Patient Policies and Agreements

Updated: January 1, 2025 Welcome to Physical Medicine Institute. We are dedicated to providing high-quality, patient-centered care with a focus on clear communication, mutual understanding, and adherence to best practices. To ensure transparency and compliance with state and federal regulations, we have developed this comprehensive patient policy and agreement. This document outlines important information regarding financial responsibilities, cancellation policies, medical records, prescription refills, pain management, and other key areas of care. These policies are designed to protect your privacy, ensure effective treatment, and foster a collaborative relationship between you and your provider. They also highlight your rights as a patient, including access to high-quality care and the ability to make informed decisions, while emphasizing your responsibilities to follow the agreed-upon treatment plans. This updated version of our patient policy and agreement, effective 01/01/2025, consolidates all key elements, including financial policies, laboratory authorizations, HIPAA privacy practices, and pain management agreements. Please review the information carefully and ensure you understand the guidelines and expectations. If you have any questions or concerns, our team is here to provide clarity and support.

Patient Financial Responsibility Policy

Insurance Information

As the insured patient, you are responsible for providing accurate and up-to-date insurance information. Please present your insurance card(s) and ID at each visit. Failure to inform us of changes or providing incorrect information may result in your responsibility for charges incurred during office visits and any scheduled procedures.

Payments

Payments are due at the time of service unless prior arrangements have been made. Accepted payment methods include cash and credit cards. Returned payments will incur a $35.00 fee, which must be paid in addition to the original amount within 10 days of the returned payment notice.

Medicare

We accept assignment on all Medicare-covered charges and file claims on your behalf. If you do not have secondary insurance, you will be responsible for the 20% that Medicare does not cover at the time of your office visit. Any unpaid Medicare deductible is also due at the time of service.

HMO and PPO Plans

If we are a participating provider with your insurance company, we will file your claim. You are responsible for paying co-payments, deductibles, co-insurance, and fees for non-covered services. Co-payments for office visits must be paid at the time of your visit. For insurance plans requiring referrals or authorizations, it is your responsibility to ensure these are sent to our office before your appointment. Contact your primary care physician at least two weeks prior to your appointment to confirm that the referral has been sent. Without the referral or authorization, your visit may be rescheduled, and follow-up procedures cannot be scheduled until the authorization is received.

Private Insurance and Indemnity Plans

We will file an insurance claim on your behalf if you assign your insurance benefits to the physician. If you choose to file the claim yourself, full payment is required at the time of your visit. Deductibles must also be paid at the time of service.

Non-Covered Services

If a service is not covered by your insurance, you may be informed in advance. By proceeding with the service, you acknowledge responsibility for the associated charges.

Payment and Office Policies

Payment Policy

Co-payments and/or deductibles are collected at the time services are provided. Accepted payment methods include cash and credit cards. All medical services provided are directly billed to the patient or responsible party. If our physician is under contract with your insurance carrier, the practice will accept the negotiated rate for billed charges. However, you are responsible for any balance deemed patient responsibility, non-payable, or non-covered by your insurance. Payment is expected in full upon receipt of the invoice. If you are experiencing financial hardship, please contact our billing department.

Cancellation Policy

To cancel an appointment, please notify our office at least 48 hours in advance. A “no show fee” will apply if adequate notice is not provided. See the fee structure below.

Prescription Refill Policy

It is your responsibility to request prescription refills during your office visits. If you need to call in a refill request, please allow 48-72 hours for processing. Some medications may require prior authorization from insurance companies, which could extend the waiting period.

Medical Records Policy

A copy fee of $1.00 per page applies for medical record requests. Payment is expected in full upon receipt of your medical records.

No Show Policy

If you fail to cancel an appointment at least 48 hours in advance for office visits (72 hours for EMG/NCS and Injections) or do not show up for your appointment, a “no show fee” will apply. This fee must be paid in full upon receipt of the invoice or before your next office visit. The fees are as follows:

  • Return Office Visit (F/U): $50.00
  • EMG/NCS: $150.00
  • Injections: $100.00

Request for Form Completion

There is a charge of $25.00 per page for any forms that require completion by the physician. Payment must be received before the forms are processed.

HIPAA Privacy Practices

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. HIPAA requirements were officially implemented on April 14, 2003, and many of these policies have been part of our practice for years. Below is a simplified summary of our privacy practices. A more detailed version is available in our office.

What This Means for You

HIPAA places rules and restrictions on who can see or be notified about your Protected Health Information (PHI). These rules are designed to protect your privacy without interfering with the exchange of information needed to provide you with quality healthcare. HIPAA ensures certain rights and protections for you as a patient. Our goal is to balance these requirements while maintaining professional, high-quality care. Additional information about HIPAA is available at www.hhs.gov.

