We would like to welcome you to Texas Pain Physicians (TPP). It is our goal to get to know you and be  able to provide you with the appropriate care in order to treat you so please read all forms in their  entirety. 

Our facility offers a team of pain management that is dedicated to provide you with the most  comprehensive and conservative care possible. Based on the clinical findings found in your exam these  services might be indicated to benefit you. It is ultimately your right to choose whether you receive these  services or not. Our doctors are determined to provide you with the best care possible. We have found  that a synergistic team approach has been very effective at attaining optimal results. 

Each Clinician is trained to treat conditions related to the Neuro-Musculoskeletal System. Some of the  doctors have completed advanced training in Pain Management. We will continue to strive to be able to  offer you the best care possible and get you on the journey to live a pain free lifestyle with optimal  wellness and preventative care. 

I understand that my prescriptions must be obtained at the same pharmacy. I agree to notify the office if  the need arises to change pharmacies. 

I have received a copy of the office policies for the facility named above. 

I have read and understand these documents and agree to follow these policies to the best of my ability.  I understand that if I fail to abide by these policies I may be discharged from treatment.

The clinicians you will be seeing are the following:

• Dayla Elhady
• Haroon Rasheed
• Amr Morsy
• Tian Zhao
• Kashif Irfan
• Whitney Chouteau
• Christopher Creighton
• Amr Zidan
• Adrian Escontrias
• Seema Rasheed
• Alexandra Golden

NP's:

• Enobong Udo
• Ugonna Onwunali
• Wendy Santos
• Michelle Simmons
• Kimberly Player
• Karen Albright
• Mimi Song Idicula
• Marchele Johnson
• Martha Santiago

By signing this you agree to be treated at our facility by all the different practitioners.

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The undersigned patient and/or responsible party, in addition to continuing personal responsibility, and in  consideration of treatment rendered or to be rendered assigns to the physician or facilities named above the following  rights, power and authority. 

RELEASE OF INFORMATION: You are authorized to release information concerning my condition and treatment to  my insurance company, attorney or insurance adjuster, for purposes of processing my claims for benefits and  payment of services rendered to me. 

IRREVOCABLE ASSIGNMENT OF RIGHTS: You are assigned the exclusive, irrevocable right to any cause of  action that exists in my favor against any insurance company for the terms of the policy including the exclusive  irrevocable right to collect payment for such services, make demand in my name for payment and prosecute and  receive penalties, interest, court costs or other legally compensable amounts owed by an insurance company in  accordance with Article 21:55 of the Texas Insurance Code or other applicable insurance or state statute. I, as the  patient and/or responsible party, further agree to cooperate, provide information as needed and appear as needed  wherever to assist in the prosecution of such claims for benefits upon request. 

DEMAND FOR PAYMENT: To any insurance company providing benefits of any kind to me/us for treatment  rendered by the physician/facility named above, you are hereby tendered demand to pay in full the bill for serviced  rendered by the physician/facility named above within 60 days following your receipt of such bill for services to the  extent such bills are payable under the terms of my/our policy for benefits, less any amount which I/we personally  owe which are not payable under the terms of the policy. This demand specifically conforms with Article 21:55 of the  Texas Insurance Code, providing attorney fees, 18% penalty, court costs and interest from judgment upon violation. 

THIRD PARTY LIABILITY: If my injuries are the result of negligence from a third party, then I instruct the liability  carrier to dispense a separate draft to pay in full all services rendered payable directly to the physician/facilities  named above. 

STATUTE OF LIMITATIONS: I waive my rights to claim statute of limitations regarding claims for services rendered  or to be rendered by the physician/facilities named above, in addition to reasonable costs of collection, including  attorney fees and court costs if incurred. 

LIMITED POWER OF ATTORNEY: I hereby grant to the physician/facilities named above the power to endorse my  name upon any checks, drafts or other negotiable instrument representing payment from any insurance company  representing payment for treatment and health care rendered by physician/facility named above. I agree that any  insurance payment representing an amount in excess of the charges for treatment rendered will be credited to my/our  address upon request in writing to the physician/facility named above. 

TERMINATION OF CARE WAIVER: I hereby acknowledge and understand that if I do not keep appointments as  recommended to me by my caring doctor at this clinic or facilities, he/she has the full and complete right to terminate  responsibility for my care and relinquish any disability granted me within a reasonable period of time. If, during the  course of care, my insurance company requires me to take an examination from any other doctor, I will notify this  physician/facility immediately. I understand that failure to do so may jeopardize my case. 

A photocopy of this instrument will serve as the original.

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I hereby authorize my provider to appeal the determination concerning adjudication of claims billed out for  services provided to me on my behalf, as my Designated Representative, and, as part of the claim appeal  process. 

I hereby allow my health insurance carrier, in its decision letter and in connection with the processing of my  appeal, to communicate with my Designated Representative in all aspects of the appeal. 

I understand this information is privileged and confidential and will only be released as specified in this  authorization, or as required or permitted by law. This authorization is valid for the entire period of 1 year  form the last date of service. 

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We welcome you to our medical practice and facilities. Texas Pain Physicians (TPP) has some services  that are out of network for your insurance. 

Your health insurance provides you with out of network benefits which allows you to receive full medical  care by a non-participating physician or facility. If you would like to locate a participating provider, please  contact your health insurance company. 

TO BE COMPLETED BY PATIENT OR PATIENTS LEGAL GUARDIAN. 

By placing my signature on this form, I acknowledge the following: 

1. I was made aware that any medical services provided such as Anesthesia, or injections  performed at different surgery centers are covered by my Out of network Benefits provided by my  health insurance and will be billed out as Out of Network Claims. 

2. I understand that I may be responsible for costs for services provided as specified in my out of  network benefit plan and that absent financial hardship, the provider is prohibited from waiving  deductibles, co-pays and co-insurances. 

3. I was given an opportunity to contact my health insurance plan before obtaining services. 

4. I am voluntarily choosing to obtain services and procedures from Texas Pain Physicians and  affiliated Out of Network facilities.

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We believe that part of good healthcare practice is to establish and communicate a financial policy to our patients. We are  dedicated to providing the best possible care for you, and we want you to completely understand our financial policy. This  policy applies to the following clinics or facilities; Texas Pain Physicians. 

1. PAYMENT is expected at the time of your visit. We will accept cash, certified check and credit/debit card payments.  Effective September 1, 2016 we will no longer accept personal checks. Payment will include any unmet deductible, co-insurance,  co-payment amount, or non-covered charges from your insurance company. If you do not carry insurance, or if your coverage is  currently under a pre-existing condition clause or grace period, payment in full is expected at the time of your visit. We do ask  for a copy of an ID card or license due to the many cases of identity theft in the news lately. (Please do not be offended!) 

2. INSURANCE We are participating providers with many insurance plans. We will file insurance claims on your behalf as a  courtesy. 

Please remember that insurance is a contract between the patient and the insurance company and ultimately the patient is  responsible for payment in full. If your insurance company does not pay the practice within a reasonable period of time, you  may be billed. 

If our doctors are not listed in your plan’s network, you may be responsible for partial or full payment. Due to the many  different insurance products out there, our staff cannot guarantee your eligibility and coverage though we will make every effort  to do so. Be sure to check with your insurer’s member benefits department about services and physicians before your  appointment. You are responsible for obtaining a properly dated referral if required by your insurer and will be responsible for  payment if your claim rejects for the lack of one. 

Not all insurance plans cover all services. In the event your insurance plan determines a service to be “not covered”, you will  be responsible for the complete charge. Payment is due upon receipt of a statement from our office. All procedures billed in this  office are considered covered unless limited by your specific insurance policy. 

Patients who insist on “day of” urgent/emergent scheduling or care after hours or on days the clinic is closed will be assessed an  additional urgent care or after hours’ fee. These fees will be billed to your insurance carrier or collected as part of the office  charges for self-pay patients. 

3. FORMS FEES: completing insurance forms, copying medical records, etc. Requires office staff time and time away from  patient care for our doctors. We require pre-payment for completing forms, copying medical records, notarizing, or for extra  written communication by the doctor. The charge is determined by the complexity of the form, letter, or communication. Base  form charges are $10 per occurrence plus and applicable postage or notary fees. Postage is additional and payment is required  in advance. Fees for Medical Records is $25 for the first twenty (20) pages and $0.50 per page in excess of twenty. The  office asks to allow 5-7 business days in which to copy records before making them available for patient to pick up, and these 5- 7 days will commence after payment has been received and after patient has signed this form authorizing records’release. 

4. CANCELLATIONS OR MISSED APPOINTMENTS: If you do not cancel your appointment at least 24 hours before,  or if you no-show, we will assess a $25 missed appointment fee for Office Visits and a $50 missed appointment fee for Injections  or Procedures. 

5. RESPONSIBILITY FOR PAYMENT: I understand that I, personally, am financially responsible for charges not covered  by the assignment of insurance benefits. 

6. INSURANCES WE WON’T BILL/PATIENTS WE WON’T ACCEPT INTO THE PRACTICE: I am not currently  eligible for, Medicaid, I will notify the office in writing immediately if I become eligible for any of these payors, thus terminating  my care from the office, who WILL NOT accept new patients with Medicaid, nor bill these payors if patients switch after  becoming established with the office. 

7. RELEASE OF INFORMATION: I hereby authorize and direct the office to release to governmental agencies,  insurance carriers, or others who are financially l iable for such professional and medical care, all information needed  to substantiate claim and payment. 

8. INSURANCE ASSIGNMENT: I hereby authorize payment to be made directly to my provider by my insurance company  for any charges for services covered by the terms of my policy. I agree to cooperate, aid and assist the facility in procuring all  possible insurance benefits initiation and fulfillment of all policy provisions such insurance companies may require for payment. 

Texas Pain Physicians reserves the right to not prescribe controlled substances on the first initial office visit. Texas Pain Physicians reserves the right to not prescribe controlled substances to patients who do not present some form of Texas ID. 

I have read and understand the practice’s financial policy and I agree to be bound by its terms.  I also understand and agree that such terms may be amended by the practice from time to time.

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Right to Terminate or Revoke Authorization - You may revoke or terminate this authorization by submitting a  written revocation to this office and contact the Privacy Officer. 

Potential for Re-disclosure - Information that is disclosed under this authorization may be disclosed again by the  person or organization to which it is sent. The privacy of this information may not be protected under the federal  privacy regulations. I understand this office will not condition my treatment or payment on whether I provide  authorization for the requested use or disclosure. 

If you understand and agree with all of the above policies, please sign your name below. 

We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or  disclose your health information. Please sign this form to acknowledge receipt of the Notice. You may refuse to sign  this acknowledgment, if you wish.

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Hello, we are requesting records for the following Patient;

I hereby request that my medical records be released to:

5520 LBJ FWY STE 190

Dallas, TX 75240

PH: 972-636-5727

FAX: 972-499-2540

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