EMERGENCY ROOM VISITS. I am allowed to receive pain medication in the emergency room, but it is a violation of the PSPC contract to receive narcotic medication to take home and it must be discussed with the on-call doctor prior to receiving medication. A violation includes any prescription and/or samples.
EMERGENCY ROOM VISITS. I am allowed to receive pain medication in the emergency room, but it is a violation of the AA Spine & Pain Clinic contract to receive narcotic medication to take home and it must be discussed with the on-call doctor prior to receiving medication. A violation includes any prescription and/or samples. Have you ever had any medical or legal problems with alcoholism, drug abuse (including marijuana), addiction or drug trafficking? If yes, please explain: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Have you used any illegal drugs (including marijuana) within the past six months? If yes, list the drugs you have used and when: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Have you used any prescription drugs for which you did not have a personal prescription within the past six months? If yes, please explain: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ I HAVE THOROUGHLY READ THIS AGREEMENT BEFORE RECEIVING TREATMENT AT A.A. SPINE & PAIN CLINIC I UNDERSTAND AND AGREE TO THE CONDITIONS OF CARE DESCRIBED ABOVE AND WILL COMPLY WITH THEM. ALL OF MY QUESTIONS ABOUT THE TERMS OF THIS AGREEMENT HAVE BEEN ANSWERED. I KNOW THAT FAILURE TO COMLPY WITH ANY OF THESE TERMS OF THIS AGREEMENT MAY RESULT IN IMMEDIATE TERMINATIONS OF SERVICE. Reviewed contract and answered all patient’s questions (MA): Date: _____________ Patient’s Signature: ___________________________________________Date
EMERGENCY ROOM VISITS. I am allowed to receive pain medication in the emergency room, but it is a violation of the AASPC contract to receive narcotic medication to take home and it must be discussed with the on-call doctor prior to receiving medication. A violation includes any prescription and/or samples.
EMERGENCY ROOM VISITS. I am allowed to receive pain medication in the emergency department or urgent care center, but it is a violation of the Alpine Pain Solutions patient agreement (contract) to receive narcotic medication to take home. The provider may address the issue with the on-call provider for Alpine Pain Solutions of Utah. I HAVE THOROUGHLY READ THIS AGREEMENT BEFORE RECEIVING TREATMENT AT ALPINE PAIN SOLUTIONS OF UTAH AND I UNDERSTAND AND AGREE TO THE CONDITIONS OF CARE DESCRIBED ABOVE AND WILL COMPLY WITH THEM. ALL OF MY QUESTIONS ABOUT THE TERMS OF THIS AGREEMENT HAVE BEEN ANSWERED. I KNOW THAT FAILURE TO COMPLY WITH ANY OF THE TERMS OF THIS AGREEMENT MAY RESULT IN IMMEDIATE DISMISSAL AND TERMINATION OF SERVICE. Reviewed contract and answered all patient’s questions (MA):_ Date:___/ _/ Patient’s Signature: _ _ _ _ _ Date:___/ _/
EMERGENCY ROOM VISITS. I am allowed to receive pain medication in the emergency room, but it is a violation of the A.A. Pain Clinic contract to receive narcotic medication to take home and must be discussed with the on-call doctor prior to receiving medication. A violation includes any prescription and/or samples. Have you ever had any medical or legal problems with alcoholism, drug abuse (including marijuana), addiction or drug trafficking? If yes, please explain: Have you used any illegal drugs (including marijuana) within the past six months? If yes, list the drugs you have used and when: Have you used any prescription drugs for which you did not have a personal prescription within the past six months? If yes, please explain: I HAVE THOROUGHLY READ THIS AGREEMENT BEFORE RECEIVING TREATMENT AT A.A. PAIN CLINIC, INC. I UNDERSTAND AND AGREE TO THE CONDITIONS OF CARE DESCRIBED ABOVE AND WILL COMPLY WITH THEM. ALL OF MY QUESTIONS ABOUT THE TERMS OF THIS AGREEMENT HAVE BEEN ANSWERED. I KNOW THAT FAILURE TO COMLPY WITH ANY OF THESE TERMS OF THIS AGREEMENT MAY RESULT IN IMMEDIATE TERMINATIONS OF SERVICE. Reviewed contract and answered all patients’ questions (MA): Date: Patients’ Signature: Date:
