Your First Pain Relief Visit

Patient First Name:

Patient DOB:

Patient Last Name:

Patient Primary Address:

City:

State:

Zip code:

Preferred Reminder Method:

Gender:

male

female

Marital Status:

Single

Married

Widowed

Divorced

Race:

Ethnic Group:

Declined

Hispanic

Not Hispanic or Latino

Other:

Emergency Contact:

Phone#

Relationship:

Do you give permission to release medical information to this person?

YES

NO

Pharmacy

Pharmacy

Name:

Address:

Phone #:

Primary Care Physician

Primary Care Physician

Name:

Address:

Phone #:

I certify that the above demographic information is correct.

Signature:

Date:

Information Form

Information Form

Date:

Name:

Date of birth:

Employer:

Occupation:

Do you work now?

Yes

No Part-time

What does your work involved?

Name of Doctor who referred you:

List of other Doctors you have seen for this pain problem:

Give details of injury or circumstances causing your pain:

Were you injured on the job?

Yes

No

How and when were you treated for this problem?

Have you had surgery for this problem?

Yes

No

If YES give:

Date

Hospital

Name of surgeon

Test performed:

Where and When:

What is your pain status now?

Worst

Better

Same

Has it changed and how?

What other treatment have you received: (i.e bedrest, physical therapy, chiropractic therapy)

Medications

Medications

Drug Allergies/ Food allergies:

Please list medication you have previously taken for pain:

Please list medication you have previously taken for pain:

Medication and dosage

Was it helpful?

Yes

No

Reason for stopping

Please list medications you are currently taking for Pain:

Please list medications you are currently taking for Pain:

Medication and dosage

Is it helpful?

Prescribing Doctor

Please list other medications you are CURRENTLY TAKING (include vitamin and supplements etc.)

Medication and dosage

Prescribing Doctor

Please circle on a scale of 0 to 10: (0 is no pain………10 is the worst imaginable)

At its best

Most of the time

At its worst

For the following descriptions, place a SINGLE number for each word that describes your pain:

None= 0

Mild=1

Moderate=2

Severe= 3

Throbbing

Gnawing

Splitting

Shooting

Hot/ Burning

Tiring

Stabbing/Sharp

Aching

Sickening

Tender

Fearful

Heavy

Cruel

Cramping

Married?

Yes

No

How many children’s do you have?

Level of education?

What type of work do you do?

Have you lost or gained weight in the last six months?

Yes

No

How many pounds?

please check:

lost

gained

Do you: Drink alcoholic beverage?

Yes (amount)

Do you smoke?

Yes (how much)

Have you ever been treated for addiction?

Yes

No

Family history (circle all that applies TO YOUR FAMILY)

Others:

Past Medical History Please circle any of the following that APPLY TO YOU

Other:

Surgical history:

Surgical history:

Date:

Name of surgery:

Name of provider:

Please mark the diagrams where you feel the symptoms described. You may have more that cone body area affected by these symptoms and you may have more than one symptoms in one specific area. Mark each area with each symptom you feel in each location.

Please mark the diagrams where you feel the symptoms described. You may have more that cone body area affected by these symptoms and you may have more than one symptoms in one specific area. Mark each area with each symptom you feel in each location.

As an example, if the symptoms is described as burning: mark for burning is XXX, put the XXX in the area where you feel a burning sensation. You may also experience perspiration in a specific area, but nowhere else. The symbol to mark in that area on the diagram is PPP. In addition, you may feel numbness in your fingers, but dull/aching pain in your shoulders. Mark these body area with the corresponding symbols +++ and NNN.

As an example, if the symptoms is described as burning: mark for burning is XXX, put the XXX in the area where you feel a burning sensation. You may also experience perspiration in a specific area, but nowhere else. The symbol to mark in that area on the diagram is PPP. In addition, you may feel numbness in your fingers, but dull/aching pain in your shoulders. Mark these body area with the corresponding symbols +++ and NNN.

Burning = XXX

Dull/Aching = DDD

Numbness = NNN

Spasm/Cramps = SSS

Perspiration = PPP

Stabbing/sharp = !!!

Pins & Needles = ///

Sensitive to tough = ###

Swelling = ***

Consultants in Pain Medicine, P.A.

423 Treeline Park, Suite 325

San Antonio, Tx 78209

Phone# (210) 546-1460 Fax# (210) 447- 6351

I hereby authorized Consultants in Pain Medicine, Inc to take my photograph for inclusion I my medical chart retained by the clinic. I understand this photograph is solely for the purpose for identification and familiarization by the office staff and the clinic physician.

Patient signature

Please fill out and sign the following release form so we can obtain copies of any medical records that may be needed in order to assess your condition more thoroughly.

