New Patient Intake Form

Your completed paperwork allows our providers to get to know you and your medical history better. We rely on its accuracy and completeness to provide you with the best care possible. Please take your time and call our office at (704) 500-2332 with any questions you may have.

Please answer the following questions to help us understand the location and nature of your pain.

Please mark any of the following tests that you may have had.

Please mark any of the following that you have undergone prior to your visit:

Check any of the following you may have recently experienced:

This is a combined form including your Medical Records Release form, HIPPA Authorized Parties form, Healthcare Consent, Financial Agreement and Treatments form, Financial Policy form, Notice of Privacy Practices, and Opioid Agreement.

This information may include medical information related to treatment of alcohol, psychiatric care, psychological assessments, substance abuse, and/or HIV/AIDS, if applicable.

I understand that if the person or entity that receives the information is not a healthcare provider or health plan covered by federal privacy regulations, the information described above may not be re-disclosed and no longer protected by these regulations. I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment or payment or my eligibility for benefits. I may inspect or copy any information used/disclosed under this authorization as allowed by law. I understand that I may revoke this authorization at any time by sending a notice of revocation in writing to Carolinas Pain Center. I further understand that I may not revoke this authorization to the extent that action has been taken in reliance on this authorization. Information about the right to revoke has been shared with me in the Carolinas Pain Center Notice of Privacy Practices.

By signing below, I authorize Carolinas Pain Center, PLLC, its agents and employees (the "Provider"), to use and/or disclose any and all of my protected health information of any kind and description to the following party or parties ("Recipients"):

I do hereby agree to pay and guarantee payment in full, of any charges for services rendered to the above-named by Carolinas Pain Center, PLLC, and by licensed healthcare provider who may provide services during this patient visit or stay. Payment is due in full within 30 days of services. In the event of nonpayment, the patient/undersigned guarantees payment of late charges for bills 30 days past due and all costs of collections, including reasonable attorney's fees. In addition, I authorize the transfer of monies paid to Carolinas Pain Center, PLLC by or on behalf of the patient and otherwise refundable to the Patient or Guarantor, to other accounts of Carolinas Pain Center, PLLC for which the Patient or Guarantor is responsible.

I authorize payments of medical benefits payable to me indirectly to Carolinas Pain Center, PLLC. I understand that BILL OF INSURANCE IS A SERVICE ONLY AND NOT A GUARANTEE OF PAYMENT. If my insurance should require pre-qualification for services, I realize it may be my responsibility to get the necessary approvals. I understand that I am personally responsible to Carolinas Pain Center, PLLC for charges not covered by insurance, including charges for health care services determined to be non-medically necessary by a private insurer's utilization review program. I understand that I may choose to continue services that are not covered by my insurance carrier at my own expense as long as Carolinas Pain Center, PLLC has notified me in advance that the insurance carrier may not cover or continue to cover services.

I understand that I may revoke or amend the following authorizations at any time except to the extent that action has already been taken; RELEASE FOR PAYMENT PURPOSES I authorize Carolinas Pain Center, PLLC to furnish any information relating to this hospitalization or treatment to representatives of my party financially responsible for the Patient's care to any governmental or charitable agencies. I understand that only information that is necessary for payment purposes will be disclosed. RELEASE FOR TREATMENT/QUALITY REVIEW PURPOSES I authorize release of medical information about the patient to the referring physician, any health care facility or physician to whom the patient may be referred and any extended care facility considered for placement. I understand that a separate consent form is necessary for disclosure of information regarding treatment of alcohol or substance abuse. I specifically consent to the disclosure of information related to AIDS, HIV infection, or other communicable diseases. ALL MEDICARE PATIENTS MUST AGREE TO THE FOLLOWING I request that payment under the medical insurance program be made on my behalf to Carolinas Pain Center, PLLC for any services rendered to me by the physicians and/or practitioners. I authorize any holder of medical information about me to release it to the Health Care Financing Administration and its agents any information deemed necessary to determine these benefits payable for related services. I permit a copy of this authorization to be used in place of the original.

By reading and signing this agreement, you agree to pay for all services rendered to you in a timely manner.

If you have a balance on your account, you will receive a monthly statement. It will show your previous balance, any new changes acquired since your previous statement, and your new account balance.

Payments may be made in our office at the time of your appointment, by phone, or by mail. Our billing office hours are Monday through Friday, 8 AM to 4 PM.

If we are contracted with your insurance company, we must follow our contract and their requirements. If you have a co-pay or deductible, we are required by your insurance company to collect this at the time of service. It is the insurance company that makes the final determination of your co-pay and amount due, NOT OUR OFFICE.

Any co-payments required by an insurance company must be paid at the time of service. Because this is an insurance requirement, we cannot bill you for the co-pay, these are required to be paid at the time of your visit. If you do not have your co-pay available, you will be required to reschedule your appointment. Self-pay patients have a pre-determined co-pay due when checking in with the receptionist.

There is a fee (currently $25) for any returned check. Once a check has been returned, the returned check fee and amount of the check must be paid in full before another appointment can be scheduled. In addition, we will no longer be able to accept checks and payment must be paid in cash or by credit card.

You understand if this account is submitted to a debt collector or agency, if we have to litigate in court, or if your past due account is reported to a credit reporting agency, the fact you were treated at our office may become a matter of public record.

In case of divorce/separation, the party responsible for the account prior to the divorce/separation will remain responsible for the account. After a divorce/separation, the parent authorizing treatment for a child will be responsible for the subsequent charges. If the divorce settlement should require the other parent to pay all or part of the treatment cost, it is the authorizing parent's responsibility to collect from the other parent.

