Patient Information
Appointment Details
WITHOUT YOUR PHOTO ID YOU WILL ONLY BE ELIGIBLE FOR INJECTIONS
NO SHOW POLICY- To assure that all of our patients ace access to care when needed by maximizing the utilization of available appointments, you (the patient) are required to cancel your scheduled appointment with appropriate prior notice (24 hours.) Failure to cancel your appointment without 24-hour notice is considered a DzNo Show.dz If you have two DzNo Showdz occurrences, a $50.00 penalty fee will be charged to your account.
IF YOU HAVE AN HMO- You will NOT receive any injections at your first visit. Any HMO requires authorization and in order to obtain that authorization proper documentation of the initial visit must be done.
IF YOU DO NOT HAVE AN HMO- Your initial appointment is a consultation only. If you were referred for an injection there is no guarantee you will receive it at your initial visit. It is possible, but again, no guarantee. Getting any injection is a decision that is made between you and the doctor at the time of your visit. Ultimately it is at physician’s discretion, regardless of any prior treatment or referrals you may have received.
SOME INSURANCES- Will only cover injections if they are performed in a surgery center. If this is the case you injection will be scheduled for a later date during your initial appointment.
REGISTRATION FORM
ASSIGNMENT OF BENEFITS, AUTHORIZATION TO SETTLE CLAIM AND DIRECTION TO PAY MEDICAL PROVIDER DIRECTLY
FINANCIAL AGREEMENT
AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
PAIN QUESTIONNAIRE
MEDICAL HISTORY
MEDICAL RELEASE FORM
LIEN AND LETTER OF PROTECTION
THE FEDERAL GOVERNMENT REQUIRES COLLECTION OF THE FOLLOWING INFORMATION. THE CHOICES ARE FEDERALLY MANDATED. PLEASE SELECT THE ANSWERS THAT BEST APPLY TO YOU. THANK YOU.
MEDICATION AGREEMENT AND INFORMED CONSENT
As a patient of Dr. Edwin Maldonado’s, I understand that I may be prescribed medications that are
considered addictive. Such medications include narcotics, tranquilizers, and muscle relaxants. Although those medications may be appropriate in my care, I understand that I bear the following responsibilities:
FOR YOUR SAFETY
1. Patients receiving narcotic medications from pain management may not receive any narcotics prescripts from any other physician or clinic office. If you are receiving any narcotic medications from another physician’s office, clinic or emergency room, you may be discharged from our practice.
2. I will take the medications as prescribed and not more unless approved by my physician, and I will NOT take another person’s prescribed narcotic medication.
3. All time- released medications should be taken whole. They are not to be crushed, ground up or mutilated before taken.
4. Your medications are your own. Keep them in a safe place. Do NOT share them with your spouse, friends, or anyone else.
5. Prescriptions will be accompanied by an office visit.
6. It is the policy of the practice that only the patient will be able to sign for prescriptions.
7. All patients must understand that narcotic medications are potentially dangerous.
8. All patients receiving narcotic prescriptions will sign and receive a copy of the agreement.
9. I understand that alcohol may potentate the effects and duration of my medication. I acknowledge that I have been advised to avoid alcohol consumption.
10. Routine urine analysis may be performed at the discretion of Dr. Edwin Maldonado.
11. Any evidence of illicit drugs found in your urine analysis testing may result in discharge from our practice.
12. If you lose your prescription, you will not receive a refill until the scheduled time of your next appointment.
13. If your prescription is stolen, a police report will be required before any additional medications are written.
14. Pharmacy miscounts are your responsibility and not that of the pharmacy or Dr. Edwin Maldonado.
15. The doctor’s office may and will call local pharmacies for confirmation of prescriptions.
16. It is the policy of the practice not to renew or prescribe pain medications after hours, on the weekend or without patient’s medical records at hand.
If any of the above requirements are not met by myself , I understand that no additional medications will be prescribed and that all of my treating physicians and pharmacies may be notified of my non- compliance. Additionally, I may be discharged from this medical practice and I may be asked to seek future pain treatment from another physician and/or undergo detoxification. I agree to the terms and conditions outlined above in this document.