HEALTH INSURANCE INFORMATION:

DISCLOSURE OF ANY PENDING LITIGATION:

If YES, please proceed to window and ask for our Billing Department to discuss your payer claim.

DISCLOSURE OF CURRENT MOTOR VEHICLE ACCIDENTAL CLAIM/LAWSUIT:

All professional services rendered are billed to the health insurance.  Necessary claim submission will be completed to help expedite insurance carrier payments electronically, However, the patient is responsible for all fees that are not covered by the insurance policy, regardless of insurance coverage once claims are processed and deemed patient responsibility including any service denied by insurance carrier due to insurance benefit exclusions after services have been rendered.  It is also customary to pay for fees on the day of actual service.  I request that payment for authorized Medicare/Other Insurance company benefits made to me or on my behalf to DENNIS SLAVIN, MD dba Rio Grande Pain Team for any services furnished me by that party who accepts assignment.  Regulations pertaining to Medicare assignments of Benefits apply.  I authorize any holder of medical or to the information about me released to the SSA and Health Care Financing Administration or its intermediaries or carriers any information needed for this or related Medicare Claim/Insurance claim, I permit copy of this authorization to be used in a place of the original.  I understand it is mandatory to notify the health care provider of any other party who may be responsible for paying for my treatment.  Dennis Slavin MD has the authority to report all outstanding delinquent  accounts to a collection agency after failure of receiving payment  for services rendered without written notification.  *DENNIS SLAVIN, MD reserves the Right not to bill any private insurance carrier for auto accident claims/ Open-Old litigation claims on file.*

Section 1128B SSA&31U.S.C. 3801-3812 provides penalties for withholding this information.

SOCIAL HISTORY:

POLICY FOR ALL PATIENTS UNDER OPIATE MEDICATION REGIMEN REGARDING CBD OIL/PRODUCTS, HEMP, KRATOM supplements, SPICE products:

Due to lack of evidence based medicine on risks and or benefits with CBD oil/ CBD products, Kratom supplements, HEMP products for human consumption in any form not limited to vaping (smoking), topical creams or sublingual oral drops, Rio Grande Pain Team has a ZERO tolerance for the usage of these products.

IF ANY PATIENT TESTS POSITIVE (+) FOR ANY THC (MARIJUANA), OR OTHER ILLICIT SUBSTANCE INCLUDING THE CONSUMPTION OF ANY USE OF CBD PRODUCTS, THERE WILL BE NO PRESCRIBING OF OPIATES FROM THIS OFFICE.

I have read and understood the policy regarding the CBD oil and all its derivative products containing CBD ingredients.  I understand that I maybe discharge from this practice for the violation of this policy and that there will be no future Opiate prescription given to me.

Consent to Treatment/Financial Responsibility Consent

I desire to be treated at Dr. Dennis Slavin medical office.  I understand that I may discontinue treatment at any time.

I understand that in order to receive appropriate treatment, I will undergo a clinical evaluation consisting of, but not limited to, a medical history and evaluation, and may include an x-ray, MRI, physical therapy evaluation, physical capacities evaluation, and psychological assessment.  The purpose of the evaluation is to assist in identifying the cause of my problem and applying the most effective medical treatments possible.

1.PHOTOGRAPH:  Photo Image will be used to identify patient in the Electronic Medical Record profile..

2. URINE DRUG SCREEN: As part of the medical procedures or tests, I understand that I may be asked to provide a Urine specimen at random, if a doctor orders the test for diagnostic purposes during my tenure as a patient and as part of the monitoring of all prescribed medications.  Special Toxicology Urine testing will detect but not limited to ethenol levels, metabolite of illegal substance and indicate all mediations ingested.

3. GUARANTEE OF PAYMENT  I agree to be responsible to the center for charges resulting from services and supplies rendered at its prevailing rates.  I agree all bills are due in full upon demand.  Should I fail to honor this agreement, I agree to pay any collection cost or attorney fees resulting from the collection of my accounts.).  Special orders are made only once all parties involved have confirmed and agree to all medical fees. Regardless to Insurance benefit-coverage.

