NEW PATIENT PACKET

Texas Pain Partners PLLC enforces a Zero Tolerance Policy to maintain a safe and respectful environment.

Purpose:

To emphasize our commitment to providing a safe, respectful, and supporting environment for our patients and their visitors within the Texas Pain Partners PLLC, we have created standards of expected behavior.

We expect everyone to:

• Treat all TPP staff, doctors, other patients, and visitors with courtesy and respect.
• Communicate in a calm and cooperative manner.
• Maintain an alcohol, illegal substance, and weapon free premises.
• Refrain from using abusive, threatening or violent language or behavior.

We have a zero-tolerance approach to any form of:

1. Abusive Language: Including yelling, swearing or discriminatory remarks.
2. Threatening Behavior: Such as intimidation, bullying or verbal threats.
3. Violence: Any physical aggression, including throwing objects or assault.
4. Harassment: Sexual, racial, or any other form of harassment.
5. Damage or theft to Property: Intentional damage to practice property or personal belongings of others.
6. Smoking, drinking alcohol, vaping, or substance abuse on the premises
7. Weapons-possession on the premises is strictly prohibited.
8. Discussing medical practice staff, reception staff, management and/or contracting doctors on social media platforms
9. Taking videos or photos of medical practice staff, reception staff, management and/or contracting doctors or the practice setting without permission from the practice

Expected Behavior

Patients and visitors are expected to:

• Cooperate with medical practice staff, reception staff, management and/or contracting doctors and follow reasonable instructions.
• Respect the privacy, dignity and diversity of others.
• Avoid disrupting the care or comfort of other patients.
• Refrain from bringing prohibited items (e.g., weapons, drugs, or alcohol) onto the premises.

I acknowledge and understand the Zero Tolerance Policy as stated above. 

This agreement is made between you, the patient, and Texas Pain Partners to ensure safe, responsible, and effective use of controlled substances, including opioids, as part of a comprehensive pain management program. The goal is to improve function and quality of life while minimizing the risk of medication(s) misuse, diversion, and addiction. Failure to comply may result in termination of the patient-provider relationship through Texas Pain Partners and possible notification to Federal, State, or Local Law Enforcement authorities if a crime is believed to have been committed.

Consent to Treatment and/or Drug Therapy: By initialing, I am certifying that I understand and agree:

Prescription Policy and Opioid Agreement: By initialing, I am certifying that I understand and agree:

I understand that my opioid medication(s) may be discontinued if...

I agree that I have had ample opportunity to ask any questions regarding informed consent, prescription policy and my opioid contract with my Texas Pain Partners provider to my satisfaction. I have read and understand the Informed Consent, Prescription Policy, and Opioid Agreement. I agree to the terms and conditions stated above and I authorize:

Texas Pain Partners and its medical staff to collect and test urine and/or other biological samples to monitor my medication usage.

My Pharmacy of Record to release any and all patient information to Texas Pain Partners staff for the purpose of medication(s) compliance and my continued patient care.

Any past, present, or future medical treatment providers to release my personal medical information and patient medical records, at the request of Texas Pain Partners. I further authorize the medical treatment provider to discuss my medical treatment and/or medical care with Texas Pain Partners upon their request.

I have read and understand this Controlled Substance Agreement. I agree to the terms and conditions stated above.

Purpose:

To ensure safe, effective, and compliant management of medications—particularly controlled substances TexasPain Partners PLLC requires all patients prescribed such medications to participate in routine drug screening. This authorization complies with Texas Medical Board Rule §170.3 and federal guidance regarding pain management protocols.

Authorization and Consent:

I hereby authorize Texas Pain Partners PLLC and its medical staff to collect and test urine and/or other biological samples to monitor my medication usage. I understand that these screenings are required to:

• Ensure compliance with prescribed therapy
• Identify potential misuse, diversion, or abuse of substances
• Comply with state and federal guidelines for controlled substances

Frequency and Conditions:

I acknowledge that drug screening is required as a condition of treatment if I am prescribed controlled substances. I agree to submit to the following without prior notice:

• Initial drug screen at the time of first narcotic prescription
• Random or scheduled screenings every three (3) months thereafter
• Additional tests if misuse or diversion is suspected

Results and Confidentiality:

I understand that the results of any drug screen will be documented in my medical record and may be shared with referring providers, pharmacies, or legal entities as permitted or required by law. I understand that refusal to submit to testing, tampering with samples, or non-compliance may result in modification or discontinuation of treatment, or dismissal from the practice.

Patient Acknowledgment and Signature:

I have read and understand the above information. I have had the opportunity to ask questions, and all my questions have been answered. I voluntarily agree to comply with the drug screening policy of Texas Pain Partners PLLC.

Texas Pain Partners PLLC (TPP) offers telemedicine services to provide convenient and timely access to medical care. Telemedicine involves the use of electronic communications to enable healthcare services at a distance, including video conferencing and secure messaging.

Telemedicine Services

By signing this form, I consent to engage in telemedicine with TPP. I understand that:

• Telemedicine allows me to consult with a provider remotely using video or audio technology.
• My medical information will be protected using secure, HIPAA-compliant technology.
• I may decline or withdraw consent at any time without affecting my right to future care or treatment.
• There are potential risks, including interruptions, unauthorized access, or technical failures, which may affect the quality of care.
• My provider may determine that an in-person visit is necessary for further evaluation or treatment.

Technology Requirements

I understand that I must have access to a device with a camera, microphone, and internet connection to participate in telemedicine visits.

I have read and understand the information provided above regarding telemedicine. I have had the opportunity to ask questions, and all my questions have been answered.

Texas Pain Partners PLLC (TPP) is committed to providing clear communication and quality care to all patients. Interpreter services are available at no cost to patients who prefer to communicate in a language other than English or who require sign language assistance.

Patient Acknowledgment

Please review and complete the section below to inform us of your communication preferences:

I understand that I have the right to receive interpreter services when needed. If I require services at any time during my care with Texas Pain Partners, I will inform the staff.

At Texas Pain Partners PLLC (TPP), we are committed to treating our patients with dignity, respect, and compassion. We believe that informed patients who understand their rights and responsibilities can actively participate in their healthcare.

Patient Rights

• To receive considerate, respectful, and compassionate care regardless of race, ethnicity, age, gender, religion, sexual orientation, or disability.
• To be informed about your diagnosis, treatment, and prognosis in a way that you can understand.
• To ask questions and receive clear answers regarding your care.
• To accept or refuse treatment to the extent permitted by law and to be informed of the medical consequences.
• To privacy and confidentiality concerning your medical care.
• To review and obtain copies of your medical records, subject to legal and policy guidelines.
• To receive care in a safe environment free from all forms of abuse or harassment.
• To voice concerns or complaints without fear of retaliation and to have those concerns addressed promptly.

Patient Responsibilities

• To provide accurate and complete information about your health history and current condition.
• To follow the treatment plan recommended by your provider and to communicate if you do not understand or cannot follow the plan.
• To respect clinic staff, providers, other patients, and visitors.
• To arrive on time for scheduled appointments and provide advance notice for cancellations.
• To fulfill financial obligations related to your care in a timely manner.
• To inform us of any changes in your insurance, contact information, or health status.

I acknowledge that I have read and understand the Patient Rights and Responsibilities outlined above. I agree to uphold my responsibilities and understand my rights as a patient of Texas Pain Partners.

I understand that these documents may be amended from time to time, and that I may request a current version from TPP at any time. I also understand that refusal to sign any of these forms may impact the services that can be provided to me.

This document outlines the financial and administrative policies of Texas Pain Partners PLLC (TPP). By signing below, you acknowledge that you have read, understand, and agree to the terms outlined.

Insurance & Billing

• I understand that it is my responsibility to provide accurate and current insurance information at the time of service.
• I authorize TPP to bill my insurance carrier directly for services provided.
• I am responsible for all co-pays, deductibles, coinsurance, and any services not covered by insurance.
• If my insurance company denies payment, I understand that I am responsible for the full amount.

