Patient Intake & Registration Forms


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.

THANK YOU FOR YOUR UNDERSTANDING IN THIS MATTER


REGISTRATION FORM

Patient Information

Other Language Preferences



Referred to clinic by:



INSURANCE INFORMATION

(PLEASE GIVE YOUR INSURANCE CARD TO THE RECEPTIONIST.)

Primary Insurance
Secondary Insurance


IN CASE OF EMERGENCY

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Cannabis MD or insurance company to release any information required to process my claims.


ASSIGNMENT OF BENEFITS, AUTHORIZATION TO SETTLE CLAIM AND DIRECTION TO PAY MEDICAL PROVIDER DIRECTLY



By my signature below, for good and valuable consideration (including but not limited to the extension of credit to me), I hereby adding, transfer and convey to Edwin Maldonado MD/ Certified Spine and Pain Care ȋhereinafter Dzthe ProvideddzȌ all of my rights, title and interest in and to medical expenses reimbursement in whatever form, including but not limited to any automobile liability medical expenses payments or other health benefits indemnification and/or agreement otherwise payable to me. This payment shall not exceed my indebtedness to the above named assignee and I acknowledge that I will timely pay any indebtedness owed by me to the assignee that is not otherwise that is not otherwise satisfied by the above mentions assigned proceeds.

I further authorize the Provider to negotiate, collect and settle any claim with any insurance carrier or other third party with regard to these service, which authorization shall include authority to (1) re quest and receive form any insurer or any other party and all documentation and records that I am empowered to request regarding this claim, including without limitation any Independent Medical Examination Reports, Records Review Report, Explanation of Benefits, and Benefit Payment Sheets or Logs (PIP Payout Sheets), without regard as to whether such documentation has already been provided to me, and (2) endorse in my name any check issued for payment where benefits are assigned.

I further direct my insurer to direct all payments for services rendered by the Provider to: Certified Spine and Pain Care, at the address listed below.

THIS IS A DIRECT AND IRREVOCABLE ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER MY POLICY OF INSURANCE.

A photocopy of this form shall be considered as effective and valid as the original. I have read the foregoing and understand and agree to each of the above provisions.


FINANCIAL AGREEMENT

I hereby give authorization for payment of insurance benefits to be made directly to the provider and any assisting physicians for services rendered. I understand that I am financially responsible for all charges whether or not they are covered by insurance. In the event of default, I agree to pay all costs of collection and reasonable attorney fees. I hereby authorize this health care provider to release all information necessary to secure the payment of benefits. I further agree that a photocopy of this agreement shall be valid as original.
Insurance authorization must be obtain before a patient is seen, if I do not inform the physicians seen in this clinic of my current insurance and the services are denied because of no authorization, I will be responsible for payment. If authorization is not obtained from the insurance company before my scheduled appointment and I still choose to see the doctor, I will be responsible for the bill at the time of service.


AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION



By signing below, you hereby authorize us to use or disclose information about yourself (or another person whom you have the authority to sign) that is protected under federal law, for the sole purpose and time period described below. You may refuse to sign this authorization. Subject to certain exceptions, you have the right to inspect and copy the protected health information. Information to be used or disclosed (must be identified in specific and meaningful fashion); and purpose of use and disclosure: MRI, CT, XRAY and Lab reports; last H&P, evaluation, and office notes for the purposes of pain management evaluation and treatment.

Please initial all boxes:
I hereby authorize CSPC, LLC to verbally disclose my health information to:

I hereby authorize CSPC, LLC to verbally disclose my health information on my answering machine.

This information about you is protected under federal law, and you have the right to revoke this authorization in writing. Please be advised, however, that any revocation will be effective only to the extent we have not already taken action in reliance on your authorization. By signing below, you recognize that the protected health information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient of this disclosure and may no longer be protected under federal law. We will not condition treatment based on your authorization. You may refuse to sign the authorization.

As personal representative, I have authority to act for the individual because I am:


ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I acknowledge that I have received a copy of the CSPC, LLC: Dz Notice of Private Practicesdz which sets forth privacy practices and my rights regarding privacy of my protected health information.


PAIN QUESTIONNAIRE

Date of Birth

Please take a few minutes to complete this Pain questionnaire. Accurate information will help us in evaluating your medical status and taking care of your medical needs. Thank you.