Dr. SLAVIN dba Rio Grande Pain Team does not bill any OUT-of NETWORK insurance carriers:

As a service and courtesy to our patients, non-participating health insurance plans will be billed as non-assigned claim. Any outstanding balances are the responsibility of the patient.

4. Assignment of Benefits (other than Medicare and Medicaid): I hereby assign all rights and privileges and authorize payment directly to the center for any claim filed on my behalf or on the behalf of the person for whom I am duly authorized to sign for insurance benefits.  I agree this assignment is primary to any assignment given after this date including any cost relative to attorney fees.  I also understand that I am financially responsible to the center for co pays, deductibles, coinsurance due at the time of service, and charges not covered by this assignment or by my insurance plan or not paid on a timely basis by the insurance company.

5. Assignment of Benefits (Medicare and Medicaid):  I request that payment of authorized Medicare and/or Medicaid benefits be made to the center or on my behalf for any servitor supplies furnished by the center, including physician services.  I authorize any holder of medical or other information about me to release it to the Center for Medicare and Medicaid Services and its agents or to the Kentucky Medicaid Program and its agents, as appropriate, any information needed to determine these benefits or benefits for related services.  I understand that I am responsible for any coinsurance, unmet deductibles, and services and items not covered by Medicare and/or Medicaid.  CO-PAYS AND OR DEDUCTIBLE FEES WILL BE COLLECTED ON THE DAY OF SERVICES PRIOR TO SEE A PHYSICIAN IN THIS OFFICE..

6. The assignment of benefits is intended to grant to the center all rights that I may have in connection with benefits or other rights, under ERISA, any plan documents applicable to me, or applicable laws or regulations, including Medicare and Medicaid, associated with the services to the same extent, and to the fullest extent that I would be entitled or have the power to exercise such rights on my own behalf or on behalf of my covered dependents. *Courtesy verification of any fees due will be done by this clinic at the time of service.

7.TELEPHONE NUMBER: I give my consent for the phone numbers listed to be used to contact me for medical office purposes only

8. RETURNED CHECK FEES DUE TO NSF(INSUFFICIENT FUNDS)  

Any returned check from the bank for non-payment (insufficient funds) shall result in the patients account being assessed a $50.00 fee per check returned.  This office will not re-deposit NSF check.

9. Specialty Referrals:

If your insurance requires you to choose a primary care physician (PCP), you may need to have a prior authorization completed by your PCP prior to seeing a specialist (pain specialist, Sport Medicine, Physical Therapist and certain ancillary services) it is the patient responsibility to ensure a prior authorization is obtained.  All charges incurred without a required prior authorization will be the responsibility of the patient.

10. MEDICATION REFILLS: I will be responsible for requesting my medication refill 7-days in advance before I ran out of medication. I understand Dr. Slavin will have 72hr to prepare and grant my refill medication.    

I herby authorize all professional staff to release any information acquired in the course of the examination and treatment to: (1) referring physician; (2) insurance company; (3) worker’s compensation carrier;(4) the Center’s attorneys and consultants in accordance with applicable privacy laws.

*I understand that if I missed my assigned appointments (3)times consecutively, those will be ground for dismissal from care and I will be refer back to my primary doctor, and there will be no further actions. I have read and understand this financial policy for RGPT.

RIO GRANDE PAIN TEAM/ DENNIS SLAVIN, MD

INFORMED CONSENT AND PAIN MANAGEMENT AGREEMENT

REQUIRED BY THE TEXAS MEDICAL BOARD

TO THE PATIENT: As a patient, you have the right to be informed about your condition and the recommended medical or diagnostic procedure or drug therapy to be used, so that you may make the informed decision whether or not to take the drug after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you, but rather it is an effort to make you better informed so that you may give or withhold your consent to the drug(s) recommended to you by me, as your physician.  For the purpose of this agreement the use of the word “physician is defined to include not only my physician but also my physician’s authorized mid-level professional associates as might be necessary or advisable to treat my condition.

