Hapeville Medical Center
Patient Name: __________________________ Date: ______________________
PATIENT REGISTRATION FORM
Patient Name: ______________________________ Social Security Number: ________-________-__________
Date of Birth: _____/_____/_____ Sex: M / F (Circle one) Married/Single/Divorced/Widow
Address:______________________________City_________________State & Zip code__________________
Home Phone: (______) _____________-___________ E-mail Address: ________________________________
Cell Phone: (______) _____________-___________
Employer Name: ______________________________Employer Phone Number: (_____) __________________
Employer Address: __________________________________________________________________________
How did you hear about our Practice? ____________________________________________________________
Who to call for an emergency:
Name: ________________________________ Address:____________________________________________
Home Phone: (__) _______ - ________ Work Phone: (___) _______-_______ Relationship: ________________
PRIMARY INSURANCE INFORMATION
Plan Name: _____________________________________ I.D. Number: ___________________________
Address: _______________________________________ Group Number: _________________________
Policy Holder: ___________________________________ Effective Date: __________________________
Policy Holder’s Social Security Number: _________ - ________ - ________
Policy Holder’s Date of Birth: _____/_____/_____ Sex: M / F
SECONDARY INSURANCE INFORMATION
Plan Name: _____________________________________ I.D. Number: ___________________________
Address: _______________________________________ Group Number: _________________________
Policy Holder: ___________________________________ Effective Date: __________________________
Policy Holder’s Social Security Number: _________ - ________ - ________
Policy Holder’s Date of Birth: _____/_____/_____ Sex: M / F
IS YOUR VISIT DUE TO A JOB RELATED INJURY OR AUTOMOBILE ACCIDENT? Y _____ N_____
IF YES, PLEASE NOTIFY THE RECEPTIONIST
I authorize the release of any medical information necessary to process this bill to my insurance company, and
request payment of benefits to Northeast Health. I acknowledge that I am financially responsible for payment
whether or not covered by insurance.
Signature: ____________________________________________________ Date: _____________________
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Hapeville Medical Center
Patient Name: __________________________ Date: ______________________
Primary Care Physician
Primary Care Physician:______________________________ Phone:________________ Fax: _____________
Address:___________________________________________________________________________________
Date of last physical:________________________ Abnormal Findings: ( ) Yes ( ) No If Yes then describe
below:
___________________________________________________________________________________________
Pharmacy Information
(please list all pharmacies that you get prescriptions from)
Pharmacy Name: ____________________________________ Phone:________________ Fax: _____________
Address:_____________________________________________________________________________________
Pharmacy Name: ____________________________________ Phone:________________ Fax: _____________
Address:_____________________________________________________________________________________
Pharmacy Name: ____________________________________ Phone:________________ Fax: _____________
Address:_____________________________________________________________________________________
Pharmacy Name: ____________________________________ Phone:________________ Fax: _____________
Address:_____________________________________________________________________________________
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Hapeville Medical Center
Patient Name: __________________________ Date: ______________________
Chief Complaint
Please describe you main problem / complaint : ___________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
How long have you had this problem: ___________________________________________________
Did you problem start suddenly or gradually with time: _____________________________________
Are there any events, such as injuries, falls, illnesses, etc that coincide with the date your problem started:
( ) Yes ( ) No If yes then please give describe below:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
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Hapeville Medical Center
Patient Name: __________________________ Date: ______________________
Past Medical History
Have you previous had surgery: ..) ( ) Yes ( ) No If yes then please list below
Physician Name: _______________________________ Phone:________________ Fax: _____________
Address: _______________________________________________________________________________
Date of surgery: _______________________________ Type of surgery : __________________________
Physician Name: _______________________________ Phone:________________ Fax: _____________
Address: _______________________________________________________________________________
Date of surgery: _______________________________ Type of surgery : __________________________
Physician Name: _______________________________ Phone:________________ Fax: _____________
Address: _______________________________________________________________________________
Date of surgery: _______________________________ Type of surgery : ___________________________
Please list below all medical problems you may have not just the problem(s) you are here for.
Problem: ______________________________ Date Started: _______________________
Problem: ______________________________ Date Started: _______________________
Problem: ______________________________ Date Started: _______________________
Problem: ______________________________ Date Started: _______________________
Problem: ______________________________ Date Started: _______________________
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Hapeville Medical Center
Patient Name: __________________________ Date: ______________________
Allergies
Do you have any adverse reactions to any medications? ( ) Yes ( ) No If yes then please list below
Medication: ____________________________ Reaction:________________________________
Medication: ____________________________ Reaction:________________________________
Medication: ____________________________ Reaction:________________________________
Medication: ____________________________ Reaction:________________________________
X-ray contrast:
( ) Yes ( ) No
Reaction: ________________________________
Iodine / Betadine:
( ) Yes ( ) No Reaction: ________________________________
Shell fish:
( ) Yes ( ) No Reaction: ________________________________
Are you allergic to anything else (i.e. food, animals etc..) ( ) Yes ( ) No If yes then please list below
Allergic to: ____________________________ Reaction:________________________________
Allergic to: ____________________________ Reaction:________________________________
Allergic to: ____________________________ Reaction:________________________________
Allergic to: ____________________________ Reaction:________________________________
Family History
Please describe the current health, cause of death or illness of the following family members, please include
alcoholism and drug dependency, drug abuse or drug addiction.
Father:______________________________________________________________________
Mother: _____________________________________________________________________
Brother: _____________________________________________________________________
Sister: ______________________________________________________________________
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Hapeville Medical Center
Patient Name: __________________________ Date: ______________________
Social History
Are you currently on (please check one):
( ) Full Duty ( ) Light Duty ( ) unemployed ( ) Retirement ( ) Disability
Occupation: ____________________________________________ Employer: ______________________
If you are currently on disability please list reason:
__________________________________________________________________
Is your disability (please check one): ( ) Permanent ( ) Temporary
Tobacco use: ( )Current ( )Never ( )Quit Packs per day ____ Age Started ____ Age Stopped: _______
Alcohol use: ( )Current ( )Never ( )Quit Amount per day _____ Age Started: ___ Age Stopped: ______
What type: _________________
Drug use: ( )Current ( )Never ( )Quit Age Started _______ Age Stopped: _________
( ) Marijuana ( ) Cocaine
( ) Heroin ( ) Methamphetamine ( ) Other: ___________________
Have you ever been treated for substance dependence, abuse or addiction: ( ) Yes ( ) No
If yes please list below what type of treatment and where: (if additional room is needed use the back of this form)
Facility Name: _______________________________ Phone:________________ Fax: _____________
Address: _______________________________________________________________________________
Dates of Treatment : _______________________________ Type of Treatment_______________________
Facility Name: _______________________________ Phone:________________ Fax: _____________
Address: _______________________________________________________________________________
Dates of Treatment : _______________________________ Type of Treatment_______________________
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Hapeville Medical Center
Patient Name: __________________________ Date: ______________________
Review of Systems
General Symptoms:
Fatigue
Weight Loss
Fever, Chills
Loss of appetite
Other: _______________________________
Neurological / HEENT:
Bowel / bladder dysfunction
Headaches
Blurry or double vision
Dizziness
Passing out (Syncope)
Hearing loss
Weakness
Difficulty speaking or walking
Problems swallowing
Strokes
Seizures
Other: _______________________
Psychiatric Illness:
Depression
Insomnia
Anxiety
Psychiatric Illness
Other: _____________________________
Genitourinary:
Incontinence
Prostate Disorder
Blood in Urine
Difficulty or Painful Urination
Kidney Disease or Disorder
Other: _____________________
Musculoskeletal
Swelling in feet / legs
