Agreement for Chronic Pain Medication Administration
I understand the purpose of this agreement is to prevent misunderstandings about certain medications that I will be taking for pain management. This is to help me, and my doctor comply with the law regarding controlled medications. I understand that if I break this agreement, Pain Care Specialists of Florida will stop prescribing my pain medications. I agree that I will not mix alcohol or any illegal substance with pain medication. I agree that driving or operating any type of machinery will not be allowed while I am being prescribed opioid medication. I will not increase or decrease the dosage of my medication without the consent of the prescribing physician. I will not share or sell my medications with anyone, nor will I take another person's medication. I will not receive any pain medications from any other doctors. I understand that it is my responsibility to safeguard my prescription and medications. Should my prescription or medication be lost, stolen, or destroyed, under no circumstances will it be replaced. I understand that there may be risks associated with the use of pain medication, including risk of death, respiratory depression, bowel and bladder dysfunction, sexual dysfunction, and others. I agree to submit to random urine drug testing and/or pill counts at the request of the providers. I have read and understand the above information.
Patient Signature — Medication Agreement:
Financial Responsibility Agreement
I, the below-named patient, hereby knowingly and voluntarily agree, acknowledge, and represent to the above-named health care provider that in addition to any other contract(s) existing or hereafter entered into between myself and the said healthcare provider, I am responsible for paying the full amount(s) billed to me or on my account for the health care services provided to me or for my benefit, including but not limited to care, treatment, other services, medicine, and supplies, and that no act or omission by the healthcare provider shall constitute a waiver of the right to charge to and be paid by me and the entire amount(s) billed to me or on my account. In further consideration of the care, treatment, services, medicine, and/or supplies provided to me or on my behalf by the healthcare provider. I do hereby waive any and all statutes of limitation on any claim or cause of action that the healthcare provider may have or hereafter acquire against me regarding the care, treatment, services, medicine and supplies provided to me or for my benefit, including the charges and bill(s) due therefor, whether any such claim be in law or equity, and do further waive any and all head of family or other protection(s) from collection by a creditor under Florida and/or Federal law. If you provide more than one-half of the support for a child or other dependent. All or part of your income is exempt from garnishment under Florida Law. You can waive this protection only by signing this document. By signing below, you agree to waive the protection from garnishment. I understand and agree that the said healthcare provider is relying on my aforesaid inducements, promises, agreements, and representations in agreeing to provide me with healthcare. I agree that such reliance by the healthcare providers is reasonable in all respects. Further if I should have any right to seek or compel arbitration of any matter with the healthcare provider, I hereby irrevocably waive that right, and agree that all of the rights given to the healthcare provider by me herein, are and shall constitute a grant coupled with an interest, and therefore, among other things, shall be irrevocable by me, and the undersigned patient, and no obligation of mine to this healthcare provider is or can become delegable to any other person.
If the patient is a minor, the parent must sign below on the parent's and the minor's behalf:
Parent / Guardian Signature (if patient is a minor):
Assignment of Benefits
I hereby authorize and direct you, my insurance company and my attorney(s), jointly and severally, to pay directly to Pain Care Specialists of Florida (referred to herein as "Spine" or "Assignee") such sums as may be due and owing Assignee for services rendered by reason of accident, illness, and for any other bills issued by Assignee, and to withhold such sums from any disability benefits, medical payments, or any other health or liability insurance benefits in which I may have or acquire a right or interest in any respect, as may be necessary to fully satisfy the charges of said Assignee. With regard to submitting for no-fault ("PIP") benefits or reimbursement for services personally rendered by a Physician or other healthcare provider who may be an employee or contractor of Spine, I hereby assign to such individual physician(s) or other healthcare provider(s) who render any services to me all rights and benefits I may have, or come to have, under Personal Injury Protection / No-Fault Insurance ("PIP"), Including the right to submit to any such PIP carrier directly for reimbursement bills for services rendered to me. Said assignment by me is not a delegation of any duties that I may have under any such PIP insurance. Further, should any or all such physicians or healthcare providers authorize Spine, in any manner, to bill, receive, or process any PIP payments I have hereby assigned for the benefit of any or all such physicians or other healthcare providers, then in that event Spine shall be considered merely a billing agent of or clearinghouse for such physicians or other healthcare providers, regardless of whether any such billings for PIP reimbursements or benefits may appear to be in the name of Spine (and as such, Spine shall be acting merely as an agent of/for said physicians and other healthcare providers, rather than billing or submitting for PIP reimbursements or benefits in its own right.) To supplement this process I specifically give and grant to Spine a power of attorney rendering Spine my attorney-in-fact to act as my agent to facilitate any/all such physicians' and other healthcare providers' individual rights and efforts to process all applications for payment and receipt of payment of POP benefits or reimbursements in the name and under the EIN of any such physician or other healthcare provider or his/her practice entity, or in the name and under the EIN of Spine as the billing agent or clearinghouse for any/all such physicians or other healthcare providers, at Spine's election, with all PIP payments received to be posted to the given Physicican's or other healthcare provider's account as revenue of said physician or other healthcare provider. This power of attorney granted to Spine by me herein is a grant coupled with an interest, is irrevocable, and shall survive the end of services rendered to me for a period of sixty (60) months. Whether I do or do not have insurance coverage or may have any rights under any insurance policy (including a liability policy upon which I may have or come to have the right to make a claim), I understand that I am and shall remain personally responsible for payment in full of all bills for services rendered by the Assignee and healthcare providers who may be employees or contractors of Assignee. This is to act as an assignment of my rights and benefits to the extent of the Assignee's services provided, but not a delegation of any duties I may have under or regarding any benefits I have or hereby assign. In the vent that any insurance company that may be obligated to make payments to me upon or concerning charges made by the Assignee or healthcare providers who may be employees or contractors of Assignee for services rendered to me, either delays or refuses to make such payment upon such cause of action that I might have or that might exist in my favor against such company, I authorize Assignee and healthcare providers who may be employees or contractors of Assignee to prosecute said cause of action either in my name or Assignee's, and I further authorize Assignee to compromise, settle, or otherwise resolve said claim or cause of action as Assignee sees fit.
Direction of Payment
I hereby authorize and instruct any insurance company, attorney, and all other agents or representatives of mine to pay in full directly to Assignee the amount of all bills for services rendered to me. Without limitation of any other terms of this agreement or any other agreement with the Assignee, I also agree to pay directly to Assignee in a current manner any difference between the total charges and the amount paid by any insurance company. This agreement and the foregoing power of attorney also allows Assignee to endorse any check or draft provided to Assignee in my name for purposes of payment for services rendered to me by Assignee or its employees, contractors, or agents. Assignee is an express beneficiary and a third-party beneficiary of the instructions I have given in assignment and can enforce any or all of said instructions in its own name and right just as if I were the Assignee seeking to enforce said instructions.
PIP Log and Declaration Sheet Request
I hereby authorize Assignee to release requested information, which is pertinent to my case(s) or condition(s), to my insurance company or the attorney involved in any such case(s), pursuant to Section 627.4137, Florida Statutes. I hereby request that a copy of the PIP log and declaration sheet, which reflects the policy limits available at the time of or any other accident in which I may be involved, be provided to this Assignee upon each and every request of said Assignee. I hereby authorize this Assignee to request and receive a copy of my PIP log periodically as Assignee deems necessary. If any term or provision of this Assignment and Authorization or the application thereof to any person or circumstance shall, to any extent, be determined to be invalid or unenforceable, the remainder of this Assignment and Authorization, or the application such term or provision to persons or circumstances other than those as to which it is held invalid or unenforceable, shall not be affected thereby, and each term and provision of this Assignment and Authorization shall be valid and enforced to the fullest extent of the law (for example only, as by any physician or other healthcare provider who rendered any service to me, instead of by Spine.)
Reservation of Benefits
Be further advised, I am hereby placing you on notice pursuant to Florida case law that should you (the insurance company/carrier) deny, reduce, delay, or fail to pay any part of or the entire bill which was submitted on my behalf from this healthcare provider, I (the assignor) as well as the assignee (for itself any and all physicians and other healthcare providers who may be employees or contractors for Spine) are requesting, in advance that you reserve, or "set-aside," the amount reduced or denied or delayed until the dispute is resolved. Should you submit a check to Spine or any physician or other healthcare provider who may be an employee or contractor of Spine which is less than the correct amount, and it contains any language referring to or purporting to declare payment(s) as "Full and Final Payment," or the like, then I have instructed assignee to return the check to you (the insurer) and consider the bill still due and owing (i.e. a late payment as defined in F.S. 627.736). Additionally, should the remaining amount of my benefits approach an amount where there would be insufficient funds to pay the amount you reduced, delayed or failed to pay, please notify me (the assignor) and the assignee in writing immediately.
Medical Records Release Form
I give permission for my medical information / medical notes to be disclosed to:
Patient Signature — Medical Records Release:
