Precision Diagnostics • Personalized Care • Pain Relief

William Tham, MD
Susan Zimmerman, MD
Thomas Lee, MD
Joseph V. Ferraro, MD
Robin Medic, MD
Sophia Leonard-Burns, PA-C
Karen J. Scott, PA-C
Caryn F. Calka, PA-C
Amy Fernandez, PA-C
David Brian Abell, PA-C
CONSENT TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION
Physical Medicine and Pain Management will use your health related information for the purposes of providing
you with medical treatment, obtaining payment for services rendered and/or for general health care operations. Your health
related information will be submitted through the following mechanisms: US Postal Service, fax submissions, Internet
submissions for insurance inquiries (protected by Firewall), voice mail and/or personal communications. The most common
entries that will receive this information are: other providers, facilities, insurance companies and pharmacies. More specific
information pertaining to our practice policies is provided for you in our “Notice of Privacy Practices” statement. You have
a right to review this statement prior to receiving health care and prior to signing this consent. The terms of our Notice of
Privacy Practices may change, at anytime. You may contact the office and request a revised policy. Also, if you so choose,
you may request that we restrict the use or your health information for the purpose of treatment, payment and/or health care
operations. We are not required to agree with your requested restrictions. In the event we do agree with your requested
restrictions, we will adhere to these restrictions. If we do not agree with your request, we will discontinue treatment.
I have been provided a copy of the practice’s Notice of Privacy Practices. X___________________ (Initial)
I understand that I may revoke, at any time, this consent. This revocation will not effect previous actions, prior to revocation.
X___________________ (Initial)
DESIGNATION OF PERSONAL REPRESENTATIVE
I ______________________________________ authorize my health care provider and/or medical staff to discuss my
medical records, medical procedures, receive test results (i.e. blood work, MRI, x-rays, surgery, etc) schedule appointments,
cancel appointments, discuss health insurance information and/or accounting questions, call for refill on my medications or
to pick up any medication the doctor prescribes for me with the designated persons listed below.
__________________________________________________________________________________________________
If you want to limit your disclosure of health information, please list below the limitations.
__________________________________________________________________________________________________
Patient Name (Print)
X __________________________________________
Patient (or Patient’s Representative) Signature
Date: ________________
X__________________________________________________
Witness Signature: ______________________________________________________________
Precision Diagnostics
Annapolis, MD Office
2002 Medical Parkway, Suite 430
Annapolis, MD 21401
(410) 266-2700 • fax (410) 268-1862
•
Personalized Care
Glen Burnie, MD Office
331 Oak Manor Drive, Suite 102
Glen Burnie, MD 21061
(410) 761-0030 • fax (410) 761-4895
•
Pain Relief Solutions
Prince Frederick, MD Office
130 Hospital Road, Suite 101
Prince Frederick, MD 20678
(410) 535-1108 • fax (410) 535-4088
William Tham, MD
Susan Zimmerman, MD
Thomas Lee, MD
Joseph V. Ferraro, MD
Robin Medic, MD
Sophia Leonard-Burns, PA-C
Karen J. Scott, PA-C
Caryn F. Calka, PA-C
Amy Fernandez, PA-C
David Brian Abell, PA-C
MEDICATION/NARCOTIC MANAGEMENT AGREEMENT
This Agreement between__________________________________ (“Patient”) and Physical Medicine and Pain Management Associates (“Doctor”) is for the purpose of establishing an agreement/understanding between Doctor and Patient on clear conditions for the
prescribing and use of pain controlling medications prescribed by the Doctor for the Patient.
Doctor and Patient agree/concur that this Agreement is an essential factor in maintaining the trust and confidence
necessary in a doctor/patient relationship.
The Patient agrees to and accepts the following conditions for the use of pain medications prescribed by the providers of this practice.
• I understand that a reduction in the intensity of my pain and an improvement in my ability to do activities of daily living are the
goals of this program.
• I realize that it is my responsibility to keep myself and others from harm, including the safety of my driving. If there is any question
of impairment of my ability to safely perform any activity, I agree that I will refrain from the activity until I have clearance from a
provider of this practice.
• Pain medications are to be prescribed only by a single physician. I will not attempt to get pain medication from any other health
care provider while I am under the care of the practice. If the pain trial is successful, this practice will transfer prescription writing
to my primary doctor for long-term follow-up.
• No lost or stolen prescriptions or medications will be replaced. I am responsible for my own medications, and it is my responsibility
to verify that prescriptions are filled correctly and that the medication supply will last until my next scheduled follow-up visit.
• No increase in medication doses will be made without the approval of this practice. No prescriptions will be refilled early due to
independent increases in medication. These independent increases in medication dosage will not be tolerated.
• I understand that pain medications will not be refilled over the phone. Medications can be refilled only during normal business
hours, i.e., Monday through Friday 9 a.m. - 5 p.m.
• All patients are expected to comply fully with their individual treatment recommendations. Failure to keep any of Patient’s
scheduled appointments or follow the above agreements will be interpreted as an act of noncompliance, and may result in discharge
from the care of this practice.
• It is understood that emergencies do arise and under special circumstances, exceptions may be made to these policies.
CAUTION: Opioid medications may cause drowsiness. Alcohol should be avoided while using pain medications.
Use care when operating a car or dangerous machinery. Federal law prohibits the alteration of a prescription or transfer
of these drugs to any person other than the patient for whom they were prescribed.
I, the undersigned, attest that the above guidelines have been explained to me, and that all of my questions and concerns regarding
treatment have been adequately addressed. I agree to comply with the above guidelines. I have received a copy of this document.
**Please note, should a violation of this policy occur it may result in your discharge from the practice.
You may be subject to periodic lab testing at your healthcare provider’s discretion.**
Patient Signature: __________________________________________________________
Date: ________________________
Witness: ______________________________________________________
Date: __________________
Precision Diagnostics
Annapolis, MD Office
2002 Medical Parkway, Suite 430
Annapolis, MD 21401
(410) 266-2700 • fax (410) 268-1862
•
Personalized Care
Glen Burnie, MD Office
331 Oak Manor Drive, Suite 102
Glen Burnie, MD 21061
(410) 761-0030 • fax (410) 761-4895
•
Pain Relief Solutions
Prince Frederick, MD Office
130 Hospital Road, Suite 101
Prince Frederick, MD 20678
(410) 535-1108 • fax (410) 535-4088
William Tham, MD
Susan Zimmerman, MD
Thomas Lee, MD
Joseph V. Ferraro, MD
Robin Medic, MD
PATIENT NAME __________________________________
Sophia Leonard-Burns, PA-C
Karen J. Scott, PA-C
Caryn F. Calka, PA-C
Amy Fernandez, PA-C
David Brian Abell, PA-C
DATE OF BIRTH ____________________
AUTHORIZATION TO PAY BENEFITS TO THE PHYSICIAN: I hereby authorize payment
by (insurance company) _________________________________ be paid directly to Physical Medicine & Pain
Management Associates, P.C. (PM&PMA) for services rendered.
AUTHORIZATION TO RELEASE MEDICAL INFORMATION: I hereby authorize the release
of medical information required by my insurance carrier or its designated review agent, or if applicable my
employer’s workers compensation insurance carrier in order to determine benefits to which I may be entitled,
or to designated agents of Physical Medicine & Pain Management Associates, P.C. a copy of this authorization
will be deemed as valid as the original authorization.
FINANCIAL AGREEMENT: I hereby assume financial responsibility for and agree to make payment in full
to Physical Medicine & Pain Management Associates, P.C. for any/or all charges for services or medical
supplies received by me and/or any of my dependents not otherwise authorized or paid by my insurance carrier.
Payment is to be made within 30 days as statements are presented with settlement in full, or payment
arrangements to be made with the Business Office. I certify that the financial information given is true, accurate
and complete to the best of my knowledge, and further authorize PM&PMA to investigate any and all financial
information given concerning this or related claims. I further understand and agree that PM&PMA reserves the
right to charge interest on, collect reasonable attorneys fees for collection of, and/or report delinquent accounts
to Equifax Credit Information Services, Inc.
This entire authorization and agreement are valid for all episodes of care rendered by any and all physicians
and/or physician assignments associated with PM&PMA. I permit a copy of this authorization and agreement
to be used in place of the original.
____________________________________
Signature of Witness
____________________________________
Signature of Patient
____________________________________
Date
Precision Diagnostics
Annapolis, MD Office
2002 Medical Parkway, Suite 430
Annapolis, MD 21401
(410) 266-2700 • fax (410) 268-1862
•
Personalized Care
Glen Burnie, MD Office
331 Oak Manor Drive, Suite 102
Glen Burnie, MD 21061
(410) 761-0030 • fax (410) 761-4895
•
Pain Relief Solutions
Prince Frederick, MD Office
130 Hospital Road, Suite 101
Prince Frederick, MD 20678
(410) 535-1108 • fax (410) 535-4088
William Tham, MD
Susan Zimmerman, MD
Thomas Lee, MD
Joseph V. Ferraro, MD
Robin Medic, MD
Sophia Leonard-Burns, PA-C
Karen J. Scott, PA-C
Caryn F. Calka, PA-C
Amy Fernandez, PA-C
David Brian Abell, PA-C
Dear Patient:
To save you time on your initial office visit, we are sending you the patient history and
information sheet ahead of time. Also, enclosed is our office and financial policy sheet. Please
complete all of these forms, sign and bring them with you at the time of your appointment.
You may retain the policy information for your records.
If you are covered by insurance, please bring your card and a referral if required. If we
participate with your HMO/PPO we expect your co-payment at the time of service.
APPOINTMENT DATE __________________
TIME ____________________________
DOCTOR ______________________________
LOCATION ______________________
Please arrive at least 30 minutes before your scheduled appointment and bring the following
items with you:
• X-ray films/MRI/CT films and reports
• Referring Physicians reports
• Laboratory reports
• List of medications and supplements
• Insurance ID card and referral if required
• Valid Photo ID
Directions to Annapolis Office:
From Route 50 Heading East: Take Exit 23 (Parole), stay in the right lane and continue on to the stop
light (staying in the right hand lane as you drive). Turn right on to Jennifer Road. Go to the fourth (4th)
traffic light and turn left on to Medical Parkway. The Sajak Pavilion will be the building on your left (the
Anne Arundel Medical Center will be on your right). Sajak Pavilion Management requires patients to park
in the parking garage. There is no fee.
From Route 50 Heading West: Take Exit 23A, Jennifer Road. Make a left at the light onto Jennifer
Road. Continue on Jennifer Road thru 1 light passing (Medical Parkway). Make the next right into Sajak
Parking area and continue to parking garage.
Precision Diagnostics
Annapolis, MD Office
2002 Medical Parkway, Suite 430
Annapolis, MD 21401
(410) 266-2700 • fax (410) 268-1862
•
Personalized Care
Glen Burnie, MD Office
331 Oak Manor Drive, Suite 102
Glen Burnie, MD 21061
(410) 761-0030 • fax (410) 761-4895
•
Pain Relief Solutions
Prince Frederick, MD Office
130 Hospital Road, Suite 101
Prince Frederick, MD 20678
(410) 535-1108 • fax (410) 535-4088
William Tham, MD
Susan Zimmerman, MD
Thomas Lee, MD
Joseph V. Ferraro, MD
Robin Medic, MD
Sophia Leonard-Burns, PA-C
Karen J. Scott, PA-C
Caryn F. Calka, PA-C
Amy Fernandez, PA-C
David Brian Abell, PA-C
OFFICE & FINANCIAL POLICY
We welcome you as a new patient to Physical Medicine & Pain Management
Associates. The following information will help to familiarize you with some of the
basic office and financial polices.
APPOINTMENTS: The doctors are available to see patients on an appointment only
basis Monday thru Friday. You will be seen by a Physician Assistant on follow up visits,
unless otherwise determined by the Physician. Please notify us 24 hours in advance if you
will be unable to keep your appointment. Our office reserves the right to charge $25 for
missed appointments. The doctors do their best to see patients without having them wait
too long; however in a practice such as this, emergencies do arise and such patients will
be seen immediately, ahead of those waiting. If you arrive more than fifteen (15) minutes
late for your appointment, you may be asked to reschedule your appointment. The Sajak
Pavilion Management requires that patients park in the garage. There is no fee.
FEES: Payment for services rendered is expected at the time of the appointment. Cash,
check or credit card will be accepted. The only exception is if our practice has contracted
with your HMO/PPO to accept the insurance payment in full after all deductibles have
been met and all co-pays have been paid. Charges for initial office visits range from
$100 - $250. Charges for return office visits range from $40 - $120. Any questions
regarding your bill should be directed to our Business Office at 410-266-2701.