CONSENT TO TREATMENT AND/OR DRUG THERAPY: I voluntarily request my physician (Dennis Slavin, MD) and such associates, technical assistants, nurses and other health care providers as he may deem necessary or advisable, to treat my condition which has been explained to me as chronic pain. I hereby authorize and give my voluntary consent to administer or prescribe the prescription(s) for dangerous and/or scheduled drugs (medications) as an element in the treatment of my chronic pain.

It has been explained to me that these medication(s) include opioid/narcotic drug(s), which can be harmful if taken without medical supervision. I further understand that these medication(s) may lead to physical dependence and/or addiction and may, like other drugs used in the practice of medicine, produce adverse side effects or results. The alternative methods of treatment, the possible risks involved, and the possibilities of complications have been explained to me as listed below. I understand that this listing is not complete, and that it only describes the most common side effects or reactions, and that death is also a possibility as a result from taking these medication(s).

THE SPECIFIC MEDICATION (S) THAT MY PHYSICIAN PLANS TO PRESCRIBE WILL BE DESCRIBED AND DOCUMENTED SEPARATE FROM THIS AGREEMENT.  THIS INCLUDES THE USE OF MEDICATIONS FOR PURPOSES DIFFERENT THAT WHAT HAVE BEEN APPROVED BY THE DRUG COMPANY AND THE GOVERNMENT (this is sometimes referred to as “OFF-LABEL” prescribing)  MY DOCTOR WILL EXPLAIN HIS TREATMENT PLAN(S) FOR ME AND DOCUMENT IT IN MY MEDICAL CHART.

I HAVE BEEN INFORMED AND UNDERSTAND that I will undergo medical tests and examinations before and during my treatment. Those tests include random unannounced checks  (Urine, Saliva ,Blood) or any psychological evaluations or  other test indicated and deemed necessary , and I hereby give permission to perform the tests or my refusal may lead to termination of treatment. Presence of unauthorized substances or absence of authorized substances may result in my being discharge from your care.  

I UNDERSTAND THAT THE MOST COMMON SIDE EFFECTS THAT COULD OCCUR IN THE USE OF THE DRUGS USED IN MY TREATMENT INCLUDE BUT ARE NOT LIMITED TO THE FOLLOWING: constipation, nausea, vomiting, excessive drowsiness, itching, urinary retention, orthostatic hypotension(low blood pressure), arrhythmias (irregular heartbeat), insomnia, depression, impairment of reasoning and judgment, respiratory depression (slow or no breathing), impotence, tolerance to medication(s), physical and emotional dependence or even addiction, and death. I will not be involved in any activity that may be dangerous to me or someone else if I feel drowsy or am not thinking clearly.  I am aware that even if I do not notice it, my reflexes and reaction times might still be slowed.  Such activities include but are not limited to: using heavy equipment or a motor vehicle, working in unprotected heights or being responsible for another individual who is unable to care for himself/ or herself.  

The alternative methods of treatment, the possible risks involved, and the possibilities of complications have been explained to me, and I still desire to receive medication(s) for the treatment of my chronic pain.

The goal of this treatment is to help me gain control of my chronic pain in order to live a more productive and active life. I realize that I may have a chronic illness and there is a limited chance for complete cure, but the goal of taking medication(s) on a regular basis is to reduce (but probably not eliminate) my pain so that I can enjoy an improved quality of life. An appropriate treatment goal may even mean the eventual withdrawal from the use of all medication(s). I realize that the treatment for some will require prolonged or continuous use of medication(s) , but an appropriate treatment goal may also mean the eventual withdrawal from the use of all medications(s).  My treatment plan will be tailored specifically for me.  I understand that I may withdraw from this treatment plan and discontinue the use of the medication(s) at any time and that I will notify my physician of any discontinued use.  I further understand that I will provided medical supervision if needed 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 cure of any condition. The long-term use of medications to treat chronic pain is controversial because of the uncertainty regarding the extent to which they provide long-term benefit. I have been given the opportunity to ask questions about my condition and treatment, risks of non-treatment and the drug therapy, medical treatment or diagnostic procedure(s) to be used to treat my condition, and the risks and hazards of such drug therapy, treatment and procedure(s), and I believe that I have sufficient information to give this informed consent.

PAIN MANAGEMENT AGREEMENT:

I UNDERSTAND AND AGREE TO THE FOLLOWING:

That this pain management agreement relates to my use of any and all medication(s) (i.e., opioids, also called ‘narcotics, painkillers’, and other prescription medications, etc.) for chronic pain prescribed by my physician and/or any appropriately authorized assistant(s). I understand that there are federal and state laws, regulations and policies regarding the use and prescribing of controlled substance(s). Therefore, medication(s) will only be provided so long as I adhere to the rules specified in this Agreement.

My physician and/or any appropriately authorized assistant(s) may at any time choose to discontinue the medication(s) at his/her discretion. Failure to comply with any of the following guidelines and/or conditions may cause discontinuation of medication(s) and/or my discharge from care and treatment. Discharge may be immediate for any criminal behavior:

• My progress will be periodically reviewed and, if the medication(s) are not improving my quality of life, the medication(s) may be discontinued.

• I will disclose to my physician all medication(s) that I take at any time, prescribed by any physician.

• I will use the medication(s) exactly as directed by my physician and /or his appropriately authorized assistant(s).

• I agree not to share, sell or otherwise permit others, including my family and friends, to have access to these medications.

• I will not participate in the diversion of my medication; nor will I give or sell them to anyone else.

• All medication(s)  must be obtained at one pharmacy, where possible.  Should the need arise to change pharmacies, my physician must be informed. I will use only one pharmacy and I will provide my pharmacist a copy of this agreement. I authorize my physician and/or his appropriately authorized assistant(s) to release my medical records to my pharmacist at his/her discretion and I will provide my pharmacist a copy of this agreement.  

• My pain management physician will manage the chronic pain symptoms.  All other health related issues must be managed by my primary care physician.  

• I understand that my medication(s) will be refilled on a regular basis. I understand that my prescription(s) and my medication(s) are exactly like money. If either are lost or stolen, they may NOT BE REPLACED.

• Refill(s) will not be ordered before the scheduled refill date. However, early refill(s) are allowed when I am traveling and I make arrangements in advance of the planned departure date. Otherwise, I will not expect to receive additional medication(s) prior to the time of my next scheduled refill, even if my prescription(s) run out.

• I will receive medication(s) only from ONE physician and/or his appropriately authorized assistant(s) unless it is for an emergency or my physician approves the medication(s) that is being prescribed by another physician. Information that I have been receiving medication(s) prescribed by other doctors that has not been approved by my physician may lead to a discontinuation of medication(s) and treatment.

• If it appears to my physician and/or his appropriately authorized assistant(s) that there are no demonstrable benefits to my daily function or quality of life from the medication(s), then my physician and/or his appropriately authorized assistant(s) may try alternative medication(s) or may taper me off all medication(s). I will not hold my physician or his appropriately authorized assistant(s) and/or any member of his staff liable for problems caused by the discontinuance of medication(s).

• I agree to submit to urine and/or blood screens to detect the use of non-prescribed and prescribed medication(s) at any time and without prior warning. If I test positive for illegal substance(s), treatment for chronic pain may be terminated. Also, a consult with, or referral to, an expert may be necessary: such as submitting to a psychiatric or psychological evaluation by a qualified physician such as an addictionologist or a physician who specializes in detoxification and rehabilitation and/or cognitive behavioral therapy/psychotherapy.

• I recognize that my chronic pain represents a complex problem, which may benefit from physical therapy, psychotherapy, alternative medical care, etc. 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 the pain management program recommended by my physician to achieve increased function and improved quality of life.

• I agree that I shall inform any doctor who may treat me for any other medical problem(s) that I am enrolled in a pain management program, since the use of other medication(s) may cause harm.

• I hereby give my physician and/or his appropriately authorized assistant(s) permission to discuss all diagnostic and treatment details with my other physician(s) and pharmacist(s) regarding my use of medications prescribed by my other physician(s).

• I must take the medication(s) as instructed by my physician and/or his appropriately authorized PA-C/ assistant(s). Any unauthorized increase in the dose of medication(s) may be viewed as a cause for discontinuation of the treatment.

• I must keep all follow-up appointments as recommended by my physician and/or his appropriately authorized assistant(s) or my treatment may be discontinued.

