• Physician - Patient Contract for Narcotic Medication or Buprenorphine Treatment

  • Patient Information

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  • Demographics

  • Additional Information

  • Insurance Information

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  • Office Policies for Suboxone Treatment and Medical Office Visit

    In the event of a crisis situation, go to your nearest emergency room or call 911.

    Appointment Scheduling and Cancellation General Medical Office Visit
    • Please note that the doctors are not in the office every day and their schedules fill up quickly. You are strongly encouraged to schedule your appointments two weeks in advance.
    • If you need to cancel a appointment, you must call or emailat least one day prior, or you will be charged the full fee for the office visit.
    • If you need disability forms or lengthy forms completed, this must be done during an office visit.

    Medications/Refill Requests

    • Controlled substances will NOT be refilled without an office visit.
    • To request a refill, your pharmacy must fax a refill request form to 703­361­0346.
    • Please allow 72 hours for refill requests to be completed.
    • Please schedule your follow-up appointment BEFORE your medication runs low.
    • No refill requests will be processed on a weekend or holiday.
    • Some medications require pre-authorization from your insurance company. This may take up to a week depending on your insurance plan.
    • New symptoms will require an appointment; the physicians will not diagnose via telephone.

    Buprenorphine(Suboxone, Zubsolv and Bunavail)Program Guidelines

    • Photo identification with current address is required.
    • You are required to submit to routine urinalyses while on buprenorphine.
    • No prescription will be replaced if lost, stolen, damaged or misplaced.
    • You must provide us with your pharmacy name and phone number.
    • Our practice will only prescribe Suboxone® film (no subutex), Zubsolv and Bunavail in most cases.
    • Fees for Urine Drug Tests are the responsibility of the patient.
    • The physician may require that you attend counseling while on buprenorphine.
    • If you are attending support groups, you will need to bring proof of attendance.
    • If you are under the care of a therapist, you will be required to sign a medical release form so that we may verify that you are in ongoing treatment while on buprenorphine.
    • If you attend groups at New Leaf Counseling, the fee is $30.00 per session.
    • Inability to adhere to the buprenorphine program guidelines will result in termination of the patient-physician relationship.

    Confidentiality

    • The staff adheres to a strict confidentiality policy. We require specific written authorizations to release information to anyone.
    • In order to maintain your privacy, our staff members will not accept ‘friend requests’ on facebook or any other social networking site.
    • A copy of our Notice of Privacy Practices is available upon request.
    • If you have questions or concerns, please call the Privacy Officer at 703­361­4357.

    Communication

    • The administrative staff handles all requests for appointments and correspondence. If you have a need that cannot be fulfilled by the administrative staff, a written message will be given to the physician. Every attempt will be made to return your call within one business day. However, please note that the doctors are not in the office every day.
    • If you need a phone session with your physician, you will be billed at the standard office rate.

    Fees & Professional Services

    • Payment is due at the time service. If you are unable to pay at the time of service, your appointment will need to be rescheduled.
    • We are under no obligation to render services if you have an outstanding balance
    InitialEvaluation $200.00 If Physician see you Byweekley $120.00
    Follow up $180.00 Every Three week $160.00
    If Physician see you weekley

    $80.00

    We do not accept Checks

    Outside Lab feeis Pt Responsibility

    Mandated Reporting

    • Please note that physicians are mandated reporters. This means they are required to notify the proper officials if we suspect abuse or neglect of a child or a compromised adult.
    • Even if abuse or neglect happened years ago, if it occurred when you were a child, and you reveal that to your physician, he or she is required to report the issue to legal authorities.

    I understand and agree to the above policies: {name}

  • Clear
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  • I, {name} agree to the following conditions:

    • I understand that I have a chronic pain problem or opioid dependence problem that currently requires the prescription of narcotic medication or buprenorphine to increase my function. The risks, side effects, and benefits of the medication have been discussed with me in detail.
    • I will obtain prescriptions for narcotics and other controlled medicines only from Dr. Lee or Other Mega Health Practitioners.
    • I will take the medication only as prescribed and will promptly notify Dr. Lee or other Alt-med Practitioner, if I do not.
    • I may not combine narcotics/buprenorphine with alcohol.
    • I agree to random urine and blood tests to assess my compliance.
    • I agree to random pill counts.
    • I understand the eventual goal of tapering the narcotic/buprenorphine medication.
    • I agree to attend regular N/A-A/A meetings or meet with a private counselor/therapist if I am in the buprenorphine program. My logsheet will be brought to each office visit.
    • I will meet regularly with Alt-med Practitioner to assess my progress. Lost, misplaced, or stolen medications/prescriptions will not be replaced. Refills will not be given early for any reason. If I deviate from the above guidelines, I will be permanently discharged from all care provided by Mega Health Services providers.
    • I understand when my treating doctor deems it necessary, that I may be asked to under-go psychological evaluation and/or counseling.
    • I have read the above document, or have had it read to me. I have asked all questions necessary and wish to proceed with the treatment plan.