We require written authorization by worker's compensation carrier prior to your initial visit. If your claim should be denied, you will be responsible for the payment. If you are being treated as part of a personal injury lawsuit, we require verification from your attorney's office prior to your initial consultation. In addition to this, we require that you allow us to bill your health insurance. WE CANNOT BILL YOUR ATTORNEY DIRECTLY as we do not file "third party billing."

I understand that as a healthcare provider, my physician may share my medical information for treatment, billing, and/or healthcare purposes. By signing this statement, I acknowledge that I have been given Carolinas Pain Center, PLLC "Notice of Privacy Practices," which describes how my medical information may be used or shared. I understand Carolinas Pain Center, PLLC holds the right to change the privacy notice at any time and that I may obtain an updated copy at any time by contacting our office at 704-500-2332 or by visiting our website at www.CarolinasPainCenter.com. My signature below acknowledges that I have been provided with a copy of Carolinas Pain Center, PLLC "Notice of Privacy Practices"

I hereby authorize the physicians of Carolinas Pain Center, PLLC to prescribe opioid medications to treat my pain. The providers have explained to me the anticipated benefits of these medications as well as the risks of the medications. These RISKS include but are not limited to: * Constipation, trouble passing urine, nausea, vomiting, or changes in appetite. * Changes in thinking, such as confusion. * Sedation, dizziness, sleepiness, drowsiness, aggravation, depression, breathing too slowly, headaches, dry mouth, sweating, weakness, itching, and/or rash. * Problems with coordination or balance that could make it unsafe to operate a motor vehicle or operate heavy machinery. * Alcohol, opioids and sedatives are a potentially FATAL combination. * PHYSICAL DEPENDENCE: the body becomes dependent on the medication and, if stopped abruptly, could cause withdrawal symptoms: runny nose, rapid heart rate, difficulty sleeping for several days, abdominal cramps, diarrhea, nausea, vomiting, chills, sweats, goose bumps, anxiety. This is not addiction; most patients will become physically dependent on opioids if taken for an extended period of time. * PSYCHOLOGICAL DEPENDENCE: This means it is possible that stopping the drug will cause you to miss or crave it. * TOLERANCE: This means you may need more and more drug to get the same effect. * PROBLEMS WITH PREGNANCY: If you are pregnant or contemplating pregnancy, discuss with your provider. * ADDICTION: A small percentage of patients may develop addiction problems based on genetic or other factors. I have read this document, understand the risks associated with opioid treatment, and have had all my questions answered satisfactorily.

I hereby authorize the providers of Carolinas Pain Center, PLLC to prescribe opioid medications to treat my pain I agree to abide by the following conditions/agree with the following statements

I hereby authorize the staff of Carolinas Pain Center to furnish to any local, state, or federal law enforcement agency, any information obtained pursuant to my treatment which is deemed by Carolinas Pain Center staff to evidence possible criminal drug activity in connection with medications prescribed to me as part of said treatment. I have read, or had read to me, the above document. I have had all of my questions answered to my satisfaction and I fully agree to all of the above statements and conditions. I fully intend to abide by the conditions set forth by Carolinas Pain Center for the administration of my opioid therapy. I have read and understand the potential risks and benefits as outlined above. I understand that if I failed to comply with all of the provisions outlined above, I may be dismissed from this narcotic agreement and from the clinic.

I agree to allow the physicians to communicate with my referring and primary physician as well as my pharmacy regarding the use of my prescribed medications. I agree to allow the pharmacy to release my records to Carlinas Pain Center, PLLC in order to prove compliance. I understand that loaning, borrowing, or selling of opioids is illegal. I acknowledge that this clinic will assist police in all prosecutions if I participate in such activities. From the time a prescription is written, I will be responsible for the medication until the next appointment. I agree to report any lost or stolen prescriptions/medications to the police or proper authorities. I agree to bring the police report to the clinic at the next visit for consideration of any further refills. I understand no replacement medications will be given. If a female of childbearing age, I certify that I am not pregnant and that I will take appropriate measures to prevent pregnancy during the course of my treatment with opiods. I will make my bottle of narcotics/controlled substances available for counting at any given time notified. I agree to keep all my scheduled appointments with Carolinas Pain Center, PLLC. I will participate to my fullest abilities in other services recommended by Carolinas Pain Center, PLLC for the treatment of my pain-related condition. These services may include psychological or psychiatric counseling or physical rehabilitation. I also understand that failed appointments or noncompliance in any recommended treatments may result in the termination of my treatment. I understand that should any illegal substances be found in my blood or urine, this will be cause for immediate dismissal from the clinic. This includes but is not limited to marijuana, cocaine, heroin, non-prescribed opioids, etc. I hereby authorize the staff of Carolinas Pain Center, PLLC to furnish any local, state, or federal law enforcement agency, any information obtained pursuant to my treatment which is deemed by Carolinas Pain Center, PLLC staff to evidence possible criminal drug activity in connection with medications prescribed to me as part of said treatment. I have read, or had read to me, the above document. I have had all of my questions answered to my satisfaction and I fully agree to all of the above statements and conditions. I fully intend to abide by the conditions set forth by Carolinas Pain Center, PLLC for the administration of my opioid therapy. I have read and understand the potential risks and benefits as outlined above. I understand that if I fail to comply with all of the provisions outlined above, I may be dismissed from this narcotic agreement, and from the clinic.

By signing below, you indicate your understanding of and consent to the Medical Records Release, HIPPA Authorized Parties, Healthcare Consent, Financial Agreement and Treatments, Financial Policy, Notice of Privacy Practices, and Opioid Agreement of Carolinas Pain Center, PLLC.

Please answer all questions, please respond carefully to this question. Try to choose the choice that most accurately reflects your abilities.

During the last month,