• I understand many prescription medications for chronic pain produce serious side effects including drowsiness, dizziness, and confusion.  Alcohol will enhance all of these side effects and should be discontinued before starting these medications.  

*I certify and agree to the following:

1)​I am not currently using illicit drugs or abusing prescription medication(s) and I am not undergoing treatment for substance dependence (addiction) or abuse. I am reading and making this agreement while in full possession of my faculties and not under the influence of any substance that might impair my judgment.

2)​I have never been involved in the sale, illegal possession, diversion or transport of controlled substance(s) (narcotics, sleeping pills, nerve pills, or painkillers) or illegal substances (marijuana, cocaine, heroin, etc.)

3)​No guarantee or assurance has been made as to the results that may be obtained from chronic pain treatment. With full knowledge of the potential benefits and possible risks involved, I consent to chronic pain treatment, since I realize that I would otherwise continue to have chronic pain.

4)​I have reviewed the side effects of the medication(s) that may be used in the treatment of my chronic pain. I fully understand the explanations regarding the benefits and the risks of these medication(s) and I agree to the use of these medication(s) in the treatment of my chronic pain.

NOTICE OF PRIVACY PRACTICES-ACKNOWLEDGEMENT

Rio Grande Pain Team keeps on file a medical and billing record of all the health care services that were provided to you by us.  This may include physician notes; lab and radiology reports, consult notes and other health care information that helps us provide you quality health care.  It is your right to ask to obtain a copy of that record.  You also may ask for the record to be changed or corrected if you see a discrepancy.  Rio Grande Pain Team will not disclose this information without your authorization or where the law allows for treatment, payment, or healthcare operations.  We will release this information when federal or state laws require us to do so.  Should you desire copies of your medical record or other protected health information, please contact our Medical Record Department at (956)992-0319

Medical Record Administrative Fee:

*$25.00 Medical Record fee may apply for the first 20pgs, and 0.50cents each page after.

*$15.00 Additional fee if a Notary affidavit  signature is required

I authorize Rio Grande Pain Team physicians to share or discuss the medical plan of care with immediate family next of kin or others involve in the care rendered here at this medical clinic not limited to appointment reminders.  The following authorized next of kin are:

Patients with Medical Implantable Devices:

If necessary and if applicable to my medical care, this office will require the assistance and presence of the following medical device companies for the adjustment, calibration, reprogramming of any specific medical device implanted:  

Medtronic, USA., St Jude Co, Boston Scientific, Inc  such services will be for the sole purpose of continuity of medical care.

Today's Date:

DENNIS SLAVIN, MD

AUTHORIZATION TO REQUEST HEALTH INFORMATION

I hereby authorize the request of information from the medical record of:

Date of Birth

I authorize the following individual or organization to disclose the above named individual's health information:

This information may be released to and used by the following individual or organization:

Dennis Slavin, MD Medical Record Department

910 E. 8th St. Suite 1

Weslaco, TX 78596

Phone: 956-973-0565    

FAX: 956-973-0683

For the sole purpose of:   Continuity of care, please expedite request.

I understand that the information is for the specific purpose stated above.  Any other use of this information without the written consent of patient is prohibited.  I understand that I have the right to revoke this written authorization at any time.  I understand that if I revoke I must do so in writing and present my written revocation to the individual or organization releasing the information.  I understand that the revocation will not apply to the information already release in response to this authorization.  I understand that the revocation does not apply to the insurance company when the law provides my insurer with the right to contest a claim under my policy.  Unless otherwise revoked, this authorization expires upon the completion and duration  of all medical care rendered here at RGPT Dr. Dennis Slavin.  I understand that authorizing the disclosure of this health information is voluntary.  I can refuse to sign this authorization, I need not sign  this form in order to ensure treatment.  I understand that I may inspect or copy the information to be used or disclosed.  I understand that any disclosure of information carried with it the potential for an unauthorized re-disclosure and the information may not be protected by Federal confidentiality rules.  If I have any questions about the disclosure of health records, I can contact the Medical Record Dept at 956-973-0565 Option #4.