329 Edwin Drive Suite 101 Virginia Beach, VA 23462 Phone ... · 329 Edwin Drive Suite 101 Virginia Beach, VA 23462 Phone: 757-227-3820 Fax: 757-226-9021 ... When I choose to have

329 Edwin Drive Suite 101

Virginia Beach, VA 23462 Phone: 757-227-3820 Fax: 757-226-9021

PHYSICIANS

PHYSICIAN ASSISTANT

PHYSICAL THERAPISTS

Robert M. Spear, DO

Eric Rymal PA-C

Kathryn Bragg, PT

Bonnie J. Nock, DO

Scott Burch,

PT

Robin Levine PT

Thank you for choosing Coastal Virginia Spine and Pain Center to provide you with health care services. We appreciate your trust in us, and we pledge to do all that we can to accommodate your needs and expectations. On the day of your appointment please arrive approximately thirty (30) minutes early, so that we can ensure all necessary paperwork is in order. Your initial visit will require that you be in our office for approximately ninety (90) minutes. Occasionally, due to unforeseen circumstances, th is length of time may be longer. We also would like to familiarize you with some record-keeping items that will facilitate your visit with us. Enclosed, you will find the following forms. Please complete each of these forms prior to your scheduled appointment.

Patient Registration Form

General Consent/Agreement to Outpatient Services

In-Office Visit during Covid-19 Pandemic - Patient Authorization and Consent Form

Financial Agreement – Office Visit

Informed Consent for Spinal or Joint Injection

PQRS Form

The following documents are available for your review in our office or on our website www.CovaSpineandPain.com.

• Our Notice of Privacy Practices (HIPAA)

• Notice of Patient Rights and Responsibilities

On the day of your appointment, please bring your insurance card, a state-issued ID (driver's license, Virginia ID card) and your specialist co-pay in order to be seen. The doctors and staff of Coastal Virginia Spine and Pain Center are dedicated to excellence in patient care, service and satisfaction. If you have any questions please do not hesitate to ask any staff member in our practice. Sincerely, Coastal Virginia Spine and Pain Center

COVA PROCEDURES PACKET: 1 of 9 EFFECTIVE: 1/1/2019 REVISED: 5/29/2020

PATIENT REGISTRATION PLEASE PRINT

The information below will be used to improve the quality of healthcare by granting us the ability to measure and minimize care disparities

based on ethnicity, race and preferred language. It gives the practice an accurate estimate of our patient population, and accordingly assesses

the need for different services such as interpreter services translated patient forms and cultural competency training for our staff. You have the

RACE: (Please check one) DECLINED

American Indian/Alaska Native Asian Black/African American Native Hawaiian/Pacific Islander White Other Race

ETHNICITY: (Please check one) DECLINED

Hispanic/Latino Not Hispanic/Latino Unknown

LAST NAME: ____________________________________________ First:______________________________________ MI: _____

Date of Birth: __________________ Sex M F Social Security #:______________________________________________

Address:__________________________________________________________ City________________ State______ Zip________

PHONE: HOME:______________ CELL:____________ WORK:____________ E-MAIL: ____________________________________

INSURANCE INFORMATION (if Worker’s Comp, please write W/C under Primary Insurance)

PRIMARY INSURANCE PLAN: _______________________________________________________________

ID#____________________________ GROUP #:_______________________________________

Policy Holder: SELF OTHER

If Other: Last Name:__________________________________________ First Name__________________________ MI_____

Relationship to Patient: _________________________Policy Holder: Date of Birth:________________ Last 4 digits of SSN: ______________

Address if different from patient: _________________________________________________________________________________________

SECONDARY INSURANCE PLAN: ____________________________________________________________ I

ID#____________________________ GROUP #:_______________________________________

Policy Holder: SELF OTHER

If Other: Last Name:__________________________________________ First Name__________________________ MI_____

Relationship to Patient: _________________________ Policy Holder: Date of Birth:________________ Last 4 digits of SSN: ______________

Address if different from patient: __________________________________________________________________________________________

ASSIGNMENT and RELEASE

I hereby assign my insurance benefits to be paid directly to the physician.

