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I would ask you to read this through and if you agree we will have you electronically sign this for inclusion in the electronic health record. A copy is available for you in paper format.
  1. Patient Rights
    1. You have the right to dignified and respectful care.
    2. You have the right to know about and understand your physical condition.
    3. You have the right to obtain any information requested by you to give informed consent before any treatment and/or procedure.
    4. You have the right, at your own expense, to consult with another physician or specialist.
    5. You have the right to refuse treatment, as permitted by law, and to be informed of the consequences of your refusal.
    6. You have the right to be treated in a safe environment that is free of physical and psychological threats.
    7. You have the right to privacy regarding visitors, mail, and/or telephone conversations.
    8. You have the right to expect that all communications and records regarding your care will be held confidential.
    9. You have the right to expect continuity of care and that you will not be discharged or transferred to another facility without prior notice.
    10. You have the right to communicate verbally or in writing with anyone outside the practice.
    11. You have the right to know the identity, professional status, and institutional affiliation of anyone treating you.
    12. You have the right to request an itemized statement of all services provided to you through this practice.
    13. You have the right to be informed of all practice rules and regulations governing your conduct as a patient and to understand the procedure for registering a complaint.
    14. You have the right to treatment or accommodations required by your medical condition regardless of race, creed, sex, or national origin.
  2. Patient Responsibilities
    1. You are responsible for providing complete information about your health and for reporting the effects of your treatment.
    2. You will be responsible for participating in the development of your plan of care.
    3. You will be responsible for attending scheduled therapy and participating in activities prescribed by your treatment plan.
    4. You will be responsible for considering the rights of other patients and office personnel during your treatment in this practice.
    5. You are responsible for following practice rules and regulations, which I present here as guidelines.
I care for patients with chronic pain in a solo practice. Patients must realize their condition is managed from this perspective.
a. Visit Times
I want to help you achieve a manageable level of pain. I need your help is this effort. The first part of this includes having the right amount of time to hear and understand. While most visits of a follow-up nature can be accomplished in 15 minutes, there are many times when new symptoms need to be addressed, more questions need to be answered, and more time spent. I am happy to do this, but need your help in scheduling this. If you know you have questions or a new complaint that will take more time to cover, please let my staff (right now my wife Jeanne, and my nephew, James) know so that we can schedule the right amount of time for the visit. Neither you, nor I wish to feel rushed.
You have the right to be heard and believed as to the level of your pain and its effects on you. I will do my best to help with a variety of interventions. You must do your best to comply with the directed therapy.
b. Your Advocate
I am your advocate for the achievement of a manageable level of pain. I will help you, but there are times when you will need to help yourself, especially if that requires lifestyle changes, compliance with medical / pharmacokkklogic regimens, or simply following directions. Sometimes, unfortunately, you need others to help you get the care you deserve. This may mean working with your insurance carrier to have them understand and allow me to help you.
c. Respect:
You have the right to compassionate care provided to you with respect for your privacy and maintenance of medical confidentiality. Respect and consideration are two-way streets. I must ask that you treat my staff with the respect as well.
I cannot tolerate misbehavior, crude language or threatening actions. We are a small family run office. Disruptive or belligerent behavior is grounds for discontinuation of care.
d. New Symptoms
: If new, unusual or threatening symptoms appear that cannot wait until the next business day for evaluation, patients should go to the emergency room or an urgent care facility for evaluation. One of the reasons we coordinate with Primary Care Physicians (PCP) is that I expect them to be the first to see patients for new conditions. While I may begin work-up of new symptoms as they relate to ongoing management of the chronic pain condition, I may also refer you back to the PCP.
e. Therapeutic Relationship
I enter into a therapeutic relationship with patients once we both agree to that end. Your participation in care provided is an example of your agreement to the relationship. If, at anytime, you wish to terminate this relationship you can of course do so. Most patients do so by simply not returning to the doctor for care. For my part, if that becomes necessary, I will be obliged to inform you formally.
f. Forms
Please let my staff and I know up front if forms need to be completed. I am happy to complete disability forms and return to work forms, but be advised that these forms are best completed together. So, this takes time for us to complete these and time needs to be scheduled. So, allow my staff to schedule the right amount of time for the visit.
Also, disability forms may require separate payment for their completion.
g. Prescriptions
: In terms of opiates and benzodiazepines, we must agree that once I become your doctor I would be the only one prescribing these types of medicines for you. There are of course circumstances when this is not appropriate, but for the most part this is a rule in place to keep you safe. If your PCP / family doctor is doing this then I am making recommendation to her/him for this and I will not be prescribing. Either way we need to be clear about this. Getting opiates (morphine / Norco / Vicodin) and benzodiazepines (valium / ativan / klonopin) from two or more MD's is not right. Also, the Pharmacies and DEA keep track of this and don't think much of that either. So, this would be grounds for discontinuation / termination of the therapeutic relationship.
Refills for any narcotic or scheduled medication must be done during an office visit. __ (initials)
They will not generally be refilled through office calls or contacting the pharmacy for refills. I cannot comply with California State Law to document your positive response to the medication, control of side effects and increased activity when you contact me through the pharmacy or call the office. Nor can I ensure and properly document compliance with the prescribed regimen of medication without an office visit for controlled medications. Therefore, refills for narcotics and benzodiazepines must routinely be accomplished through an office visit.
Refills for non-scheduled medications should be coordinated during in-office visits as well. When the refill is completed for non-scheduled medications through either contact by phone through the office or the pharmacy, separate time must be allocated to account for and document the transaction. This time is charged as pharmacologic management. Your insurance may or may not pay for this.
h. On Call
There is no on-call system. You may leave a phone message, but on the weekend that will be answered Monday morning. ____ (initials)
i. Payment
Presently, we take cash or checks for co-payments. Speaking of payments, missed appointments carry a $50 charge. Completing forms without your presence is $25. Again, disability forms are best completed together, especially when limitations as to lifting, carrying, sitting, standing etc. are required. Also, If you participate in the pharmacy automatic refill program and they contact us to fill a prescription, or if you call to request a refill, understand you may incur a $25 refill charge from us. So, if you wish to avoid additional charges, please discuss your refill needs during your appointment. In this way, the doctor can review your file and determine your current needs at that point. If you have any questions concerning billing you may contact our biller via the internet site or via phone.
j. Office Closure
When the office will be closed for an extended period, we will have the information at the office and on the phone system.

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