INSURANCE: The doctors of this practice are participating providers with Blue
Cross/Blue Shield of Maryland and the National Capital Area as well as with several
HMO/PPO plans. If you have insurance coverage through a company that we have contracted with, we require a copy of your insurance card, mailing address, and payment of
your deductible and/or co-pay at the time of service. Failure to provide this information
or present without a referral (if applicable) may result in your appointment being
rescheduled or pay in full at the time of service. It is your responsibility to notify our
office of any change of insurance coverage or change of primary care physician. We
will file claims for office visits and related procedures only if we are members of your
insurance plan.
CONTINUED ON OTHER SIDE
Precision Diagnostics
Annapolis, MD Office
2002 Medical Parkway, Suite 430
Annapolis, MD 21401
(410) 266-2700 • fax (410) 268-1862
•
Personalized Care
Glen Burnie, MD Office
331 Oak Manor Drive, Suite 102
Glen Burnie, MD 21061
(410) 761-0030 • fax (410) 761-4895
•
Pain Relief Solutions
Prince Frederick, MD Office
130 Hospital Road, Suite 101
Prince Frederick, MD 20678
(410) 535-1108 • fax (410) 535-4088
MOTOR VEHICLE ACCIDENT: This office does not bill a third party, therefore the
patient is required to use their individual PIP coverage. All available PIP benefits will be
utilized first. When PIP becomes exhausted we will bill your health insurance. For this
reason you must provide us with your health insurance information. If your health
insurance requires a referral, you will need to bring referrals to all appointments while
using PIP, as referrals cannot be backdated. This office does not wait for settlement of
any services rendered and you will be asked to sign a financial agreement making you
aware of your financial responsibility.
WORKERS COMPENSATION POLICY: Your Workers’ Compensation Adjuster
must authorize each visit before you see a physician. Workers’ Compensation patients’
must also provide our office with their health insurance prior to the first visit. The health
insurance carrier will be billed only in the event that the W/C carrier contest or denies
your claim. The patient will be responsible for any remaining balance after the health
insurance carrier has paid.
PHONE CALLS: The doctors will be happy to return your calls regarding simple
medical questions. If the doctor you normally see is not available, your message may be
given to one of the other providers. Please understand the doctors are busy during office
hours and may not return your call immediately.
MEDICATION / NARCOTICS POLICY: Pain medications are to be prescribed only
by a single physician. You will be asked to sign an agreement stating that you will not
attempt to get pain medication from any other health care provider while you are under
the care of this practice. No lost or stolen prescription medications will be replaced.
You may be subject to periodic lab testing at your healthcare provider’s discretion
including urine drug screening.
PRESCRIPTION: Requests for prescription refills should be called directly to your
pharmacy. The pharmacy will then fax the request to our office. Prescription requests
require 24-48 hours and are not considered an emergency. Due to HIPPA, only the
patient can pick up narcotic prescriptions. An ID and signature will be required.
Narcotic prescriptions cannot be called in or mailed.
FORMS / MEDICAL RECORDS: Please be advised that there is a fee for filling out
forms and/or copying of medical records.
Name: _________________________________________ Chart# _______________ Date of Visit ______________
William Tham, M.D., Susan Zimmerman, M.D., Thomas Lee, M.D., Joseph V. Ferraro, M.D., Robin Medic M.D., Sophia Leonard-Burns,
P.A.-C, Karen J. Scott, P.A.-C, Caryn F. Calka, P.A.-C, Amy Fernandez, P.A.-C, David Brian Abell, P.A.-C
2002 Medical Parkway, Suite 430, Annapolis, MD 21401 (410) 266-2700
331 Oak Manor Drive, Suite 102, Glen Burnie, MD 21061 (410) 761-0030
130 Hospital Road, Suite 101, Prince Frederick, MD 20678 (410) 535-1108
Who referred you? _______________________________Family Doctor __________________________________
Where is your pain?
Age __________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
When did your problem start? _______________
Is this from a car accident?
yes
no If yes, give date of accident
Is this a work injury?
yes
no If yes, give date of accident
/
/
/
/
How bad is your pain right now?
How about when it flares up?
No pain 0—2—3—4—5—6—7—8—9—10 severe pain
No pain 0—2—3—4—5—6—7—8—9—10 severe pain
How often do you get flare ups?
______________________________________________________________
How would you describe your pain?
Burning
Stabbing
Throbbing
Aching
Pins & Needles
Cramping
Constant
Intermittent
Other __________________
Bending
Lifting- ______lbs
Push/pulling
Laying down
Coughing and Sneezing
Driving
Squatting
Other __________________
What makes it worse?