Self‐Pay Patients

• I understand that if I do not have insurance or choose not to use it, I am considered a self-pay patient.
• Payment is due in full at the time services are rendered unless a payment plan is arranged in advance.
• Payment plan options may vary and must be approved by the billing department.

Appointment Cancellation & No‐Show Policy

• I agree to provide at least 24 hours’ notice if I am unable to attend a scheduled appointment.
• I understand that failure to cancel or reschedule in advance may result in a no-show fee.
• The no-show fee is $100 for missed office visits and $200 for missed procedures.

Medical Records Requests

• Medical records are available upon request and may be subject to fees as outlined in the Texas Administrative Code.
• Records may take up to 15 business days to process.
• Authorization of electronic communication

I have read and understand the financial agreement and office policies described above. I agree to comply with these terms.

Patient Information

Beneficiary Designation

Scope of Authorization

I understand that this authorization:

⚊ Permits staff to communicate only non‑sensitive information (e.g. medication reminders, basic treatment status).

⚊ Does NOT allow release of full medical records, sensitive health details, or billing/insurance information.

⚊ May be revoked at any time by submitting a written notice to Texas Pain Partners.

Effective Period:

Acknowledgment & Signature

I affirm that I am the patient (or legal guardian) and authorize Texas Pain Partners to share the designated information with the named beneficiary, as outlined above.

Revocation of Authorization

To revoke this authorization, I must submit a written notice to Texas Pain Partners at the address or email on file. Revocation will not affect disclosures made before TPP received my revocation.

Consent to Treatment

I voluntarily consent to evaluation and treatment by the healthcare providers at Texas Pain Partners PLLC. I understand that my treatment may involve diagnostic procedures, physical examinations, and other medical treatments deemed necessary by my provider.

I understand that I have the right to ask questions and receive explanations about my treatment before procedures are performed. I also understand that I may withdraw this consent at any time by notifying Texas Pain Partners in writing.

Acknowledgment of Receipt of HIPPA Notice of Privacy Practices Form

I acknowledge that I have received a copy of the Texas Pain Partners PLLC Notice of Privacy Practices. I understand that this Notice describes how my medical information may be used and disclosed, and how I can access this information.

I understand that Texas Pain Partners may revise its Notice of Privacy Practices at any time and that I may obtain a revised copy by contacting the office or visiting the website at www.txpainpartners.com.

Photograph

I hereby authorize Texas Pain Partners PLLC, Inc., to take my photograph for inclusion in my medical chart retained by the clinic. I understand this photograph is solely for the purpose of identification and familiarization by the office staff and clinic physician(s).

Private Insurance Authorization for Assignment of Benefits and Information Release:

Medicare Lifetime Signature on File

I request that payment of authorized Medicare benefits be made on my behalf to Texas Pain Partners PLLC for any services furnished to me by the physician. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits payable for related services.

Medication History Consent Form

Texas Pain Partners PLLC, P.A has adopted an electronic medical record system in order to improve the quality of our services. This system also allows us to collect and review your "medication history." A medication history is a list of all prescription medicines that we or other doctors have prescribed for you. This list is collected from a variety of sources including: your pharmacy, your health insurer and other healthcare providers. An accurate medication history is very important in helping us treat you properly and avoiding potentially dangerous drug interactions.

By signing this consent form you give us permission to collect, give your pharmacy and your health plan permission to disclose information about your prescriptions that have been filled at any pharmacy or covered by any health insurance plan This includes prescription medicines to treat AIDS/HIV and medicines used to treat mental health conditions such as depression. This information will become part of your medical record.

This medication history is a useful guide, but it may not be completely accurate. Some pharmacies do not make medication histories available to us and the medication history from your health plan might not include medication that you purchased without using your health insurance. Your medication history might not include over the counter medicine, supplements or herbal remedies. It is still very important for us to take the time to discuss everything you are taking and for you to point out and report any errors in your medication history to our staff.

PATIENT ACKNOWLEDGEMENT

give permission for Texas Pain Partners PLLC, Inc., to obtain my medication history from my pharmacy, my health plans and other healthcare providers.