1. Please check how your current problem began:

2. Are your symptoms mostly in the:

Do you have any radiating pain?

If yes, specify where:

Any numbness or tingling?

If yes, specify where:

From a scale of 1-10(1=no pain at all; 10=the worst pain), what number do you give?

3. How long have you had these symptoms?

The pain is

Check all of the following activities that make your pain BETTER?

Check all the following activities that make you pain WORST?


PREVIOUS TREATMENT & TESTS

1.What medications have you taken for this problem?

2. What tests have you had?

3. Did you receive physical therapy/ chiropractic treatment?

Did the treatments improve your symptoms?

4. Did you have any injections for this problem?


MEDICAL HISTORY

1. List all drug and non-drug substances that you are allergic to:

2. Any complications under Anesthesia:

3.List all of your previous major surgeries:

4. Do you smoke cigarettes?

5. Do you drink alcohol?

6. Could you be pregnant?

Check all of the following medical problems you are currently or have ever been treated for:

Please circle any of the following that you currently have:

Constitutional

Dermatologic

Eyes

Ent

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

Psychiatric

Endocrine

Gynecological

Hematologic

Musculoskeletal

Neurologic

Please list all medications you are currently taking (include Aspirin, Ibuprofen, Vitamin E)

Name of Drug



Dose (mg and times per day)



Reason



EVERY QUESTION MUST BE ANSWERED, PLEASE CIRCLE YOU’RE ANSWER

Chief complaint related to the accident

1. Date of Accident

2. Type of Accident

What type of vehicle were you in:

The Other Vehicle:

3. In your own words, describe how the accident happened:

Were you hit from the:

4. Were you:

5.When the accident occurred, did you hit:

6. When the accident occurred, were you wearing you seatbelt:

7. When the accident occurred, did the airbags deployed:

8. Did you hit your head in the accident:

9. Did you loose consciousness

10. Did you go to the hospital

11. Were you keep overnight at the Hospital

12. What treatment did you receive at the hospital

13. Were X-Rays taken at the hospital

PAST HISTORY

13. Have you been involved in a previous Accident?


MEDICAL RELEASE FORM

Date of Birth


I give permission to release my protected health information to the following entity:

Name: Certified Spine and Pain Care
Main Office Location: 3345 Burns Rd., Suite 202. Palm Beach Gardens, FL 33410
Phone Number: 561-578-4582
Fax Number: 561- 828-2377


Lien and Letter of Protection

I hereby authorize and direct my attorneys (whether now or hereafter representing me) to pay directly to Certified Spine and Pain, all sums due and owing for all services rendered by Certified Spine and Pain, including but not limited to, medical services rendered, supplies provided, reports made or duplicated, depositions given, or time spent as an expert or witness in my case. I hereby give and grant unto Certified Spine and Pain a first priority lien upon and to any and all monies that I may have the right to or benefit of, or come to have the right to or benefit of, from any source whatsoever, including but not limited to any settlement, judgment, recovery, or other source of funds, to the extent of all sums owed by me to Certified spine and pain stemming from my care or treatment, or any case I may institute involving, in whole or part, said care or treatment. This lien is prior in dignity and superior to any right in any such funds that anyone else may possibly claim, including my attorney(s). I authorize and hereby instruct my attorneys to withhold such sums from any insurance settlement, judgment, verdict or other source of funds that I may have the right to or benefit of, or come to have the right to or benefit of, as may necessary to fully pay and adequately protect Certified spine and pain as first priority, including all funds owed to me from my case by way of the tortfeasor(s), insurance payments, judgment, verdict, or other source which may be paid to my attorney or myself.

I fully understand that I am personally and directly fully responsible to Certified Spine and Pain for all medical bills for services rendered to me, whether or not submitted to any insurer or other entity for payment in whole or part. I further understand that this agreement is made solely for my protection in consideration of Certified Spine and Pain providing me care and treatment that I believe to be reasonable to obtain or medically necessary, from my perspective as the patient, and for Certified Spine and Pain awaiting payment for said care and treatment. The physicians of Certified Spine and Pain may contract with an insurance plan that they or I participate in; however, this provider may or may not elect to bill my insurance or accept payment(s) from that insurance company, and in any event, I hereby waive any right I may be perceived to have to request or require that Certified Spine and Pain or any of its physicians submit any bills to any insurance carrier. I understand that nothing herein releases me from my absolute and ultimate responsibility and obligation to pay Certified Spine and Pain in full for services rendered, I further understand that my obligation of payment is not contingent on any settlement, judgment, verdict, or anything else whatsoever.

