INFORMED CONSENT AND PAIN MEDICINE AGREEMENT AS REQUIRED BY THE TEXASMEDICAL BOARD REFERENCE: TEXAS ADMINISTRATIVE CODE, TITLE 22, PART 9, CHAPTER 170

6th Edition: Developed by the Texas Pain Society, January 2024 (www.texaspain.org)

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(s) 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/permission to use 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 associates, technical assistants, nurses, staff, and other health care providers as might be necessary or advisable to treat my condition. 

CONSENT TO TREATMENT AND/OR DRUG THERAPY: I voluntarily request my physician (name at bottom of agreement) to treat my condition of chronic pain, which is a state of pain that persists beyond the usual course of an acute disease or healing of an injury. I hereby authorize and give my voluntary consent for my physician to administer or write a prescription(s) for dangerous and/or controlled drugs (medications) as a part of the treatment of my chronic pain.

It has been explained to me that these medication(s) include opioid/narcotic drug(s). I have discussed with my Pain Medicine Physician the risks and benefits of the use of controlled substances for the treatment of chronic pain, including an explanation of the following: (a) diagnosis; (b) treatment plan; (c) anticipated therapeutic results, including realistic expectations for sustained pain relief, improved functioning and possibilities for lack of pain relief; (d) therapies in addition to or instead of drug therapy, including physical therapy or psychological techniques; (e) potential side effects and how to manage them; (f) adverse effects, including the potential for dependence, addiction, tolerance, and withdrawal; and (g) potential complications and impairment of judgment and motor skills. 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 accidental overdose, injury and death are also possibilities as a result of taking these medication(s).

I understand that concurrently consuming sedating substances like alcohol or taking additional types of sedating controlled medications such as benzodiazepines and gabapentenoids along with opioids increases my chance for accidental overdose, injury, and death. If in the unusual situation, it is medically indicated for me to receive multiple types of controlled substances, I understand that I will require close supervision of medical specialists to maximize my safety. I agree to follow their direction on the proper use of these medications. Deviation from using medications as directed is grounds for discontinuation of pain therapy. 

THE SPECIFIC MEDICATION(S) THAT MY PHYSICIAN PLANS TO PRESCRIBE WILL BE DESCRIBED AND DOCUMENTED SEPARATELY FROM THIS AGREEMENT. THIS INCLUDES THE USE OF MEDICATIONS FOR PURPOSES DIFFERENT THAN WHAT HAVE BEEN APPROVED BY THE DRUG COMPANY AND THE GOVERNMENT (THIS IS SOMETIMES REFERRED TO AS “OFFLABEL'' 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 for drugs (urine, blood, saliva or any other testing indicated and deemed necessary by my physician at any time) and psychological evaluations if and when it is deemed necessary, and I hereby give permission to perform the tests, and my refusal may lead to termination of treatment. The presence of unauthorized substances or absence of authorized substances may result in my being discharged from my Pain Medicine Physician’s care.

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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 (inability to urinate), 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 want 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 to live a more productive and functional life. I realize that I may have a chronic illness and there is a limited chance for a complete cure, but the goal of taking medication(s) regularly is to reduce (but probably not eliminate) my pain so that I can enjoy an improved quality of life. I realize that the treatment may require prolonged or continuous use of medication(s), but an appropriate treatment goal may also mean the eventual withdrawal from the use of all medication(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 be 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 benefits. I have been given the opportunity to ask questions about my condition, treatment, risks of non-treatment, drug therapy, 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.

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I understand that, at present, there have not been enough studies conducted on the long-term use of many medication(s) to ensure complete safety of my unborn child(ren). With full knowledge of this, I consent to its use and hold my physician harmless for injuries to the embryo, fetus, or baby.

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PAIN MANAGEMENT AGREEMENT: 

I UNDERSTAND AND AGREE TO THE FOLLOWING: 

This pain medicine agreement relates to my use of any and all medication(s) called dangerous drugs and/or controlled substances (i.e., opioids, also called narcotics or painkillers, and other prescription medications) for chronic pain prescribed by my physician. I understand that there are many strict 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 follow the rules specified in this Agreement.

The term “Pain Medicine Physician” below means your primary Pain Medicine Physician or your physician who is managing your pain, or that physician’s Physician Assistant or Nurse Practitioner, or another physician covering for your primary Pain Medicine Physician.

My Pain Medicine Physician may at any time choose to discontinue medication(s). 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.

(Patient Shall Acknowledge All Provisions by Initialing)

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NOTICE OF PRIVACY PRACTICES 

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND ENCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION 

PLEASE READ IT CAREFULLY 

OUR PLEDGE REGARDING YOUR MEDICAL INFORMATION 

We are committed to protecting medical information about you. We create a record of the care and services you receive for use in your care and treatment. 

We are required by law to: 

● Make sure that your medical information is protected; 

● Give you the opportunity to review this Notice describing our legal duties and privacy practices with respect to medical information about you; and 

● Follow the terms of the Notice that is currently in effect. 

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU 

For Treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, or other health system personnel who are involved in your care. We may also share medical information about you with other personnel, agencies or facilities in order to provide or coordinate the different things you need, such as prescriptions, lab work and x-rays. 

For Payment. We may use and disclose medical information about you so that the treatment and services you receive may be billed to and payment may be collected from you, an insurance company or a third party.

For Health Care Operations. We may use and disclose medical information about you for the purpose of quality of care. Your medical information may also be used or disclosed to comply with law and regulation, for contractual obligations, patients' claims, grievances or lawsuits, health care contracting, legal services, business management and administration, underwriting and other insurance activities. 

Individuals Involved in Your Care or Payment for Your Care. We may release medical information to anyone involved in your medical, e.g., a friend, family member, personal representative, or may individual you identify. We may also give information to someone who helps pay for your care. 

As Required By Law. We will disclose medical information about you when required to do so by federal or state law. 

To Avert a Serious Threat to Health or Safety. We may use and disclose medical information about you when necessary to prevent or lessen a serious and imminent threat to your health and safety or the health and safety of the public or another person. Any disclosure would be to someone able to help stop or reduce the threat. 

Workers’ Compensation. We may use or disclose medical information about you for Workers’ Compensation or similar programs as authorized or required by law. 

Public Health Disclosures. We may disclose medical information about you for public health purposes. These purposes generally include the following: 

● Preventing or controlled disease (such as cancer and tuberculosis), injury or disability; 

● Notifying a person who may have been exposed to a disease or may be at risk of contracting or spreading a disease or condition; 

● Reporting to the employer findings concerning a work-related illness or injury or workplace-related medical surveillance; 

● Notifying the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence and make this disclosure as authorized or required by law. 

Health Oversight Activities. We may disclose medical information to governmental, licensing, auditing, and accrediting agencies as authorized or required by law. 

Clinical Research. We may utilize medical information about you to help identify candidates that may qualify for ongoing clinical research studies.

Lawsuits and Other Legal Actions. In connection with lawsuits or other legal proceedings, we may disclose medical information about you in response to a court or administrative order, or in response to a subpoena, discovery request, warrant, summons or other lawful process. 

Law Enforcement. If asked to do so by law enforcement, and as authorized or required by law, we may release medical information about criminal conduct. 

National Security and Intelligence Activities. As authorized or required by law, we may disclose medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities. 

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU 

Your medical information is our property. You have the following rights, however, regarding medical information we maintain about you: 

Right to Inspect and Copy. With certain exceptions, you have the right to inspect and/or received a copy of your medical information. To inspect and/or to receive a copy of your medical information, you must submit your request in writing. If you request a copy of the information, there is a fee for these services. We may deny your request to inspect and/or to receive a copy in certain limited circumstances. If you are denied access to medical information, in most cases, you may have the denial reviewed. 

Right to Request an Amendment or Addendum. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information or add an addendum. You have the right to request an amendment or addendum for as long as the information is kept by or for us. To request an amendment, your request must be made in writing. In addition, you must provide a reason that supports your request. In addition, we may deny your request if you ask us to amend information that: 

● Was not created by us; 

● Is not part of the medical information kept by or for us; 

● Is not part of the information which you would be permitted to inspect and copy; or 

● Is accurate and complete in the record. 