  • I will have prescriptions filled at only one pharmacy (Pharmacy Name & Location:)      
    I will also immediately inform you if my contact information has changed.

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  • Medical History

    to be completed by patients
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  • Have you ever had an EKG?      .      
    Date:   Pick a Date  . 

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  • Childhood Illnesses
    Measles :                               
    Mumps:         
    Chicken Pox:          

    Have you or a family member ever been diagnosed with a psychiatric or mental illness?       .  
    (Please describe)        

    Have you ever taken or been prescribed antidepressants?       . For what reason      .
    Medication(s) and dates of use:      Why stopped:      .

    Please list all current prescription medications and how often you take them (example: Dilantin 3x/day).DO NOT include medications you may be currently misusing (that information is needed later):      

    Please list all current herbal medicines, vitamin supplements, etc, and how often you take them:      

    Please list any allergies you have (eg, penicillin, bees, or peanuts):      

  • Name: {name}

    Date of Birth: {dateOf}

  • Tobacco History

    Cigarettes: Now?(Yes or No)     . In the past?(Yes or No)      How many per day, on average?      For how many years?      

    Pipe: Now? (Yes or No)      .In the past? (Yes or No)    .How often per day, on average?   For how many years?      

    Have you ever been treated for substance misuse?(Yes or No)      .(Please describe when, where and for howlong)      

    How long have you been misusing substances?      

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  • Did you ever stop using any of the above because of dependence?(Yes or No)            (Please list)      

    What was your longest period of abstinence?      

    Are you receiving, or have you ever received counseling support? (Yes or No)      (Please describe when and for
    howlong)      

  • Name : {name}

    Date of Birth: {dateOf}

  • Social/Family History

  • Patient Name: {name}

  • Children:(Yes or No)      . Current ages(Please List)    .  
    Residing with you? (Yes or No)      .If No, where?      .
    Where are you currently living?      .
    Do you have family nearby?(Yes or No)    .  (Please describe)      .

  • Are you currently employed?(Yes or No)      .Where (if no, where were you last employed)?            
    What type of work do/did you do?      How long have/did you work(ed) there?      

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  • If you are not currently attending meetings, what factors led you to stop?      .Have you ever been in counseling or therapy? (Yes or No)      (Please describe)      

  • Authorization for Use and Disclosure of Protected Health Information

  • Patient Name: {name}

    Address: {address}

    Phone:{mobileNumber}

    Date of Birth: {dateOf}

    SSN:  {ssnNumber}

     

    I, {name} authorize to  disclose protected health information to:                                                           

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  • *Specific Authorization to Disclose Sensitive Records*

  • *This information is disclosed from records whose confidentiality is protected by federal law. Federal regulations prohibit you from making any
    further disclosure of this information without the specific written consent of the person to whom it pertains, or as otherwise permitted by such
    regulations. A general authorization is NOT sufficient for this purpose.*

    • I understand that I may revoke this authorization, in writing, at any time except to the extent that Physician Group of Utah has
    already relied on this authorization.

    • I understand that I may revoke this authorization by mailing or faxing a written notice to the Regional Compliance and Privacy
    Officer, at Altmed Medical Center, Inc 8708 Sudley Road, Manassas, VA 20110 or fax to 703­361­0346, stating my
    intent to revoke this authorization.

    • Unless otherwise revoked, I understand that the specific date or event upon which this authorization expires is “none” unless
    otherwise specified here: Expiration:   Pick a Date   

    • I understand that Mega Health Services may not condition treatment, payment, enrollment or eligibility for benefits on the
    completion of this authorization form.

    • I understand that information being disclosed may be subject to re-disclosure by the recipient and may no longer be protected by
    the Federal privacy law, if the recipient is not a “covered entity.”

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  • PLEASE NOTE: THIS FORM MUST BE COMPETED IN ITS ENTIRETY. THANK YOU FOR YOUR COMPLIANCE

  • Statement of Patient Financial Responsibility

  • Patient Name: {name}

    Date of Birth: {dateOf}

  • The Mega Health Services appreciates the confidence you have shown in choosing us to provide for your health care needs. The service you have elected to participate in implies a financial responsibility on your part. The responsibility obligates you to ensure payment in full of our fees. As a courtesy, we will verify your coverage and bill your insurance carrier on your behalf. However, you are ultimately responsible for payment of your bill.

    You are responsible for payment of any deductible and co-payment/co-insurance as determined by your contract with your insurance carrier.We expect these payments at time of service. Many insurance companies have additional stipulations that may affect your coverage. You are responsible for any amounts not covered by your insurer. If your insurance carrier denies any part of your claim,or if you or your physician elects to continue past your approved period, you will be responsible for your balance in full.