I agree to keep Certified Spine and Pain apprised of the name and address of all attorneys who represent me. Notification of any such changes must be made to Certified Spine and Pain within ten (10) days, and in any event, before any case or claim settlement is made, or any funds are paid (whether by a tortfeasor, insurance company, or any other payer whatsoever) to me, or to my attorney(s) on my behalf. I instruct any/all attorney(s) who represent me to honor this agreement and fulfill it, whether or not they sign a copy of this Lien and Letter of Protection, and also understand that if my attorney does not wish to cooperate in protecting Certified Spine and Pain such does not change the attorney’s or my obligation and the attorney’s signature on this document is not necessary for the instructions I give him/her herein to bind said attorney. In the event of my attorney’s failure to cooperate despite my instructions made herein ( to which Certified Spine and Pain is an express, intended, third-party beneficiary), such will be a breach by me of this agreement entitling Certified Spine and Pain to all remedies available at law and in equity, and Certified Spine and Pain will be immediately released from any obligations under this Agreement, including that it shall not have to await payment and can require me to pay the account on a current basis.

By my signature below I established that I have read, understood, and consented to the terms of this agreement.

Effective Date: This agreement becomes effective when the Patient signs the agreement below.

Lien and Letter of Protection

In the event any dispute arises as to the charge for any services rendered by Certified Spine and Pain. I hereby authorized and direct my attorney to withhold from any source of funds that I may have the right to or benefit of, or come to have the right to or benefit of, the full sum claimed by Certified Spine and Pain until said time as the matter is settled by compromise or judgment. I also agree that I shall be responsible for all costs, including attorney’s fees and costs of collection, incurred by Certified Spine and Pain whether or not there be any litigation between us involving or concerning this agreement, such costs, including attorney’s fees and collection costs, to be payable by me to Certified Spine and Pain on demand.

The undersigned, being the attorney for the above patient, does hereby recognize the instructions given me by the patient, my client, and I do agree to observe all the terms of the above and agree to withhold such sums from any insurance payment, settlement, judgment, verdict, or other source whatsoever as may be necessary to protect and pay Certified Spine and Pain the full amount of all sums billed by, due, or to become due Certified Spine and Pain from or on behalf of the above- named patient (including but not limited to any monies from any tortfeasor, insurance company, or other payer whatsoever). If I receive money on the patient’s behalf from any source, including money paid in this case, then I agree to hold and preserve sufficient funds to fully satisfy the sums due and owing Certified Spine and Pain, or to become due and owing to it according to the terms of this document. If a dispute arises, payout will be made only upon agreement of all parties or court order. I agree that all sums will be due immediately upon being billed by Certified Spine and Pain, and must be paid to Certified Spine and Pain from funds received by me on behalf of the patient, my client, within ten (10) days from the resolution of the subject litigation relating to my client, or upon my coming into possession of any other funds whatsoever for or on behalf of the patient.

In addition, I further agree that any and all charges for medical records duplication, review of records, independent medical evaluations, depositions, conferences, expert testimony, and photocopying are not charges payable upon a contingent basis and that I, the patient’s attorney, am fully responsible for such charges when I request any such thing/ service. These charges are payable to Certified Spine and Pain regardless of the outcome of the litigation and even if there is no recovery obtained from a third party to pay for these services.

I agree to notify Certified Spine and Pain in writing within ten (10) days, if the above named patient changes his/her status as my client and I am no longer the patient’s attorney. Lastly, I agree that any action brought on account of any matter set forth above shall be brought in the Circuit Court in Palm Beach County Florida, as the exclusive venue therefore.

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.

Ethnicity

Race- Primary (Select ONLY one)

Primary or Preferred Language ( Select ONLY one)

Pharmacy E- Prescribe

We are required to electronically prescribe certain medications. Please provide preferred Pharmacy
information. 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.

Request an Appointment

Thank you for contacting the office of Certified Spine and Pain Care. One of our staff members will confirm your appointment shortly.

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