I understand that I am financially responsible for all non-covered services

I authorize the physician to release any information required to process this claim

SIGNED: __________________________________________________________ DATE:__________________

Referring Physician: ___________________________________________Patient PCP: ____________________________________

Preferred Pharmacy: _____________________________________________________________ Phone: ___________________

Employer: ______________________________________________________________________ Phone: ____________________

Marital Status: ________________ If married, Spouse’s Full Name:____________________________________________________

EMERGENCY CONTACT: ________________________ Relationship to Patient: ______________ Phone:____________________


1. CONSENT TO TREATMENT: I hereby consent to treatment by Coastal Virginia Spine & Pain Center

(COVA), their associates, and/or assistants, and accept responsibility for payment of fees for such medical services. I understand that treatment by include injections, manipulation, medication management, medical appliances, and/or other procedures as deemed necessary and appropriate. I understand that I could be tested for HIV, and have the right to opt out. I understand that my consent will be requested for HIV and other testing in case of an unintended exposure of a healthcare worker..

2. PAYMENT FOR SERVICES: I understand that COVA may bill my health plan for the care I receive. I agree

that payments from my health plan may go directly to COVA. If I should receive the payments, I understand that I will be responsible for paying COVA. I understand that I must pay any co-payment or other part of the bill that my health plan says I must pay. I know that I may need to pay this before I am treated. I understand and agree that if my plan does not pay the physician or their associates/assistants, I will have to do so. I understand that COVA will hold me responsible in any one of the following situations:

a. When I choose to have a service that my health plan covers, but I do not obtain the required referral or authorization from my health plan.

b. When I choose not to use my health plan and agree to pay for services myself. (Use Do Not Bill Insurance Form)

c. When my health plan does not participate with COVA for the services I want or need and I agree to pay for my care myself.

d. When I receive services that are not covered under my health plan.

3. ADVANCED DIRECTIVES: COVA does not honor Advanced Directives. Unexpected complications due to procedures and/or treatment are not natural causes, and therefore will be treated. This means that if an adverse event occurs during your treatment at this facility, we will initiate resuscitative or other stabilizing measures, and transfer you t an acute care hospital for further evaluation. At the acute care hospital, further treatment, or withdrawal of treatment measures already begun, will be ordered in accordance with you wishes, Advanced Directive, or Health Care Power of Attorney. The admitting facility is not affiliated, or in partnership with COVA.

4. ELECTRONIC PRESCRIBING: I authorize SureScripts, an electronic prescribing network, to release my medication refill history to COVA for the purpose of continued treatment.

5. RELEASE OF INFORMATION: I authorize COVA to release healthcare information for purposes of

treatment, payment or healthcare operations. Healthcare information may be released to any person or entity liable for payment on the patient’s behalf in order to verify coverage or payment questions, or for any other purpose related to benefit payment. Healthcare information may also be released to my employer’s designee when the services delivered are related to a claim under Worker’s Compensation.

If I am covered by Medicare or Medicaid, I authorize the release of healthcare information to the Social Security Administration or its intermediaries or carriers for payment of a Medicare claim or to the appropriate state agency for payment of a Medicaid claim. This information may include, without limitation, history and physical, laboratory reports, operative reports, physician progress notes, physical therapy notes and consultations.

Federal and state laws may permit this medical practice to participate in organizations with other healthcare providers, insurers, and/or other health care industry participants and their subcontractors in order for these individuals and entities to share my health information with one another to accomplish goals that my include, but no limited to: improving the accuracy and increasing the availability of my health records; decreasing the

GENERAL CONSENT/AGREEMENT TO OUTPATIENT SERVICES


time needed to access by information; aggregating and comparing my information for quality improvement purposes; and such other purposes as may be permitted by law. I understand that this facility may be a member of one or more such organizations. This consent specifically includes information concerning psychological conditions, psychiatric conditions, intellectual disability conditions, genetic information, chemical dependency conditions and/or infectious diseases including, but no limited to blood borne diseases, such as HIV and AIDS.

6. DISCLOSURE TO FAMILY AND FRIENDS: I give permission for my Protected Health Information to be disclosed for purposes of communicating results, findings and care decisions to the family members and others listed below:

NAME RELATIONSHIP CONTACT NUMBER

7. COMMUNICATION CONSENT and TELEPHONE CONSUMER PROTECTION ACT: I agree that when I provide my landline or cell phone number(s) below, I am giving express consent for COVA and its associates, assignees, successors, and agents, to contact me at these numbers, or at any number that is later acquired for me and to leave live or pre-reordered messages on voicemail or to text, regarding scheduling or scheduled appointments, my services, or my bill. For greater efficiency calls or texts may be delivered by an auto-dialer. I realize that as a consequence of providing this consent, I may receive future calls or text messages that deliver pre-recorded messages by or on behalf of COVA. Charges from your carrier may apply. Providing a telephone or cell number is not a condition of receiving services.

You may be contacted via voicemail or text to remind you of an appointment, to obtain feedback on your experience with our healthcare team, and to provide general health information. I consent to receiving healthcare communications at the phone number provided. This request to receive text messages applies to future communications unless I request a change in writing.

Home Phone: __________________________ Cell Phone: ___________________________

OR ____ (initials) _____ I decline to receive communications via text

8. NOTICE OF PRIVACY PRACTICES: I acknowledge that I have received/reviewed COVA’s Notice of Privacy Practices. I understand that I may contact the Privacy Officer if I have a question or complaint. To the extent permitted by law, I consent to the use and disclosure of my information for the purposes described in the practice’s Notice of Privacy Practices.

9. AUTHORIZATION FOR RELEASE OF PRESCRIPTIONS: I hereby authorize COVA Spine and Pain Center to release my prescriptions to the following in the event that I am unable to pick up my prescriptions.

Name: ______________________________________________ Relationship: ______________________

Name: ______________________________________________ Relationship: ______________________ I agree to the items as outlined in the Agreement,

Name (Print): _____________________________________

Signature :________________________________________ Date: ___________

Relationship to Patient (Self/Parent/Personal Representative):______________________________________


In Office Visit During COVID Patient Authorization and Consent Form

1. During the COVlD-19 pandemic, there is some increased risk for patients who visit a healthcare provider. Health problems can happen from being exposed to:

• other patients,

• healthcare staff

• healthcare facilities.

2. Some patients have a higher risk of complications from COVID-19, including those with:

• asthma,

• chronic lung disease,

• serious heart disease or problems,

• chronic kidney disease,

• extreme obesity,

• a compromised or suppressed immune system,

• liver disease,

• pregnant,

• age 65 or older

• nursing home or long-term care facility residents.

If these high-risk patients get COVID-19, they may have a greater chance for having more health problems. These may be serious. Patients may need to be in the hospital. They could even die.

3. There are other evaluation and treatment options to meet with your doctor/clinician and be treated. You could have:

• a phone evaluation/visit or

• a telemedicine evaluation/visit.

These other options may or may not be right for you. This depends on your health problem and overall health. If remote assessment and treatment are not appropriate, your doctor will explain why you need an in-person visit.

4. Medical and office staff may help your doctor when you arrive and while you are evaluated and treated. They will follow state laws and recommendations from local, state, and national health officials related to caring for patients during the COVID-19 pandemic. However, they cannot eliminate risks, especially for high-risk patients.

Consent to Treatment

This consent form has told you about COVlD-related risks. If, after reviewing this form, you do not believe that you really understand the risks and choices, do not sign the form until all questions have been answered.

I understand the facts provided to me on this consent form. I give my consent for in-office evaluation and treatment. By signing below, I agree that the COVA staff/doctor has discussed the facts in this form with me, that no one has given me any guarantee, that I have had a chance to ask questions, and that all of my questions have been answered.

_________________________________ _______________________________ ______________ Signature of Patient or Responsible Party Name Printed Date and Time

________________________________________________ Relationship to Patient (if Responsible Party is not Patient)

____________________________________ _______________ Witness Date and Time

**COVA STAFF ONLY **

FOREHEAD TEMPERATURE: _______OF


FINANCIAL AGREEMENT OFFICE VISIT

Please initial any relevant sections. Write N/A if it does not apply to your situation.

_____ I do not have insurance coverage and understand I am fully responsible for payment at time of service for all services rendered at Coastal Virginia Spine and Pain (COVA). Services today may cost between $50 and $1500.

