individuals, family members, spouses, etc or entities ]
Please understand that if you do not list
an individual, the Practice will not be allowed to disclose any information regarding your healthcare.
Only those individuals specified on this document will be allowed to discuss your healthcare with our
Information to be disclosed (check all that apply):
_ Medical Records
_ Treatment Records
_ Diagnostic Records
This protected health information is being used or disclosed for the following purposes:
This authorization does not expire until you notify the Practice in writing that you wish to change, revise or
discontinue these permissions.
If the person or entity receiving this information is not a health care provider or health plan covered by federal
privacy regulations, the information described above may be disclosed to other individuals or institutions and no
longer protected by these regulations.
You may refuse to sign this authorization. Your refusal to sign will not affect your ability to obtain treatment or
payment or your eligibility for benefits. You may inspect or copy the protected health information to be used or
disclosed under this authorization. For protected health information created as part of a clinical trial, your right
to access is suspended until the clinical trial is completed.
Finally, you may revoke this authorization in writing at any time by sending written notification to
innova Pain Center at 11920 Astoria, Ste 130 Houston, Texas 77089.
Signature of Participant or Personal Representative