Right to an Accounting of Disclosures. You have the right to receive a list of the disclosures we have made of your medical information. To request this accounting of disclosures, you must submit your request in writing. Your request must state a time period that may not be longer than the six previous years. You are entitled to one accounting within any 12-month period at no cost. If you request a second accounting within that 12-month period, there will be a charge for the cost of compiling the accounting. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. 

Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend. To request a restriction, you must make your request in writing. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, only to you and your spouse. We are not required to agree to your request. If we do agree, our agreement must be in writing, and we will comply with your request unless the information is needed to provide you emergency treatment. 

Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time. 

CHANGES TO PRIVACY PRACTICES AND THIS NOTICE 

We reserve the right to change our privacy practices and this Notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future.

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MEDICAL OFFICE POLICIES 

PLEASE RETAIN OFFICE POLICIES FOR FUTURE REFERENCE 

OFFICE HOURS: The office is open Monday through Friday 9:0o am to 6:00 pm 

APPOINTMENTS: You must schedule an appointment to be seen by the doctors at the clinics of Texas Pain Physicians (TPP) and Solar Health Pain Management (SHPM). Please contact the office during business hours to schedule appointments. As a courtesy we will call/text to confirm your appointment: however, it is your responsibility to maintain your schedule and be on time for appointments. 

Contact us immediately if you are going to be late. If you are unable to attend your appointment, we ask that you give at least 24 hours notice so that we can attend to other patients. Without a 24 hour notice you will be charged a $25 missed appointment fee and $50 for injection appointments, payment will be required prior to your next appointment. Two consecutive no shows will result in a discharge. Five no-shows/cancellations/reschedule-within-24 hours in a 12 month span, will also be subject to dismissal from the practice.

CHANGES TO PERSONAL INFORMATION: You must contact the office with any changes to your personal information including: phone numbers, address, name change, new or cancelled insurance. 

PRESCRIPTIONS & REFILLS: Due to the nature and addictive properties of OPIOIDS prescribed for pain management it is necessary that we evaluate your treatment plan on a regular basis. It is our policy to prescribe no more than 30 day supply of medication. You are required to be present for your follow up appointment. You may be required to provide a urine sample for drug screening during your appointment. Requests made by phone or through your pharmacy will not be filled. THERE ARE NO EXCEPTIONS TO THIS POLICY. 

FORMS & MEDICAL RECORDS: There is a $15 charge for completion of all forms such as; FMLA, Disability Request, Daycare, Gym Membership, Credit Card and Insurance Forms. There is a $35 charge for medical records being released to anyone other than a licensed healthcare provider. A release form must be signed by the patient or legal guardian. Payment is required and you must allow 5-7 business days for completion from the date any of our clinics receive payment. 

PHONE CALLS: Keep in mind that the office receives a large volume of phone calls daily, please make calls brief and to the point by clearly identifying yourself and the reason for your call. Keep in mind that the staff cannot answer questions pertaining to your condition or treatment. Those questions need to be addressed with the doctor during your appointment. 

PERSONAL BEHAVIOR: Profanity, rude or discourteous behavior will not be tolerated. Inappropriate or threatening behavior will result in you being discharged from care at any of our clinics. 

PAYMENT: Payment is required at the time of service unless other arrangements have been made. For insurance patients; you will need to bring your insurance card to all appointments in the event we need to re-verify your benefits.

INSURANCE: We will work with your insurance carrier to verify your benefits and get your claims paid; however the contract is between you and your carrier. It is your responsibility to make sure that we have current information on file all times and that you respond in a timely manner if your carrier requests information from you. If you have questions about your benefits you will need to contact your carrier directly. If a claim is denied because you have not provided requested information you may be responsible for the insurance. 

MEDICARE: We will accept Medicare assignment and file claims with Medicare as a primary or secondary carrier. You are responsible for your deductible and co-insurance if you do not have supplemental insurance. 

HMO PATIENTS: You will need to provide your PCP’s contact information. You may also be asked to contact your PCP to obtain a referral. 