Pain / Swelling in Joints
Back Pain
Rheumatoid Arthritis
Osteoarthritis
Other: __________________________
Skin / Integumentary:
Rash
Ulcers
Skin disorders:
Other:___________________________
Endocrine:
Thyroid Disease / Problems
Diabetes
Yes
No
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Cardiac
Heart Failure/ Cardiovascular Disease
Chest Pain
Palpitations
Pace Maker
Heart Attack
High Blood Pressure (hypertension)
Pace Maker
Other: _________________________
Respiratory:
Shortness of Breath
Frequent cough
Wheezing
Lung Disease
Tuberculosis
Coughing Blook
Pneumonia
Emphysema
Asthma
Other: ____________________
Gastrointestinal:
Incontinence
Nausea or vomiting
Mouth Sores
Abdominal Pain
Constipation
Diarrhea
Ulcers
Bloody Bowel Movements
Liver Disease / Problems
Gall Bladder Disease
Other: __________________________
Hematologic / Lymphatic:
Bruising
Bleeding Problems
Low Blood Count
Swollen Glands
Lymph Nodes (lumps or bumps)
Blood clots
Other: _________________
Gynecological:
Pregnant
Vaginal Bleeding
Other_______________________
Endocrine:
High / Low Chloesterol
Other: ________________________
Yes
No
Hapeville Medical Center
Patient Name: __________________________ Date: ______________________
Injury Information
Is your problem: ( ) Work Related ( ) Auto or other Accident ( ) Neither
If yes then please give date of injury: ______________________________________________
Please describe your injury:______________________________________________________
Do you have legal representation:
( ) Yes ( ) No If yes then please give information below:
Name: _______________________________ Phone:________________ Fax: _____________
Address: ______________________________________________________________________
Are you covered under Worker’s Compensation:
( ) Yes ( ) No If yes then please give information below:
Name: _______________________________ Phone:________________ Fax: _____________
Address: ______________________________________________________________________
Claim Number: ________________________ Date of Injury:____________________________
Description of Pain
Character of pain (check all that apply):
( ) Sharp ( ) Dull / Ache ( ) Numb ( ) Burn ( ) Stabbing ( ) Throbbing ( ) Pins / Needles ( ) Other
Indicate the usual degree of your pain (Please circle one) 0 being no pain and 10 being unbearable
1
2
3
4
5
6
7
8
9
10
Indicate the level of your pain at its worst: (Please circle one) 0 being no pain and 10 being unbearable
1
2
3
4
5
6
7
8
9
10
Indicate the level of your pain at its best: ( Please circle one) 0 being no pain and 10 being unbearable
1
2
3
4
5
6
7
8
9
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Hapeville Medical Center
Patient Name: __________________________ Date: ______________________
Current Address: ________________________________________________
Cell Phone: ___________________________ Home Phone:________________________
Pain Assessment Form
Please mark the area(s) of injury or discomfort as shown in the example below. Mark all areas
with the appropriate symbols and indicate the degree of pain using a scale from 0 (discomfort)
to 10 (extreme pain).
Numbness - NNNN Pins & Needles PPPP
Burning BBBB
Aching AAAA
Stabbing SSSS
Circle any area of pain not represented by a symbol provided.
Complaint: ___________________________________________________________________________
Example
What is your pain level today?
1 2 3 4 5 6 7 8 9 10
In the past month what was your average pain level?
1 2 3 4 5 6 7 8 9 10
How are you sleeping?
1 2 3 4 5 6 7 8 9 10
Sleeping well
Not at all
What is your outlook on life in general?
1 2 3 4 5 6 7 8 9 10
Great
Not good at all
Current Medications: (please list all medications even ones not prescribed by us)
________________________________________________________________________________________
________________________________________________________________________________________
List any significant changes in your condition since your last visit. Include any changes to your general health.
________________________________________________________________________________________
________________________________________________________________________________________
By signing this form, I the above named patient, am stating that I have not in any way breached my Doctor / Patient /
Facility agreement by receiving any other controlled substances from other physicians / medical facilities since my
last visit. I understand that doing so may result in immediate discharge from this facility, and is a felony punishable
by law. Therefore the above information is complete and accurate to the best of my ability.
