PATIENT AGREEMENT
Wayne E. Anderson, D.O., FAHS
A Medical Corporation
Very often, people sign forms without reading them. However, we do believe
the information presented below is very important and we ask that you read
the information carefully. Please do not skip it. If you prefer to sign the
acknowledgement that you have accepted this agreement without printing
it, we still believe you should download it and save it so that you have future
access to it.
The first three sections (basic philosophy, privacy policy, and general
treatment risks) apply to all patients. The fourth section (controlled
substances) may or may not apply depending on the condition being treated.
However, even if you are not intending to use opioids currently, we ask that
you read this information for completeness and safety; if it does not apply to
you it may apply to a loved one or friend.
Neurology
American Board of Psychiatry & Neurology
Pain Medicine
American Board of Psychiatry & Neurology
in association with the
American Board of Anesthesiology
Headache Medicine
United Council for Neurological
Subspecialties
Fellow, American Headache Society
Qualified Medical Evaluator
California Pacific Neuroscience Institute
45 Castro Street Suite 225
San Francisco CA 94114
415.558.8584 tel
415.513.4521 fax
www.wayneanderson.net
1. BASIC PHILOSOPHY
Physician–patient relationship: We have a transparent, honest, and direct
type of practice. This philosophy works for most patients but not all. If you
find difficulty with this no–nonsense approach, we would be pleased to refer
you to a different physician who might have a different practice philosophy.
This is your health and you need to be comfortable with your doctor’s style.
Do not be afraid to ask for a new doctor if that is your desire.
Second opinions: Patients do not need to be afraid to ask for a second
opinion. If you would like a second opinion, we would be pleased to provide
a referral.
Emergency Situations: Any patient could experience a medical emergency
at any time. If you believe you have a medical emergency, call 911 or go to the
nearest emergency room. Emergency situations can arise from your medical
condition, a new medical condition, a medication, or any treatment, such as
surgery, stimulators, blocks, physical therapy, etc. There are many warnings
of an emergency, such as chest pain and uncontrolled bleeding. Some
neurological warning signs that may signal an emergency: •Worst
headache ever in life •Double vision •Dysarthria (trouble speaking, slurring
words, words coming out wrong) •Dysphagia (trouble swallowing) •
Weakness (trouble moving) • Sensory loss (trouble feeling) •Incontinence
(trouble with bladder or bowel control) •New or sudden pain (may signal
many conditions).
Limitations: Because the practice is limited to specific disorders, we do
require that patients have a primary care provider to address routine medical
issues and overall care. The primary care provider also is essential when Dr.
Anderson is unavailable. There is a neurologist physician on-call 24 hours
per day. However, the current neurology call group does not include a pain
specialist other than Dr. Anderson. Thus, when Dr. Anderson is not on call
for the neurology call group, pain support is limited.
Financial involvement with pharmaceutical and other medical
companies: Dr. Anderson at times is a paid employee of certain
pharmaceutical, medical device or other medically–related companies for
activities such as lecturing, research, and advisory board activities. Because
we believe in honesty and transparency, this information is posted in the office and is available at the website. Dr.
Anderson does not receive payment or kickback for prescribing any procedure, test, or medication. However, if
patients would prefer having a medication from a company that Dr. Anderson has NOT worked for in the past, this
is fine. Please read the financial disclosure posted in the office and at the website.
What is Off-label Prescribing? The medications typically used in neurology and pain management often are not
FDA approved for use for neurology, pain, or headache. This means that although there is evidence to support
their use, the medications were invented—and tested for the FDA—for other purposes. This is “off-label” use. A
hypothetical example is aspirin, originally invented and “FDA-approved” for fever, but now used “off-label” to
prevent heart attacks. The use of the medications off-label is common, legal, ethical, and appropriate based on
research and standard of care. Sometimes there is no drug that is FDA–approved for a medical condition and
therefore, any and all treatments would be considered off–label. For example, there are no FDA–approved
medications for HIV neuropathy, neuropathic pain, noncancer breakthrough pain, or idiopathic neuropathy, and
therefore any treatment for those conditions would require medications invented and approved for another
purpose.
Pharmacy Policy / Refills: Patients receive prescriptions and a number of refills to last until the next scheduled
appointment. Except for rare circumstances, refill requests are not required and pharmacy refill requests are not
authorized. If a refill is required, patients should contact the office (not the pharmacy) directly. Please remember
that pharmacy refill requests typically are not authorized.
Driving & Machinery: Many neurological conditions and medications affect the ability to drive. Conditions such
as Alzheimers, Parkinsons, epilepsy, pain, arthritis or headache can impair the ability to operate a vehicle or
operate machinery. You must assume responsibility for your own behavior: patients are instructed not to drive or
to operate any vehicle or dangerous machinery if there is any impairment whatsoever whether related to the
underlying disorder or to the medication intended to treat the underlying disorder. If in doubt, do not drive.
Patients who are impaired and choose to drive and who are pulled over by law enforcement usually are charged
with driving under the influence, with the same mandatory penalties associated with drunk driving. We are not
the DMV and we do not provide legal permission to drive or to operate machinery.
We believe in honesty and transparency. We accept many insurance plans and bill them as a courtesy to you. If
your insurance information is not correct or if your insurance company does not respond in 45 days, all charges
become your responsibility. We do NOT provide “not medically necessary” services. If an insurer denies payment
because it is not a covered benefit, retroactively rescinds payment or considers the service “not medically
necessary” or “experimental” or some other non-reimbursable status, you agree that you are financially responsible
for those charges. For work comp patients, we need your carrier’s written permission to see you. Your carrier by law
must provide payment within 60 days for non-contested claims. If your carrier does not do so, we will no longer be
able to see you as a work comp patient.
Charges for non–medical services: Not all physician services are covered benefits. Some charges are billed
directly to patients as they are services that are not part of a typical physician medical visit. Examples include:
forms, research, letters, copying records, and other activities. There are missed appointment and procedure fees.
2. PRIVACY POLICY
The U.S. Government has produced a required privacy notice. “This notice describes how medical information
about you may be used and disclosed and how you can get access to this information. Please review it carefully.”
We may provide reports to your primary care provider and other appropriate parties. We do not provide your
medical information to those not directly involved your medical treatment unless specifically authorized by you.
We do communicate your information with your other health practitioners in order to coordinate care. The Federal
Government has determined that your health information may be provided to others (even without your
permission) for Treatment, Payment, and Operations. This includes sharing information with other physicians,
providers and pharmacists, reporting to your insurance company or to your workers’ compensation carrier, legal
services, training programs, quality improvement reviews, and the like. We use electronic medical records. These
may include data from laboratories, hospitals, and other physicians. Because of the nature of these electronic
systems, we are not able to remove or hide certain information even if it comes from a different party. For example,
if you see another physician who also uses electronic medical records and that physician enters “diabetes” as a
diagnosis, your reports in this office also automatically may include “diabetes” even if you did not tell us or want
this to appear in your chart. If you are a work comp patient, your reports may contain additional information from
other physicians, laboratories, hospitals, and other parties, as above. Because we cannot remove medical
information that comes from other physicians, laboratories, hospitals, and other entities, if you authorize us to
send medical records to someone, you authorize us to send any and all information, without restriction. Once you
authorize us to discuss your medical information with someone, you can revoke that authorization anytime. There
are exceptions to the privacy laws, and your medical information may be provided to others without your consent
for: (1) State of California reporting requirements; (2) Reporting requirements for workers compensation claims;
(3) Public health; (4) Health oversight; (5) Legal proceedings; (6) Police investigations; (7) Any information on a
deceased patient; (8) Any information needed for organ donation; (9) Certain research; (10) Any information
needed by the government.
Beginning in 2014, you have the right to hide a medical visit or procedure from your insurance company and also to
keep it out of your permanent medical record. If you wish to do so, you would need to inform your healthcare
provider that you want the medical visit to be a secret BEFORE the visit. You would need to pay cash in full for the
visit BEFORE the visit. This law was made so that patients could get treatment for certain conditions without an
insurance company knowing about it or without having it in your record, such as for a sexually transmitted disease.
In this office, however, we treat chronic conditions so it would be unlikely that this secret visit would apply here. If
you wish to receive treatment for something and hide it from your medical chart or from the insurance company,
please remember that there are other methods by which an insurance company or another person might still find
out: pharmacies keep records all prescriptions and your insurance company might request a prescription list from
your pharmacy, the State of California keeps a list of all of your controlled substance prescriptions, etc., etc.
3. RISKS, BENEFITS, & ALTERNATIVES
Risks of Treatments, Procedures & Medications: Treatments are designed to provide benefit for your
condition. However, treatments have risks. Any procedure could result in an injury. Any physical activity could
increase pain or cause structural or other damage to the body. Successful treatment usually requires more than
prescription medication; it requires proper physical activity, engagement, and lifestyle changes. In most cases, the
good or beneficial part of a treatment plan is obvious: the treatment is supposed to help the problem. The risks
require more attention. Any medication could interact with another; you must let each of your providers know all
medications and supplements you use and about all health conditions you have. All medications have side effects,
some of them serious, including death. Almost every medication could cause sleepiness or insomnia, dizziness,
confusion, hallucinations, anxiety, panic, constipation or diarrhea, headache, chest pain, and nausea or vomiting.
Any of these conditions could predispose the patient to injury (such as dizziness causing the patient to fall down
stairs). Itching can occur. Sometimes itching occurs with a rash and that may herald an allergic reaction; you
should let your practitioner know about the rash immediately. Many cause a drop in blood pressure, which could
cause fainting, dizziness, stroke or other problems.
Risk: This practice does not require the use of a medication. All treatments have both known and unknown risks.
Sometimes, medications cause effects that are not predictable. Some of the medications have not been in
existence long enough to determine what potential long-term side effects could occur. The occurrence of a side
effect does not imply medical negligence and the patient agrees to hold the physician and corporation harmless for
the occurrence of an adverse effect. Patients accept the risks and freely choose to use prescription medication(s)
and/or engage in physical treatments and physical activities. At each and every visit, the patient has the
opportunity to ask further questions about the risks, potential benefits, and alternatives to any and all treatment
modalities and medications prescribed in this office above and beyond the information presented in both written
and oral form. There are alternatives to the treatments recommended or prescribed by this office, even if some of
the alternatives require the patient to see a different practitioner or obtain the services of another physician
elsewhere. Alternatives include physical modalities, psychotherapy, functional restoration programs, implantable
spinal cord stimulators, and so on. Each has its own risks and benefits.
Pregnancy, planning, and breastfeeding: You must assume that no medication is safe during pregnancy or
during breast-feeding. You must let us know if you are planning pregnancy or are pregnant. Medications may
interfere with birth control, resulting in an unplanned pregnancy. Many neurological medications cause major
birth defects.
Alcohol, illegal drugs and unknown herbals and supplements: These products are not considered safe with
the medications used in this practice. Although we understand the social aspects of drinking alcohol and the
reported potential health benefits of low-level use, if you drink alcohol, we must counsel you to stop in order to
use the medications typically prescribed.
4. CONTROLLED SUBSTANCES
If you use or are planning to use controlled substance medications for pain: In addition to addiction risks, there are
additional risks—both legal and medical—for those patients who use controlled substance prescriptions.
Additional side effects: Common side effects of controlled substance pain medications include lack of energy,
fatigue, mental clouding, nausea, sweating, constipation, itching, and sexual problems. Although nausea may
improve with time, constipation tends to continue. Diet is important. In many cases a laxative regimen is required.
Although the risk is low, there is a chance of laxative dependence. Patients who ignore the constipation may
require surgical removal of part of the intestines; untreated, constipation can be fatal. Opioids affect hormone
levels in men and women. They reduce sexual desire and sexual function. Pain medications may cause deafness.
Opioid pain medications significantly increase the risk of asthma attacks or similar lung problems. This
potentially fatal effect can occur even in very low doses.
Increased pain as a result of using pain medications: There is recent evidence that opioid-induced
hyperalgesia does exist and does occur. This is a condition where the patient develops either more pain as a result
of taking the pain medications and/or experiences a lower ability to tolerate regular pains as a result of taking the
pain medication. Here is an example: a study showed that if you take several people and have them place their
hands in a cold box, most people could tolerate the painful cold for a certain amount of time and then would
remove their hands. However, persons who took pain medications could not tolerate the painful cold as long as
persons who were not using pain medications. That is, the pain medication caused neurological changes such that
patient could not tolerate as much pain the average person. This neurological injury from the pain medications
may last years (not just a few weeks like we used to think) after tapering the pain medication. Because this is such
an important issue, here is a real-life example: Imagine an average person who goes to the gym and works out hard;
this person will have many aches and pains for the next few days. The average person, however, will tolerate the
pain and will not use narcotic pain medication for it. A pain patient on opioids, however, may go to the gym and
workout and experience the same pain, but will use narcotic pain medication for it; or, perhaps the pain patient on
opioids will completely avoid the gym because any exercise hurts.
How would I know if I have opioid-induced hyperalgesia? If a person uses pain medication for a condition
that someone else would not use pain medication for, there is a chance of opioid-induced hyperalgesia. If a
person’s medical condition remains the same but the pain seems to be increasing despite pain medication use,
there is a chance of opioid-induced hyperalgesia. Please note that this is a neurological injury caused by pain
medication; it is not psychological, imaginary, or a character flaw. It is a real medical condition and requires
medical treatment.
Addiction: The decision to use opioids or other controlled substances is not to be taken lightly. There is a risk of
addiction with the use of painkillers. The risk used to be believed low unless there is a family or personal history of
addiction to drugs, tobacco, or alcohol. However, recent medical experts have announced that addiction is more
common and more likely than was believed in the past. We cannot guarantee that you will not become addicted to
your medication. No guarantees regarding safety or addiction are stated or implied. All persons will need to keep
up with scientific evidence regarding this issue because the true risk of addiction just is not clear.
OPIOID LEGAL GUIDELINES
Guidelines: For those who receive controlled substances such as pain medications, the need to comply
with federal and state laws requires more frequent in-person visits with more extensive documentation at
each visit than one might have for other medical conditions. Also, the medications used may have greater
risk, including risk of death. If you have chronic pain, you might be a candidate for opioids when
prescribed by a physician for the treatment of pain. However you must show responsibility for the
medications. You must protect against loss, theft, or damage; you must keep them away from children,
animals and others.
Continued opioid use: In order to justify the use of controlled substances legally, you should report (1)
improved pain control, (2) increased function or increased activities, (3) no serious side effects, and (4) no
episodes of aberrancy or abuse (like running out of medication early). Improved function is considered of
paramount importance.
Drug testing: Currently, the State Medical Board and other guidelines recommend drug testing. If you are
being seen for pain management, you agree to drug testing for both prescribed drugs and illicit drugs at
any time. The presence of illicit drugs on a drug test may require us to change or stop certain treatments;
use of any illicit drugs could result in death or other severe harm.
One prescriber / one pharmacy: You agree to use one and only one physician for pain medication
prescriptions and one and only one pharmacy for pain medication dispensing with the following limited
exceptions:
1. Medication prescribed while admitted to a hospital, taken only during the hospitalization;
2. Medication prescribed by a surgeon/dentist immediately after surgery provided both Dr. Anderson
and the surgeon/dentist are aware of the situation before the prescription occurs.
3. Medications prescribed in cases where a patient may have two different types of insurance coverage
and because of the two insurance plans, two different physicians must address chronic pain,
provided that both physicians are aware of the situation before the prescription occurs;
4. Medication refills provided by the patient’s primary care practice in those rare cases where the
medications were due but Dr. Anderson was unavailable, provided that both offices are aware of
the situation before the prescription occurs;
5. Medications prescribed in cases of true emergency (such as bone fractures from trauma) in the
setting of an emergency room, provided that Dr. Anderson is informed as soon as possible.
REMS and CURES: As guidelines, laws, and regulations change, patients will have more oversight for pain
medication prescriptions. The reason for the government regulations is patient safety (as you may know,
there have been multiple deaths from abuse of pain medications). REMS is a “risk evaluation and
mitigation strategy” and may involve signing a special medication consent and, in some cases, may involve
signing–up with the government to receive certain prescription medications. Please be aware that the
California Office of the Attorney General keeps a list of your prescription medications dispensed from any
pharmacy in California. Other states have similar programs. The CURES profile, when obtained, becomes
part of your permanent electronic medical record.