Date:

I, ___________________________ hereby authorize the release of my medical records to Consultants in Pain Medicine.

Patient signature

Date

Witness

Date

Primary Care Physician:

Address:

Phone and Fax#:

Consultants in Pain Medicine, P.A.

423 Treeline Park, Suite 325 San Antonio, Tx 78209

Phone: (210)546-1460

Phone: (210)546-1460

Fax: (210)546-1459

Shaun Jackson M.D.

Christopher McAllister M.D.

Whitney Jackson D.N.P, A.P.R.N, F.N.P-C

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

Patient name:

DOB:

SSN:

I hereby authorize the release of any medical records to:

Consultants in Pain Medicine, P.A.

Dr. Shaun C. Jackson M.D.

423 Treeline Park, Suite 325 San Antonio, Tx 78209

Phone: (210)546-1460

Phone: (210)546-1460

Request medical records from:

Please check all that apply:

Patient signature:

Date:

This authorization will automatically expire two (2) years from the date signed

In order to comply with regulation for Health Insurance Portability and Accountability Act HIPAA governing the confidentiality of patient information a completed HIPAA compliant. Authorization to Release Medical Records must accompany each request for medical records even though you may have already obtained a signed consent from the patient.

We are sorry for any inconvenience this may cause, but the law were enacted to protect the confidentiality of medical information. Physician must comply with HIPAA privacy standards by requiring a fully completed form with all required information before releasing patient information. Thank you for your corporation.

*Request with incomplete addresses will not be processed*

*Request with incomplete addresses will not be processed*

Consultants in Pain Medicine, P.A.

423 Treeline Park, Suite 325 San Antonio, Tx 78209

Phone: (210)546-1460

Phone: (210)546-1460

Fax: (210)546-1459

Shaun Jackson M.D.

Christopher McAllister M.D.

Whitney Jackson D.N.P, A.P.R.N, F.N.P-C

AUTHORIZATION FOR RELEASE OF INFORMATION

AUTHORIZATION FOR RELEASE OF INFORMATION

Patient name:

DOB:

SSN:

I hereby authorized the release of records to:

Name:

Records requested:

For the purpose of:

Patient signature:

Date:

This authorization will automatically expire two (2) years from the date signed

In order to comply with regulation for Health Insurance Portability and Accountability Act HIPAA governing the confidentiality of patient information a completed HIPAA compliant. Authorization to Release Medical Records must accompany each request for medical records even though you may have already obtained a signed consent from the patient.

I hereby authorized the release of records to:

We are sorry for any inconvenience this may cause, but the law were enacted to protect the confidentiality of medical information. Physician must comply with HIPAA privacy standards by requiring a fully completed form with all required information before releasing patient information. Thank you for your corporation.

CPM Consultants in Pain Medicine, P.A.

ASSIGNMENT OF BENEFITS

ASSIGNMENT OF BENEFITS

Private insurance authorization for assignment of benefits and information release:

Private insurance authorization for assignment of benefits and information release:

I, the undersigned, authorize payment of medical benefits to Consultants in Pain Medicine for any services furnished to me by the physician. I understand I am financially responsible for any amount not covered by my insurance policy. I also authorized Consultants in Pain Medicine to release to my insurance company, referring physician and other consultants on my case information concerning healthcare, advice, treatment, or supplies provided to me. This information will be used for the purpose of evaluating the administering claims of benefits.

Patient sign:

Date:

MEDICARE LIFTTIME SIGNATURE ON FILE

MEDICARE LIFTTIME SIGNATURE ON FILE

I request that payment of authorized Medicare benefits be made on my behalf to Consultants in Pain Medicine for any services furnished to me by the physician. I authorized any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits payable for related services.

Patient sign:

Date:

Certification

Certification

Consultants in Pain Medicine, P.A. is pleased to offer you treatment for your injury or suffering. However, you are advised that according to most commercial insurance policies and generally accepted practice, treatment for work related chronic injuries must first be filed under Texas Workman’s Compensation. We will be happy to assist you this process. Also if this is a litigation case, our office needs to be informed before services are rendered.

I _______________________________ hereby certify that I am/ I am not treatment for an illness or injury that resulted from an incident/accident at my place of work or from a motor vehicle accident.

I _______________________________ hereby certify that I am/ I am not treatment for an illness or injury that resulted from an incident/accident at my place of work or from a motor vehicle accident.

MVA/Date of Incident:

If applicable, Attorney’s Name

Phone:

Patient Print Name:

Date:

Patient Signature:

Health Insurance Portability and Accountability Act

Health Insurance Portability and Accountability Act

By signing this document, I Acknowledge that I have been given the opportunity to read the Notice of Privacy Practices of Consultants in Pain Medicine, P.A.