Patient signature: ____________________________________________ Date: ___________________________
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Hapeville Medical Center
Patient Name: __________________________ Date: ______________________
Description of Pain
Please list in detail where you feel any of the following symptoms, numbness, aching, pain, pins and needles
sensation: _____________________________________________________________________________
______________________________________________________________________________________
Does your pain radiate from beyond where it starts: ( ) Yes ( ) No If yes then please describe below
______________________________________________________________________________________
______________________________________________________________________________________
What activities / positions make the pain worse: (please check all that apply)
( ) Sitting ( ) Standing ( ) Walking ( ) Bending ( ) Lying Down
( ) Other _________________
What activities / positions make the pain better:
( ) Sitting ( ) Standing ( ) Walking ( ) Bending ( ) Lying Down
( ) Other _________________
Do you need support to help you walk: ( ) Yes ( ) No If yes, then what kind of help (example cane, walker)
__________________________________________________________________________________________
Do you wear a back brace: ( ) Yes ( ) No
Neck brace: ( ) Yes ( ) No Other brace: ( ) Yes ( ) No
If other brace is worn please list here: ___________________________________________________________
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Hapeville Medical Center
Patient Name: __________________________ Date: ______________________
Current Medications
Medication:_____________________ Strength (mg): _______________ How taken: _________________
Medication:_____________________ Strength (mg): _______________ How taken: _________________
Medication:_____________________ Strength (mg): _______________ How taken: _________________
Medication:_____________________ Strength (mg): _______________ How taken: _________________
Medication:_____________________ Strength (mg): _______________ How taken: _________________
Medication:_____________________ Strength (mg): _______________ How taken: _________________
Previous Medications
Medication:_____________________ Strength (mg): _______________ How taken: _________________
Medication:_____________________ Strength (mg): _______________ How taken: _________________
Medication:_____________________ Strength (mg): _______________ How taken: _________________
Medication:_____________________ Strength (mg): _______________ How taken: _________________
Medication:_____________________ Strength (mg): _______________ How taken: _________________
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Hapeville Medical Center
Patient Name: __________________________ Date: ______________________
Diagnostic Studies
Please list below anywhere you have had X-rays, CT Scan, MRI, Nerve Conduction Study ( Please use back of form
if needed)
Facility Name: _______________________________ Phone:________________ Fax: _____________
Address: _______________________________________________________________________________
Date of study : _______________________________ Type of Study _______________________
Facility Name: _______________________________ Phone:________________ Fax: _____________
Address: _______________________________________________________________________________
Date of study : _______________________________ Type of Study _______________________
Facility Name: _______________________________ Phone:________________ Fax: _____________
Address: _______________________________________________________________________________
Date of study : _______________________________ Type of Study _______________________
Facility Name: _______________________________ Phone:________________ Fax: _____________
Address: _______________________________________________________________________________
Date of study : _______________________________ Type of Study _______________________
Facility Name: _______________________________ Phone:________________ Fax: _____________
Address: _______________________________________________________________________________
Date of study : _______________________________ Type of Study _______________________
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Hapeville Medical Center
Patient Name: __________________________ Date: ______________________
Please list below any doctors, chiropractors, acupuncturists, hospitals , emergency departments, or urgent care
centers etc you have been seen by or treated by for your current problem. ( use the back of this form if necessary)
Physician Name: _______________________________ Phone:________________ Fax: _____________
Address: _______________________________________________________________________________
Date of last visit: _______________________________ Treatments received: _______________________
Physician Name: _______________________________ Phone:________________ Fax: _____________
Address: _______________________________________________________________________________
Date of last visit: _______________________________ Treatments received: _______________________
Physician Name: _______________________________ Phone:________________ Fax: _____________
Address: _______________________________________________________________________________
Date of last visit: _______________________________ Treatments received: _______________________
Physician Name: _______________________________ Phone:________________ Fax: _____________
Address: _______________________________________________________________________________
Date of last visit: _______________________________ Treatments received: _______________________
Physician Name: _______________________________ Phone:________________ Fax: _____________
Address: _______________________________________________________________________________
Date of last visit: _______________________________ Treatments received: _______________________
The preceding patient information has been reviewed and discussed with my patient and is accurate to the best belief
of the patient.
Patient Signature: ____________________________________ Date:__________________________________
Physician Signature: __________________________________ Date: __________________________________
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Hapeville Medical Center
Patient Name: __________________________ Date: ______________________
The following are some questions given to all patients at Hapeville Medical Clinic who are being considered for
opioids for their pain. Please answer each question as honestly as possible. This information is for our records and
will remain confidential. Your answers alone will not determine your treatment.
Thank you.
Please answer the questions using the following scale:
0 = Never, 1 = Seldom, 2 = Sometimes, 3 = Often, 4 = Very Often
1. How often do you have mood swings?
0 1 2 3 4
2. How often do you smoke a cigarette within an hour after you wake up?
0 1 2 3 4
3. How often have any of your family members including parents and grandparents
4.
had a problem with alcohol or drugs?
0 1 2 3 4
How often have any of your close friends had a problem with alcohol or drugs?
0 1 2 3 4
5. How often have other suggested that you have a drug or alcohol problem?
0 1 2 3 4
6. How often have you attended an AA or NA meeting:
0 1 2 3 4
7. How often have you taken medication other than the way it was prescribed?
0 1 2 3 4
8. How often have you been treated for an alcohol or drug problem?
0 1 2 3 4
9. How often have you medications been lost or stolen?
0 1 2 3 4
10. How often have others expressed concern over your use of medications?
0 1 2 3 4
11. How often have you felt a craving for your medications?
0 1 2 3 4
12. How often have you been asked to give a urine drug screen for substance abuse?
0 1 2 3 4
13. How often have you used illegal drugs in the past five years?
0 1 2 3 4
14. How often, in your lifetime, have you had legal problems or been arrested?
0 1 2 3
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Hapeville Medical Center
Patient Name: __________________________ Date: ______________________
PRIVACY PRACTICES ACKNOWLEDGEMENT FORM
I acknowledge that I have received a copy of the “Notice of Privacy Practices”, and I
have been provided an opportunity to review it.
Name: _______________________________
Date of Birth: _________________________
Signature: ____________________________
Date: ________________________________
Correspondence
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Hapeville Medical Center
Patient Name: __________________________ Date: ______________________
CONSENT FOR USE OF PROTECTED HEALTH INFORMAITON
With my consent Hapeville Medical Center may call the following contacts at the phone numbers listed
below, to verify appointments for myself,
____________________________:
(Patient’s Name)
____________________________ _____________________
(Contact)
(Phone Number)
____________________________ _____________________
(Contact)
(Phone Number)
____________________________ _____________________
(Contact)
(Phone Number)
The following are people with whom Hapeville Medical Center, LLC may share my medical information,
including medications being prescribed, treatment plans and/or appointment dates:
____________________________ _____________________
(Contact)
(Phone Number)
____________________________ _____________________
(Contact)
(Phone Number)
____________________________ _____________________
(Contact)
(Phone Number)
____________________________ ____________________
(Patient’s Signature)
(Date)
____________________________ ____________________
(Witness)
(Date)
Correspondence
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Hapeville Medical Center
Patient Name: __________________________ Date: ______________________
CANCELLATION AND NO SHOW POLICY
Our goal is to meet the needs of all of our patients, we will make every effort to schedule your appointment as
efficiently as possible. In return, it is
your responsibility to make every effort to keep you
appointment and to arrive promptly at the time instructed.
However, we realize that unanticipated events can occur and may prevent you from keeping your appointment. In
fairness and consideration to the other patients that need to be seen as soon as possible, we hereby request that you
notifiy our office immediately when you realize you will not be keeping your appointment.
If you need to cancel or reschedule you appointment, you must do so at least 24
hours before your scheduled
appointment to avoid paying a fee of $25.00. This fee is not covered by your medical insurance or worker’s
compensation benefits.
The cancellation / rescheduled fee must be paid on or before your next schedule appointment.
Thank you for your attention in this matter.
By signing below I acknowledge that I have read and understand the cancellation and no show policy and agree to
abide by these guidelines.
_______________________________________
___________________________________
Patient Signature
Date
Correspondence
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Hapeville Medical Center
Patient Name: __________________________ Date: ______________________
FINANCIAL POLICY
Insurance coverage is a contract between you, the patient, and your insurance company;
therefore, any questions about policy coverage or claims payment should be directed to your
carrier. Your insurance carrier will determine the insurance reimbursement. You will receive a
statement each month if your account has a balance due.
While the filing of the insurance is a courtesy that we do extend to our patients, all charges are
the patient’s responsibility from the day the services are rendered. We realize that temporary
financial problems may, at times, affect timely payment of your account. Upon request, special
considerations may be extended. To avoid any misunderstanding, we ask that you make these
arrangements with the financial counselor prior to services being rendered.
______________________________________________________________________________
I understand from time to time I may incur services that my insurance company considers to be
not medically necessary and/or non-covered. I agree and warrant that in such an event, I will pay
for those charges incurred in connection with this determination. I have read, understand and
agree to the financial policy as stated above.
____________________________________ __________________
Patient’s Signature
Date
____________________________________ __________________
Witness
Date
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Hapeville Medical Center
Patient Name: __________________________ Date: ______________________
HIPAA AUTHORIZAITON FOR DISCLOSURE OF MEDICAL RECORDS
Date of Birth: _______________ Social Security Number: _____________________
I, ___________________________________, hereby authorize _____________________________ to
( ) Release To
( )
Obtain From
Name: ___________________________________________________________________________
Address: _________________________________________________________________________
Phone:_____________________________________ Fax:_________________________________
any medical information from my health record for the purpose of continuity of care. Information to be
disclosed includes: Office notes, test results, medication history, MRI, CT, X-RAY, surgery reports and lab
results, for the purpose of treatment.
Purpose of disclosure: _________________________________________________________________________________
I understand that this consent is revocable by me, in writing, at any time except to the extent that action has been taken in reliance
on it. I also understand that this consent will expire either ninety (90) days after the date of the signature or automatically when
the records requested on this form have been mailed/faxed to the requestor.
PROHIBITION ON REDISCLOSURE: This information has been disclosed to you from records whose confidentiality is
protected by law. Any further disclosure is strictly prohibited.
AUTHORIZATION INCLUDES AUTHORITY TO RELEASE MENTAL HEALTH / REHABILITATION /
ALCOHOL OR DRUG RECORDS / HIV TEST RESULTS AND/OR AIDS DIAGNOSIS AND TREATMENT. (IF
UNDER 18 YEARS
OF AGE, PARENT OR GUARDIAN MUST SIGN.) INITIAL EACH BOX THAT APPLIES IF SUCH
INFORMATION IS
NOT TO BE RELEASED.
�My diagnosis and/or treatment for alcoholism and/or drug abuse or dependency may not be released to the recipient noted above.
�My diagnosis and/or treatment concerning mental health/rehabilitation may not be released to the recipient noted above
�HIV Antibody test results and/or AIDS diagnosis and treatment may not be released to the above noted recipient .
Date: ________________________________ Signed: ______________________________________________________
(Patient)
Medical Record #: ______________________ Signed: ______________________________________________________
(Witness)
If Patient is unable to give consent because of physical condition or age, complete the following: Patient is a minor, ____ years of
age or is unable to give consent because (describe condition):
_________________________________________________________________________________________________________
Date: _______________________________ Signed: _______________________________________________________
(Parent/Guardian)
Correspondence
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Hapeville Medical Center
Patient Name: __________________________ Date: ______________________
Patient Medication Management and Treatment Agreement
This agreement between ____________________________ (Patient) and Hapeville Medical Center (The Center) is
for the purpose of establishing the conditions required for the use of Opiate / Prescription medications that the
Physician may prescribe for the patient. The Center and the Patient agree that this agreement is an essential factor in
maintaining a proper and appropriate medical relationship and for the proper and appropriate medical relationship
and for the proper and appropriate implementation of medical treatment pursuant to the guideline of the DEA, and
all other local, state and federal regulatory rules and regulations.
The Patient agrees the following conditions for the management of pain medications prescribed by the physician for
the patient. Please initial by each one.
1.
2.
3.
4.
5.
6.
7.
8.
9.
Patient understands that a reduction in the intensity of pain and an improvement in their quality of life are
the goals of this center.
Patient realizes that all medications have potential side effects. In addition to analgesia, prescriptions
prescribed by the physician may produce dependency, addiction, respiratory depression, drowsiness, mood
changes, anxiety and mental impairment.
Patient agrees to report any of the above described side effects immediately to their treating physician at the
center.
In the event any prescribed medications need to be discontinued by the physician, patient agrees to consult
with physician and strictly follow physicians care instruction for the safe tapering off of any prescribed
medications. Failure by the patient to do so may result in severe withdrawal effects and possible death.
Patient understands that even with the tapering off process the patient may suffer and experience discomfort
and withdrawal symptoms, said symptoms should be immediately reported to the center and the physician.
Patient understands the risks, side effects and benefits of any applicable prescribed medications and patient
acknowledges that the center and physician have fully explained and discussed all risks, side effects and
benefits of any applicable prescribed medications in detail.
The center and physician have discussed and explained to me in detail that medications prescribed to me may
impair my mental, and or physical abilities required for the performance of certain tasks and activities such
as driving an automobile or preforming hazardous tasks.
Patient agrees that the patient will not attempt to perform any such activity until patient ability to perform
such tasks has been evaluated by the center or physician.
Patient has been advised and informed by the center and physician that patient should not take any other
drugs, prescription medications, sedative, tranquillizers, antihistamines, alcohol, or other “over the counter
medications” without first consulting with physician. The center and physician have explained to the patient
that taking any of the above in conjunction with any medications prescribed by the physician may produce
dangerously profound effects including, but no limited to sedation, respiratory dysfunction, blood pressure
changes and depression.