_____ I understand that COVA has not received authorization and or a referral for today’s services, and I agree to pay the cost of this visit at the time of service. I understand that the visit may cost between $50 and $1500 and I agree to pay the amount of today’s session, should the visit not be covered by my insurance company.

_____ I understand that _____________________________ is NOT a covered service and that I am responsible for payment. Payment arrangements have been made by the COVA Billing Department and approved by Dr. _________, I have been made aware of, and agree to pay this fee ________. I have also agreed NOT to allow my balance to exceed $300 at any time.

_____ I understand that COVA has received insurance authorization for ___________________________, but should insurance decide to deny coverage at any time (i.e. insurance expired prior to procedure date, etc.), I agree to pay for the physical therapy services within 30 days of notification. I agree to pay my co-pay, or 20% of the procedure cost, whichever is the expected payment agreement with the insurance company at the time of service.

_____ I understand that COVA is not required to obtain insurance authorization for ___________________, but should insurance decide to deny coverage at any time (i.e. insurance expired prior to procedure date, secondary insurance plans that may be out of network, etc.), I agree to pay for services within 30 days of notification. I agree to pay my co-pay, or 20% of the visit cost, whichever is the expected payment agreement with the insurance company at the time of service.

_____ I understand that my insurance requires conservative treatment for three (3) months prior to this procedure. I understand that the visit may cost between $500 and $2000 and I agree to pay the amount of today’s session, should the visit not be covered by my insurance company.

_____ I understand that today's services will be covered under my Worker Injury Compensation, and that an authorization from my claims adjuster has been received. I also understand that COVA will file all claims for services for Worker Injury Compensation cases.

_____ I have a personal injury case in litigation. I am aware that I must be prepared to pay for my initial consultation today, and await a final decision by my physician to determine if an attorney lien will be accepted. The cost of today's appointment will range between $50 and $1500.

_____ I, _________________________, am aware that my insurance is currently listed as “inactive-pending investigation” due to a lapse in payment of my premiums. If for any reason the insurance company does not cover my visit for date of service _________, I understand that I will be responsible for the full cost of the services rendered that day.

*_______________________________________ *_______________

Patient/Responsible Party Name (Print) Date

*___________________________________

Patient/Responsible Party Signature


Patient Signature: * Date:

NAME: * DATE: *

Primary Care Physician: * Referring MD Name: *

***Please CIRCLE the appropriate answer. Please ask for assistance if you do not understand any questions.***

Y N Is this your first Injection for this problem? If no, how many have you had in the last 12 months?

Y N Are you diabetic? If yes, is your blood sugar currently well controlled? Y N

Y N Do you take insulin? Please list your diabetic medications (not doses)

Y N Are you taking any blood thinning medications? Plavix, Ticlid, Coumadin/Warfarin, Eliquis, Pradaxa, Xarelto, etc.?

Y N If yes, what date did you last take the medication?

Y N Are you currently taking: Aspirin, Motrin, Advil, Aleve, Naprosyn, Feldene, Relafen or other non-Steroidal Anti-inflammatory medications (NSAIDS)?

Please list all of the medication (not doses) you are currently taking:

Y N Are you aware of any kidney problems? Explain

Y N Do you currently have any active injection of fever? If yes, what?

Y N Are you currently taking antibiotics? If yes, what

Y N Are you allergic to IV contrast or iodine-based dyes?

If yes, did you take a Prednisone or Benadryl prep before coming today Y N

Y N Do you have any other medication allergies? If yes, please list,

Y N Have you ever had a severe allergic reaction requiring treatment at a hospital

Y N Are you allergic to latex

Y N Female Patients: Is there any chance that you are pregnant? If YES, please notify staff prior to the procedure.

Y N Are you driving yourself home today? Select “NO” if you brough a driver.

Which physician is currently treating you for this problem? Dr. Spear Dr. Nock Other:

Date of follow-up appointment with that physician.

PRE-PROCEDURE CHECK-IN

Office

Notes

VITALS PRE POST 3__ 4__

02 Sat-

Pulse

BP

Please draw the location of your pain on the diagram

Include any radiation into the arms or legs

What is your pain level TODAY? _____/10

(0 = No Pain 10 = Worst pain in your life)


INFORMED CONSENT FOR SPINAL OR JOINT INJECTION

The injection involves placing a small needle in or around the painful area injecting a numbing medication and anti-inflammatory medication

(steroid or other type of solution). If the injection is for diagnostic purposes only, anesthetic or contrast dye will be used. This injection will

hopefully give you significant pain relief and give us importantinformation that will enable us to diagnose you condition.

Some injection procedures involve the use of radiofrequency energy to interrupt nerve transmission by lesioning or shocking of specific

nerves.

Dr. ______________________ and/or his/her associate has explained the nature and purpose of this procedure and has answered my

questions. I do understand that this is considered an elective procedure. I understand my current condition for which I am having the

procedure is not life threatening.

Possible side effects associated with this procedure include:

1. Regional numbness, weakness and/or dizziness. You may have increased numbness for one-hour to six hours after the block.

We advised you not to operate a vehicle or perform any activities that require coordination for six to ten hours after the block.

2. Vasovegal reactions (fainting) could occur during or after the procedure with possible heart and blood pressure problems.

3. Reactions to medication include minor or temporary allergic reaction and/or a temporary decrease in blood

4. pressure. These problems may require more aggressive treatment including IV or other medications

5. Increased pain. Twenty percent of patients may have increased pain for one to seven days after the injection.

6. Less than one percent of patients may have a headache after the procedure. Treatment of the headache may necessitate

additional procedures and/or hospitalization.

7. Infection either around the injection site or deep in the spine is also a potential risk. Other rare complications might include hip

(bone) damage caused by steroids, temporary or permanent nerve impairment, bleeding, bruising, seizures, stroke, paralysis,

collapsed lung, bowel/bladder/sexual dysfunction and death.

If the block is performed specifically for diagnostic purposed, a steroid may not be used. If this is the case, complications or side effects

associated with steroid use will not be a possibility..

I have discussed treatment alternatives with Dr. __________________________ including no treatment.

I *________________________________________ consent to this procedure to be performed by Dr. ___________________

and/or his/her associate.

As requested by my physician, I am aware that I am NOT to drive myself home or operate a

vehicle for six to ten (6-10) hours.

Name of procedure**: _____________________________________________________(For Provider Use Only)

*_________________________________________________ *_______________________ Patient Signature Date

___________________________________________________ ________________________ Physician Signature Date

_______________________________________________ ________________________

Witness Signature Date

Time out process performed prior to procedure _____________________________

Procedure room Tech/MA Signature


PQRS QUESTIONNAIRE 2020 Coastal Virginia Spine and Pain Center (COVA) participates with the Physician Quality Reporting System. PQRS gives the physicians at COVA the opportunity to assess the quality of care they are providing to their patients, helping to ensure that our patients get the right care at the right time. Please help us further assess your health care needs by completely answering the following questions.

1. Do you have an Advanced Care Directive/Living Will or a Medical Power of Attorney?

YES NO

a. If yes, please complete one of the choices below: 1) Who has your Medical Power of Attorney? ____________________________________

2) Provide a copy of your Advanced Care Directive/Living Will

2. Have you had two or more falls in the past year or any falls with an injury in the past year?

YES NO

3. Have you had a Pneumococcal Vaccination (Pneumonia Injection)? If yes, date of injection: ___________

YES NO

4. Have you had a flu shot? If yes, date of injection: __________

YES NO

5. Are you a smoker? If yes, how many packs per day? __________ YES NO

6. Have you had a bone density study since turning 60 years of age? YES NO

7. Do you sometimes drink beer, wine or other alcoholic beverage?

How many days per week do you have an alcoholic beverage? ________ How many alcoholic beverages to you drink weekly? _________________

YES NO

BMI: Height: _________ in Weight ______ lbs BMI __________ Normal ranges for age 65 and older: 23 - 30 Normal ranges for less than 65 year of age: 18.5 - 25

Patient Name: __________________________________

Date: _________________________________

Date of Birth: ______________________________


Documents

329 Edwin Drive Suite 101 Virginia Beach, VA 23462 Phone ... · 329 Edwin Drive Suite 101 Virginia Beach, VA 23462 Phone: 757-227-3820 Fax: 757-226-9021 ... When I choose to have