    I have read the above policy regarding my financial responsibility to the Mega Health Services for providing   services to me or the above-namedpatient. I certify that the information is, to the best of my knowledge, true and accurate. I authorize my insurer to pay any benefits directly to The Mega Health Services, the full and entire amount of bill incurred by me or the above-namedpatient; or, if applicable any amount due after payment has been made by my insurance carrier.

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  • Co-Pay Policy

    Some health insurance carriers require the patient to pay a co-pay for services rendered. It is expected and appreciated at the timethe service is rendered for the patients to pay at EACH VISIT. Thank you for your cooperation in this matter.

    Patient/Guarantor Signature      Date   Pick a Date   

    Workers Compensation Injury:

    If you believe you are being seen for an injury/illness because of your job, you need to provide written authorization from your employer to confirm this, & direction from your employer on who ALTMED should bill. If you do not provide this information at the time services are provided, ALTMED

    may bill you &/or your insurance company.


    Payment Options:

    If you are unable to meet your financial obligations, payment arrangements can be made. Financing options may be available. Contact our Billing Department to discuss payment options, before your account becomes overdue. In cases of financial hardship, please ask about the practice’s hardship policy. Hardship policies vary by practice; limitations & restrictions apply.

    Making Payments

    Patients generally may pay by cash,money order or personal credit card. This includes cards for "flexible spending accounts" &/or “health savings accounts”. Card information may be kept on file by ALTMED to facilitate billing. If you have a credit balance, ALTMED may apply it to any outstanding balances on your account or the accounts of your dependents. Some locations may restrict payment by cash or check.

    Fees Assessed by ALTMED

    You may be charged fees for: (1) Returned Checks, (2) Completion of Forms (e.g. Disability or Family Medical Leave), (3) Copies of Medical Records, & (4) Failure to Cancel Appointments in Advance ("No Show"). Notify ALTMED of cancelations at least 48 hours in advance to avoid No Show fees. The No Show fee may be assessed up to the amount in our current Fee Schedule.

    Termination of Services

    If you fail to keep your account current or fail to respond to 3 notices to the address we have on file for you, you agree that ALTMED may terminate your relationship with any or all its offices. In such event, you agree that you are no longer a patient, & ALTMED will not offer you a future appointment. You will have deemed yourself as terminating our relationship if you do not obtain services from ALTMED for 3 years or if you notify us that you will no longer be a patient.Acceptance back into the practice is at the discretion of ALTMED. ALTMED may terminate your relationship with us forother reasons, such as disruptive behavior or non compliance with care plan, or for no reason.

    Authorization to Release of Medical Information

    The authorizations described in this Financial Policy may include records about infectious diseases & drug & alcohol abuse treatment. You authorize the release of information by ALTMED to third party payers (including insurance companies & their contractors), health care institutions, physicians & others involved in your medical care. You agree that as appropriate for your care, ALTMED may share information with family members & friends. You agree that ALTMED may provide your medical records to third party payers, review agencies, employers, welfare departments & others for treatment, payment or healthcare operations purposes.
    ALTMED participates in one or more Health Information Exchanges. Healthcare providers can use these electronic networks to securely
    provide access to your health records for a better picture of your health needs. With this authorization, you agree that ALTMED and other healthcare providers, may allow access to your health information through the Health Information Exchanges for treatment, payment or other healthcare operations. This is a voluntary agreement. You may opt out at any time by notifying an ALTMED Practice Manager or Compliance Officer.
    You opt out notice needs to be in writing.

    Accidents & Motor Vehicle Injuries

    ALTMED ’s providers have the discretion to decide whether to see patients injured in motor vehicle accidents or for other liability injuries. ALTMED ’s providers also have discretion to decide whether to bill the liability insurance involved (i.e. home, auto, etc.). ALTMED does not have to agree to subrogate or accept liens. You must provide accurate information about the injury & may be required to complete an injury questionnaire. In all cases, you bear responsibility for the costs of your care & must pay them promptly at any time that location decides which may include requiring
    payment in full at time of service.

    Continuing Agreement

    I have read this information carefully & agree that everything in this Agreement applies to current & future health care services provided by
    ALTMED.I acknowledge that ALTMED may change these terms without notice to me.

    Interest and Attorney's Fees:

    For any past due amounts, ALTMED shall be entitled to payment from you of interest at the rate of 2% per month (24% per annum), & you shall be responsible for all costs & expenses incurred in efforts to collect past due amounts from you, including interest charges, court costs, & reasonable attorney's fees. If a check is returned for insufficient funds, all charges incurred by ALTMED shall be your responsibility.

    Patient/Guarantor Signature      Date:   Pick a Date   

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