Patient agrees that he / she will not attempt to obtain prescriptions for any pain medications from other
physicians and or pain management facilities. Patient understands that it is a violation of both Georgia and
Federal Laws to do so and will result in felony charges.
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Hapeville Medical Center
Patient Name: __________________________ Date: ______________________
Patient Medication Management and Treatment Agreement Page 2
10. Patient has been advised that in the event the center and or physician becomes aware of the patient
attempting to or receiving pain medications from other physician or facility that the patient will be
immediately discharged from the practice and could face felony charges.
11. Patient declares to the center and physician that the patient is not presently using any illegal drugs, alcohol or
controlled substances (other than medications prescribed by the clinic) while in the care of the center and its
physician.
12. Patient consents and agrees to allow the center and physician to pill counts, blood testing and urine testing
while a patient at the center.
13. Patient agrees that patient shall not under any circumstances sell, share, trade or market any medications
prescribed by physician to any other individual or entity regardless of the circumstances as said conduct is
illegal and punishable by law.
14. Patient agrees not to conspire with any other individual or entity in order to obtain any prescription pain
medication from any pharmacy other than the specific pain medication prescribed by the physician at the
center.
15. Patient agrees to use due care in protecting their prescription from loss or theft. Patient has been advised and
agrees that any and all prescriptions prescribed by physician shall be kept out of the reach of children.
16. Patient acknowledges that patient is responsible for taking any prescribed medication(s) prescribed by
physician, in the exact and specific dose prescribed by the physician at the center.
17. All follow up visits to the center will be scheduled no earlier than 28 days, and not later than 30 days.
Patient understands that the visits and follow up treatment is required for the proper management and
treatment of the patients including, but not limited to prescription medications prescribed by the physician.
Re-fills on prescription medications will not be called in by the physician or the center and will only be refilled pursuant to the patients follow up schedule and medical necessity.
18. All female patients should immediately notify physician if they are pregnant, at risk of becoming pregnant or
may be pregnant. Failure to do so may cause harm or injury to the unborn child.
19. Patient agrees that in the event of an investigation by any Local, State or Federal Agency (including Georgia
State Board of Pharmacy), Patient authorizes center and physician to cooperate, and patient waives any and
all applicable Hipaa Privacy Rules and Regulations relating to the patient confidentiality and herby
authorizes center an physician to disclose patients medical information.
20. In the event that the center or physician determines that patient may be doing harm to themselves or others
by either abusing prescribed medication, selling prescribed medication or “doctor shopping” this document
will serve as a release of medical information in compliance with Hipaa regulations for the center or the
physician to obtain any records from any center or physician regarding any prescribed pain medication and
treatment records.
21. If patient has either been on probation in any state, or if the patient has ever been arrested or charged with
any narcotic or drug related offense, patient understands that the patient must disclose this information to the
center and the physician.
22. In the event patient changes pharmacies, patient agrees to immediately notify center and physician of such
change.
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Hapeville Medical Center
Patient Name: __________________________ Date: ______________________
Patient Medication Management and Treatment Agreement Page 3
23. Patient understands and agrees that center an or physician reserves the right to perform a urine drug screen at
any time while patient is being treated and or receiving prescribe medication from physician. In the even the
test results determine to be positive for any other substance other than that that is being prescribed by the
physician, or any substance that is not documented in the patients chart as being prescribed by another
treating physician, the patient understands that they can be dismissed immediately and all prescription
medication will be cancelled immediately and the patient will be referred to an addictionologist for clearance
before any other treatment will be considered.
24. Patient agrees that any suspicions misuse of prescribed medication by either the center or the physician may
result in immediate discharge of the patient and termination of any prescribed medication and treatment plan.
Patient also understands that they will be referred to an addictionologist for clearance before any future
treatment will be considered.
25. Patient understands that at any time during treatment should the physician or center suspect tha the patient is
falsifying symptoms in order to either be treated or obtain medications; physician shall immediately
discharge the patient.
By signing this agreement, patient agrees to abide by the terms of this agreement, and patient agrees that the failure
to abide by the terms of this agreement may result in immediate termination of treatment and prescription
medication.
____________________________________________________
________________________________
Patient Signature
Date
____________________________________________________
________________________________
Witness Signature
Date
____________________________________________________
________________________________
Physician Signature
Date
correspondence
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