Patient Print and Signature

Date

NO-SHOW/LATE CANCELLATION POLICY

NO-SHOW/LATE CANCELLATION POLICY

• Consultants in Pain Medicine, P.A. cultivates a doctor-patient relationship that is based on trust, focusing on patient as individuals. Our physician and excellent support staff strive to be fair and courteous in all of our dealings. • The following policy has been established to help us serve you better. It is necessary for us to make appointments in order to see our patient as efficiently as possible. No-shows and late cancellations cause problems that go beyond any financial impact to our practice. When appointments is made, it takes an available time slot away from another patient in need of medical care. No cancelling and appointment is a timely fashion is unfair to other patient, some of whom may be quite ill and may unnecessarily delay of delivery of health care. For their reasons we have developed the following No-show/Late Cancellation policy. • A no-show is defined as missing a scheduled appointment without calling us in advanced to cancel the appointment. A late cancellation is defined as failing to cancel or rescheduled a scheduled appointment by 3 p.m. the day before your scheduled appointment. We request that if your need to cancel or rescheduled your appointment, you must contact our office no later than 3 p.m. the day before your scheduled appointment so that we may office the appointment time to another patient who is in need of medical attention. • We understand that everyone might have unforeseen events in which you cannot make our appointment with us so we have allotted you one grace appointment each calendar year in which you will not be charged a fee, as described below, for that sudden emergency. • For each subsequent no-show or late cancellation during the same calendar year, we are charging the normal fee of $50 for office visits and $100 for procedures to cover for the staff that is on hand to provide your needs, this charge will apply to change to your insurance carrier or Medicare, as applicable. These fees are your financial responsibility and they must be paid prior to making any new appointment. A patient who ho-shows there times within a twelve month period, regardless of whether it is in the same calendar year, is subject to dismissal from the practice. • Finally, we understand that the circumstances beyond your control may arise, where adequate notice is not possible. These limited situations will be considered on a case by case basis. • Please understand that the intent of this policy is to aid us in offering a high standard of care to our patient and that this policy is in place to help us achieve that goal. We pledge to do out part to keep our schedule mobbing as efficiently as we possibly can. We value you as a patient and appreciate your understanding and cooperation.

Consultants in Pain Medicine, P.A. cultivates a doctor-patient relationship that is based on trust, focusing on patient as individuals. Our physician and excellent support staff strive to be fair and courteous in all of our dealings.
The following policy has been established to help us serve you better. It is necessary for us to make appointments in order to see our patient as efficiently as possible. No-shows and late cancellations cause problems that go beyond any financial impact to our practice. When appointments is made, it takes an available time slot away from another patient in need of medical care. No cancelling and appointment is a timely fashion is unfair to other patient, some of whom may be quite ill and may unnecessarily delay of delivery of health care. For their reasons we have developed the following No-show/Late Cancellation policy.
A no-show is defined as missing a scheduled appointment without calling us in advanced to cancel the appointment. A late cancellation is defined as failing to cancel or rescheduled a scheduled appointment by 3 p.m. the day before your scheduled appointment. We request that if your need to cancel or rescheduled your appointment, you must contact our office no later than 3 p.m. the day before your scheduled appointment so that we may office the appointment time to another patient who is in need of medical attention.
We understand that everyone might have unforeseen events in which you cannot make our appointment with us so we have allotted you one grace appointment each calendar year in which you will not be charged a fee, as described below, for that sudden emergency.
For each subsequent no-show or late cancellation during the same calendar year, we are charging the normal fee of $50 for office visits and $100 for procedures to cover for the staff that is on hand to provide your needs, this charge will apply to change to your insurance carrier or Medicare, as applicable. These fees are your financial responsibility and they must be paid prior to making any new appointment. A patient who ho-shows there times within a twelve month period, regardless of whether it is in the same calendar year, is subject to dismissal from the practice.
Finally, we understand that the circumstances beyond your control may arise, where adequate notice is not possible. These limited situations will be considered on a case by case basis.
Please understand that the intent of this policy is to aid us in offering a high standard of care to our patient and that this policy is in place to help us achieve that goal. We pledge to do out part to keep our schedule mobbing as efficiently as we possibly can. We value you as a patient and appreciate your understanding and cooperation.

I acknowledge that I have read and understand this No-show/Late Cancellation Policy I further understand that I will incur fees in the event I fail to notify this office before 3 p.m. the day before my scheduled appointment or if I fail to show up for my scheduled appointment. Any fees uncured are my responsibility to pay and in the event I incur a fee shall be pain prior to making any new appointment.

Patient Name:

Patient Signature:

Date:

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