TEST RESULTS & SCHEDULING: The office will make arrangements for diagnostic testing. Test results will be reviewed with you at your next schedule visit. You need to call the office within 72 hours of your procedure to schedule an appointment to discuss test results. 

PROCEDURES RESCHEDULE AT A SURGERY CENTER OR HOSPITAL: If you are unable to keep your scheduled appointment, we ask that you give at least 2 hours’ notice. Without a 24 hour notice you may be charged a $150 facility fee for your missed appointment. Payment will be required prior to your next appointment. 

HANDGUNS PROHIBITED: Pursuant to section 30.07, penal code (trespass by license holder with an openly carried handgun), a person licensed under Subchapter H, Chapter 411, government code (handgun licensing law), may not enter this property with a handgun that is carried openly. Pursuant to section 30.06, penal code (trespass by holder of license to carry a concealed handgun), a person licensed under Subchapter H, Chapter 411, government code (concealed handgun law), may not enter this property with a concealed handgun.

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NOTICE OF PATIENT RIGHTS & RESPONSIBILITIES 

Our goal is to provide each patient with the highest quality of comprehensive care and look forward to making your visit here with us as pleasant as possible. Each patient shall have the RIGHT to: 

• Respect, consideration, and dignity. As well as Appropriate privacy. 
• Be free of discrimination based on race, religion, sex, age, ethnicity, or handicap. 
• Be treated with Confidentiality and patients shall be given the opportunity to approve or deny the release of disclosures and records. EXCEPT when authorized by law.
• Safe, Efficient, Cost-Effective treatment. 
• Be given appropriate information regarding their diagnosis, evaluation, treatment, and prognosis. When it is deemed medically inadvisable to give such information to the patient, the information shall be given to a person authorized and designated by the patient or to a legally authorized person.
• Be given the opportunity to participate in all decisions regarding their health care, EXCEPT when such participation is deemed medically inadvisable.
• Change primary or specialty physicians if other qualified physicians are available, as well as, explore other options or a second opinion.
• Have an advanced directive (such as a living will, health care proxy, or durable power of attorney for health care) concerning treatment or designating a surrogate decision maker with the expectation that the facility will honor the intent of that directive to the extent permitted by law and facility policy.
• Information shall be available to patients and staff concerning: Provisions for after-hours and emergency care; 
• Services available at the ASC or clinic; Payment policies; Fees for services; Patients’ rights to refuse to participate in experimental research;
• Disclosure regarding physician financial interest or ownership in the Surgery Center, 

If you have a complaint with any Texas Pain Physicians Facility please feel free to speak with the Administrator or Clinical Director of the facility or you may send your complaint in writing to:

You may also call the facility to voice a complaint at 972-576-7272. If we cannot solve your complaint to your satisfaction please also be aware that the Texas Department of Health is the responsible agency for ambulatory surgical centers complaint investigations. The Texas Department of Health can be reached at the following address: 

Complaints may be registered with the department by phone or in writing. A complainant may provide his/her name, address, and phone number to the department. Anonymous complaints may be registered. All complaints are confidential. The Surgery Center or Clinic may use or disclose information about you to bill or receive payment for medical treatment or services and/or supplies provided to you to which you consent to by your signature below. These disclosures include, but are not limited to, releasing information: 

1. To your health plan to obtain prior approval or to determine whether your plan will cover the treatment or services; and 

2. To individuals or entities involved in collecting amounts owed to us. 

PATIENT RESPONSIBILITIES 

Each patient shall have the RESPONSIBILITY to: 

• Conduct themselves in a quiet and orderly manner. 
• Assure that the financial obligation of his/her care is fulfilled as promptly as possible. 
• Follow/participate in the treatment plan he/she develops with his/her health care provider. 
• Be considerate of the rights of other patients. 
• Follow the organization’s rules and regulations affecting patient care and conduct. 
• Respect the property of other patients and the healthcare organization. 
• Make it known whether he/she clearly comprehends the course of his/her medical treatment and what is expected of him/ her.
• Behave respectfully towards all healthcare professionals and staff, as well as, other patients.

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