OPIOID / CONTROLLED SUBSTANCE CHECKLIST
In addition to the information above, patients should verify their understanding of the following points:

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Opioids (narcotics) may have more risks than initially thought
Opioids may cause neurological injury making someone unable to tolerate even mild pain
Opioids may cause hyperalgesia, meaning that the patient will experience more pain, not less pain
Opioid caused neurologic injury may last two or more years AFTER you stop the opioids
Newer evidence suggests that even proper opioid use for pain may cause addiction
Opioids should not be first-line treatments; they should be used after lesser means fail
Continued opioid use should be associated with measurable functional improvement
OPIOID ACKNOWLEDGMENT
“I have read and understand the information above. I understand that the long-term advantages and
disadvantages of chronic opioid use have not been determined and that treatment may change while I am
under Dr. Anderson’s care. I understand, accept, and agree that unknown risks may be associated with the
long-term use of controlled substances (including neurologic injury) and that my physician will advise me
as knowledge and training advances are made, and may make treatment changes. I also know there are
other non-opioid options for my pain control. I agree to tell my doctor about all other medicine and
treatments that I am receiving. I will not request or accept controlled substance pain medications from any
other physician, dentist, or individual while I am receiving such medications from Dr. Anderson except in
the 5 specifically listed exceptions above. To do so may endanger my health and our physician-patient
relationship. Dr. Anderson and the office staff have my permission to discuss my pain condition and my
pain treatments with my spouse or significant other. I will take my personal medications as directed. I will
not tamper with prescribed medications by cutting, crushing, or by any other means altering the intended
dose of medication. I will not take the medications by any other than the directed route of administration
(usually oral). I will not adjust the medications by myself. I will discuss with Dr. Anderson any change in
dosage I feel I need at the next appointment. I will not increase the dose or take an extra dose unless
directly authorized to do so by Dr. Anderson. I will not hoard my medications. If I am doing better and I
am able to control my pain with fewer narcotics, I will inform Dr. Anderson. If I have lowered my dose, I
will inform Dr. Anderson. I am responsible for keeping track of the amount of medications left on my
prescription and I will plan ahead for arrangements to refill my prescriptions in a timely manner so I will
not run out of medications. If I run out of medications, I may go through withdrawal. I understand that I
must make necessary arrangement to alert Dr. Anderson of my need for a refill five (5) working days before
they run out. If I fail to provide five (5) working days’ notice, I may not be able to receive the prescription
in a timely manner and may undergo withdrawal. Medications will not be refilled early, even if they have
been lost or stolen. Medication refill requests made on Fridays, weekends, or holidays will not be honored
absent special circumstances. I understand that some rare situations may arise where one of my healthcare
practitioners may make the clinical decision that the use of controlled substance (narcotic) pain
medication may be too dangerous to continue, even long enough to taper off. In such cases, I understand
that I may experience narcotic withdrawal. I understand that if I fail to comply with the guidelines in this
agreement and the information on my prescription labels; if I obtain narcotics elsewhere (even from a
physician); if I use illicit drugs; if I share narcotics with others; or if I alter a prescription, we may need to
cease prescribing and our doctor-patient relationship may be terminated.”
5. ACKNOWLEDGEMENT FOR ALL PATIENTS
We understand that the above is a lot to read and fill out, but it is very important that you know about our policies
and procedures, and the current laws, regulations, and guidelines. Because there is computer software that allows
the reader to alter the text, your signature below indicates that you have read and have accepted the information
presented above in its original form, even if the reader has chosen to alter, omit, or add any content to the
information presented.
I have read and accepted the information in the section titled “The fine print” as presented without altering,
omitting, or adding any content.
Signature: ________________________________________ Date: ___________
Please note: if you do not wish to print this document in order to save paper and toner, you may sign the
acknowledgement contained in the new patient registration instead. We still recommend that you download and
save a copy of this agreement for future reference.
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5. ACKNOWLEDGEMENT for all patients