Our Privacy Policies

  • Confidentiality of Patient Information Patient information is kept confidential except when necessary to provide services or handle administrative matters related to your care. This includes sharing information with other healthcare providers, laboratories, and health insurance companies as needed. Patient files may be stored in open file racks but will not display sensitive details. Files may briefly be kept in administrative areas, such as the front office or exam room, but will only be accessible to office staff. By receiving care, you agree to our normal procedures for handling charts, records, PHI, and related documents.
  • Appointment Reminders and Communication We may remind you of appointments via phone calls, emails, U.S. mail, or other convenient methods. Additionally, we may send updates about office policies or new services and technologies that may benefit you.
  • Use of Third-Party Vendors We work with third-party vendors for various business functions. These vendors may have limited access to your PHI but are required to follow HIPAA confidentiality regulations.
  • Government and Insurance Inspections Government agencies or insurance providers may inspect our office and review records containing PHI as part of their routine duties.
  • Privacy Concerns or Complaints If you have concerns or complaints about your privacy, please bring them to the attention of the office manager or your physician.
  • Prohibition of PHI for Marketing Your confidential information will not be used for marketing or advertising products, goods, or services.
  • Access to Records You have the right to access your records, as permitted by state and federal laws.
  • Policy Updates Our privacy policies may be modified, added, or removed to better serve the needs of the practice and our patients.
  • Requests for Restrictions You have the right to request restrictions on how your PHI is used and to request changes to certain office policies regarding your PHI. While we will consider your requests, we are not required to implement changes if they conflict with our internal policies.

Laboratory Payment and Authorization Policy

  • Payment of authorized benefits may be made on your behalf to the following laboratories: Quest Diagnostics, LabCorp, or other laboratories as applicable.
  • Medical information or other relevant details may be released to your insurance company, laboratory, HCFA, and their agents to determine benefit eligibility for related services.
  • You may be financially responsible for all services performed by laboratories, as determined by your insurance coverage. Laboratories are authorized to release only the minimum necessary private health information required to secure payment.
  • Laboratories or their agents may contact you by phone, voicemail, mail, or other means regarding billing and collection information.
  • Physical Medicine Institute is NOT responsible for any balance resulting from non-payable or non-covered fees as determined by your insurance company.
  • By receiving services at our practice, you consent to and acknowledge agreement with the terms outlined in the HIPAA Information Form and any future changes to office policies. This consent will remain in effect moving forward.

Pain Management and Opioid Therapy Agreement

The purpose of this agreement is to provide information about medications prescribed for pain management and ensure compliance with all state and federal regulations for controlled substances. A trial of opioid therapy may be considered for moderate to severe pain, with the goal of reducing pain, improving functionality, and enhancing quality of life. Effective use of these medications requires collaboration between you and your physician to achieve the best outcomes with minimal risks.

Indication for Use

  • Not all pain responds to opioids, and these medications will not cure the underlying condition or injury.
  • Complete pain relief may not be possible, and some pain may only partially respond to opioids.
  • Medications are just one part of pain management. Regular exercise and self-care techniques are equally important.

Opioid Use May Be Discontinued If:

  • Pain relief is inadequate.
  • Persistent side effects occur.
  • There is no improvement in functionality.
  • The agreed treatment plan is not followed.

Side Effects and Risks

  • Opioids may cause drowsiness, difficulty breathing, respiratory depression, or death.
  • Opioids can impair reaction time, coordination, and judgment. Avoid driving or operating machinery if impaired. Alcohol increases these risks. Positive tests for alcohol or controlled substances may result in discharge from care.
  • Opioids can worsen sleep apnea. Inform your provider if you snore heavily, have sleep apnea, or other sleep-related issues. Compliance with prescribed treatments (e.g., CPAP or BiPAP therapy) is required.
  • Pregnancy Warning: Avoid opioids if you are pregnant, planning to become pregnant, or suspect pregnancy. Opioids can cause serious risks, including premature birth, birth defects, and Neonatal Abstinence Syndrome (NAS).

Additional Side Effects

Possible side effects include, but are not limited to:

  • Nausea, itching, sweating, constipation, dry mouth, anxiety, fatigue, drowsiness
  • Euphoria, confusion, hallucinations, depression, lack of motivation, difficulty urinating
  • Decreased testosterone (in men), menstrual irregularities, infertility, decreased sexual desire and performance, and increased pain sensitivity

Drug Interactions

Opioids may interact with other medications, increasing the risk of side effects, impaired judgment, and overdose. These include:

  • Sleeping pills (e.g., Ambien)
  • Benzodiazepines for anxiety (e.g., Xanax, Valium)
  • Barbiturates (e.g., Phenobarbital)
  • Sedatives (e.g., SOMA, Quetiapine)
  • Antihistamines (e.g., Benadryl)

Dependence, Tolerance, and Addiction

  • Physical Dependence: Abruptly stopping opioids may cause withdrawal symptoms, such as flu-like feelings, irritability, and trouble sleeping.
  • Tolerance: Over time, higher doses may be needed for the same effect, increasing risks.
  • Addiction: Some patients may develop an addiction. Notify your physician if you are concerned or have risk factors (e.g., family history of addiction, psychological stress).

Taking Your Medications

  • Take medications only as prescribed. Sharing or selling medication is illegal.
  • Store medications securely to prevent unauthorized access.
  • Do not stop taking opioids suddenly; consult your physician first.
  • Keep medications out of reach of children.
  • Lost or stolen prescriptions will not be replaced.
  • Notify your physician of any new medications prescribed by other providers.

Confidentiality Exceptions

Your information may be disclosed in the following situations:

  • Police investigations of suspected illegal use or diversion of opioids
  • Questions from pharmacists regarding your treatment
  • Emergency room treatments
  • Coordination of care with other treating physicians

Chronic Pain Management Agreement

The main goal of chronic pain management is to improve your ability to function and live as fully as possible while relieving pain. This typically involves a combination of treatments and medications that work together to reduce pain. Your active participation in the treatment plan is essential to its success. As a patient at Physical Medicine Institute, you have both rights and responsibilities, including the right to effective pain assessment and management, and the responsibility to follow the agreed-upon treatment plan.

Understanding Controlled Substances

Controlled substances (such as opioids) can be helpful but have the potential for misuse and are regulated by the government. These medications are prescribed to improve function and reduce pain—not simply for comfort. Physical dependence on these medications may occur, meaning that stopping them suddenly could lead to withdrawal symptoms. To ensure the safe and effective use of these medications, patients are expected to adhere to the following conditions:

Patient Responsibilities

  • Healthy Lifestyle Choices Follow your provider’s recommendations regarding exercise, sleep hygiene, diet, and avoiding tobacco, alcohol, and illegal drugs. These guidelines are essential for achieving the best outcomes.
  • Regular Pain Assessment Pain will be monitored regularly to evaluate treatment effectiveness. Communicate openly with your provider about your progress. If treatment goals are not met, controlled substances may be tapered and discontinued.
  • Specialist Recommendations Follow any recommendations from specialists to whom you have been referred. Report any treatment-related issues or side effects to your provider.
  • Treatment Exclusivity Do not seek treatment for chronic pain from another provider or emergency department without first consulting your provider. If emergency care is required, notify your provider as soon as possible.
  • Medication Responsibility Take medications only as prescribed. Lost, stolen, or misplaced medications will not be replaced. Any discrepancies with pharmacy-dispensed amounts should be resolved directly with the pharmacy.
  • Controlled Substance Prescriptions Controlled substances will only be prescribed by your provider. Exceptions include hospital stays, with the understanding that you will notify your provider of any changes after discharge.
  • Refill Policies
    • Refills will only be provided during regular office hours.
    • Refills will not be available at night, on holidays, or on weekends.
  • Activities While Medicated Avoid activities that could be dangerous, such as operating machinery, driving, or working at heights, if you feel impaired due to medication.
  • Pharmacy Use Use a single pharmacy for controlled substances and provide the pharmacy’s name, location, and phone number to your provider. Notify your provider of any pharmacy changes.
  • Communication Authorization Your provider may contact other healthcare providers, pharmacies, or regulatory agencies to provide or obtain information about your medications.
  • Appointments Attend all scheduled appointments or cancel at least 48 hours in advance. Repeated missed appointments or late cancellations may be considered a violation of this agreement.
  • Medication Verification Bring original pharmacy containers for prescribed medications upon request, even if they are empty.
  • Random Checks Be prepared for random medication counts or requests for oral fluid, urine, or blood samples for toxicology testing. Noncompliance may result in discontinuation of medications or discharge from the practice.
  • Psychological Evaluations Undergo psychological or psychiatric evaluations as recommended and follow any resulting treatment plans.
  • Provider Communication Inform all other providers involved in your care about this agreement.

For Women

Opioid use can harm a developing fetus. Notify your provider immediately if you are pregnant or planning to become pregnant. Opioid use during pregnancy may cause premature birth, withdrawal symptoms in the infant, or even death.

Violations and Consequences

Failure to comply with the conditions of this agreement may result in controlled substances being gradually tapered and discontinued, and you may be discharged from the practice.

Disclosure

The information provided in this agreement is intended to outline the policies and responsibilities for patients receiving care at Physical Medicine Institute. It does not constitute legal or medical advice and is subject to updates or changes as necessary. By receiving care, you acknowledge that you have read and understood the policies outlined above. For questions or concerns regarding these terms, please contact our office directly.