Sitting
Standing
Walking
Climbing
What makes it better?
______________________________________________________________________________________________
______________________________________________________________________________________________
Do you have any weakness?
numbness?
yes
yes
no
no
where?
where?
__________________________________________
__________________________________________
Please fill out other side
Physician initials/date ____________________
(CONTINUED ON BACK)
Name: _________________________________________________
Chart# ____________________
Leave this box blank
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
What kinds of doctors have you seen for this problem?
Orthopedics
Neurosurgery
Neurology
Family Doctor
Chiropractor
Pain management
Physiatry
________________________
________________________
What treatments have you had?
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
What diagnostic testing have you had?
When was it done?
When was it done?
Discogram
____________________
MRI
____________________
EMG
____________________
CT Scan
____________________
Blood Tests
____________________
Myelogram
____________________
X-rays
____________________
Bone Scan
____________________
Other: ______________________________________________________________________________________
Leave Blank (test results)
Physician initials/date ______________
Name: _________________________________________________
Chart# ____________________
What medications are you taking now, including medications for this pain?
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Are you allergic to any medications?
yes
no
What are they? __________________________________________________________________________________
______________________________________________________________________________________________
Do not write in this box. Your physician will fill this out.
Diagnosis
Osteoarthritis
Bursitis/Tendonitis
Acute Pain
Chronic Pain
Dysmenorrhea
Rheumatoid Arthritis
Other __________________________
Rational for Cox2 inhibitors: (circle)
* GI Bleeds / Peptic Ulcer / GERD
* On PPIs / Antacids / H2 Blockers / Coumadin
Steroids/Aspirin/Methotrexate/Plavix
Ticlid/Platelet Inhibitors
* Age over 60 / Chronic Smoker
* Demonstrate response to Cox2 Inhibitors
* Failed with 2 other NSAIDS
1. __________________________
2. __________________________
3. __________________________
Other pertinent patient history:
__________________________
__________________________
__________________________
__________________________
Have you had any of the following symptoms since the pain started?
Fevers, Chills or Night Sweats`
Severe Night Time Pain
Weight Loss
Chest Pain
Abdominal Pain
Coughing Up blood
Excessive Thirst
Bruise Easily
Headaches
Dizziness
Blurred Vision
Blood in Urine
Feet or Hand Swelling
Tremors
Rashes
Difficulty Walking
Fatigue
Cold Feet or Hands
Difficulty Swallowing
Shortness of Breath
Nausea, Vomiting or Diarrhea
Incontinence of Bowel or
Bladder
Ringing in Ears
Family History: (Have any members of your family had any of the following?)
Hypertension
Kidney Disease
Arthritis
Thyroid Disease
Please complete other side
Diabetes
Stomach Ulcers
Heart Disease
Lung Disease
Back or Neck Pain
Cancer
Stroke
Physician initials/date __________________________
(CONTINUED ON BACK)
Name: _________________________________________________
Chart# ____________________
What medical problems do you have?
Kidney Disease
High Blood Pressure
Irritable Bowel Disease
Liver Disease
Heart Disease
Diabetes
Thyroid Disease
Lung Disease
Ulcers / Reflux Disease
Asthma
Arthritis
Depression
Lyme Disease
Cancer
Other: __________________________________________________________________________________
Prior surgeries (include dates)
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Previous injuries including auto and work related accidents (include dates)
______________________________________________________________________________________________
______________________________________________________________________________________________
For Women:
Are you pregnant?
Do you have any problems with your menstrual cycles?
Social History:
single
divorced
separated
Are you working now?
yes
no
widowed
yes
yes
no
no
married
If no, when did you stop? __________ (year)
What is your occupation? ________________________________________________________________________
How long have you been at this job? __________ (years)
What are your job or activity requirements?
Heavy - lifting over 60 lbs frequently
Medium - lifting 30-50 lbs
Light - lifting 10-20 lbs
Sedentary - sit most of the time, very little heavy lifting
Do you smoke?
Have you had any past history of alcoholism?
Have you had any past history of drug abuse?
Have you had any current major life stress?
yes
yes
yes
yes
no (how much? __________)
no
no
no
Physician initials/date ______________________
Name_____________________________________
Unit #_______________
Mark the location of your pain
xxxxx
for sharp stabbing pain
ooooo
for dull aching pain
////////
for burning pain and numbness