New Patient Packet

PATIENT HEALTH QUESTIONNAIRE-9 (PHQ-9)

Over the last 2 weeks, how often have you been bothered by any of the following problems?

POLICIES, ASSIGNMENT, AND AUTHORIZATION OF BENEFITS I certify all the information I have supplied to this office is true and accurate to the best of my knowledge. I will notify Med One Medical Group of any changes in my insurance status or any other pertinent information. I understand and agree that (regardless of my insurance status): I am ultimately responsible for the balance of my account for any services rendered by Med One Medical Group. If the bill remains unpaid and no satisfactory arrangements have been made and executed then the account will be assigned for collections including collection and attorney fees, if applicable. I understand and agree that I am personally responsible for any bills or fees incurred by failing to give 24 hours notice to cancel or reschedule an appointment. I hereby admit that I do NOT have Medicare nor Medicaid as my primary nor secondary insurance. If I have Medicare, no claims from this office will be filed to my insurance. I will be seen by this office on a self-pay basis only. If I have Medicaid, I can NOT be seen nor treated in this office. I irrevocably assign to you, my insurance company, authorize, and direct you to pay Med One Medical Group the proceeds and such sums as may be due and owing to Med One Medical Group for professional services rendered to me for medical reasons. I understand that this in no way relieves me of my primary obligation to pay for such services and that the signing of this form does not prohibit customary billing by the doctor. All bills are expected to be paid promptly in the usual manner. I hereby instruct and direct you, my insurance company, to pay by check made out and mailed to: Med One Medical Group 7019 Harps Mill Rd., Ste. 200 Raleigh, NC 27615 This is a DIRECT assignment of my rights and benefits under this policy. Payment for such amounts to the above providers in whole or part shall constitute payment as if said payment were made directly to me. A photocopy of this Assignment shall be considered as effective and valid as the original. I also authorize the release of any information pertinent to my case to my insurance company. adjuster, or attorney involved in this case. I authorize Med One Medical Group to initiate a complaint to the Insurance Commissioner for any reason on my behalf.

Med One Drug Testing Protocol Objective: The staff of Med One Clinic is committed to providing effective treatment to patient’s suffering from disorders requiring treatment with controlled substances. This treatment includes, but is not limited to, the use of opioid analgesics, narcotic pain medications, benzodiazepines, amphetamines and stimulants. Due to the epidemic of Americans abusing prescription medications, and in order to monitor and account for the patient’s compliance in taking their medication as prescribed, all patient’s will be subject to oral or urine drug screening. Circumstance for Drug Screening: New Patients- Oral or Urine Drug Screening: All prospective patients who, if accepted, will be prescribed any controlled substance medication must submit a saliva or urine sample for drug testing prior to receiving prescription. Existing Patients- Oral or Urine Drug Screening: All existing patients who are currently taking a controlled substance, needing refills, will be required to submit a saliva or urine sample for drug screening prior to next refill of medication. All existing patients who are requiring a new start of a controlled prescription will be required to submit a saliva or urine sample for drug testing prior to receiving prescription. Routine Screening: After first initial saliva or urine drug screen, all patients on continually refilled controlled substances will be required to participate in drug screening intermittently, and up to twice yearly, at the practice. If a patient is unable to comply with routine drug screening, the prescription will not be refilled until screening occurs. Pregnancy Testing: All women of childbearing age prescribed a controlled substance will be required to be screened with a urine pregnancy test. This includes a urine HCG in office prior to any new start of a controlled substance, as well as routine screening every 6 months with urine HCG if prescription is continually prescribed. If the results are positive, patient will be tapered off medication if harmful to pregnancy, and no longer will be prescribed medication by Med One while pregnant or breast feeding. To resume medication treatment with clinic after pregnancy, they will need clearance from OBGYN and/or Medically Certified Midwife stating they are no longer breastfeeding. At that time, she will also be required to re-submit an oral or urine drug screening test with Med One. Under all patient circumstances, it will be the provider’s discretion that will determine whether oral, urine, or both will be required as samples for drug screening. Drug Testing based on Risk Assessment (For Cause) The provider reserves the right to obtain a random drug screen during an appointment if there is reason to suspect non-compliance with medication. Any patient will be called to come to the clinic to submit a drug screen if adequate cause exists. The following justifies adequate cause: a) A call has been placed to the clinic from another prescribing office or pharmacist that patient is abusing or diverting his/hers controlled prescription b) Any patient who displays behavior, signs or symptoms consistent with withdrawal. c) Any patient who displays behavior indicating a loss of their normal mental or physical faculties. Drug Testing based on Prescription Drug Monitoring Program (PDMP) Documentation The clinic staff may query the name of any patient who is receiving a controlled substance, from a clinician at our clinic, through our state PDMP. If information is found indicating that one of our patients appears to be obtaining controlled medications from another practitioner, during a period of time that would run concurrent with the prescription that the patient received from this clinic, our staff shall verify this information with the pharmacy and/or clinician identified on the PDMP report. If this report is found to be true, any controlled prescriptions that were prescribed from clinicians at Med One will no longer be refilled. Pt will reserve rights to continue medical care at the clinic, but will no longer have privileges to be prescribed controlled medications from Med One. Refusing or Cannot Provide Saliva or Urine Sample for Drug Testing: Any patient who refuses to provide a saliva or urine sample for drug testing shall not receive a prescription for a controlled substance. Drug Screening Procedures: Employees are responsible for: Requesting samples from patients Receiving samples from patients Complete and submit all documentation required by the clinic and drug testing laboratory Place samples in a secured area Maintain chain of custody in all saliva and urine samples Package and distribute saliva and urine samples to laboratory Receive all laboratory confirmations Provide clinicians with laboratory results Note: Results of oral drug screen can take up to 72 hours before clinic receives them. They are not known at the time of appointment. Use of Saliva or Urine Drug Screening Results New Patients: All new patients requiring a prescription for a controlled substance at time of appointment will submit an oral or urine drug screen, as well as be screened by the PDMP. If deemed a candidate for therapy with a controlled substance, the patient will receive up to a 7 day prescription for controlled substance. If the patient is positive for a controlled medication not prescribed to patient, or illegal substance at the time of drug screening, the patient will no longer receive controlled substances from Med One at that time. If a patient states that he/she is currently prescribed a daily controlled medication, and it does not appear positive in his/her drug screen, they will no longer be able to be prescribed controlled medications at Med One. Existing Patients: All existing patients currently prescribed a controlled substance will be screened with oral or urine drug test intermittently, up to twice yearly after initial test. If a patient fails to show up for a screening at least twice in a Calendar year, the patient will not receive a refill of medication until drug screen is completed in office. If the patient is positive for a controlled medication not prescribed to patient, or illegal substance at the time of drug screening, the patient will no longer receive controlled substances from Med One at that time. If a patient is prescribed a daily controlled medication, and the prescribed medications do not show positive in drug screen, they will no longer be able to be prescribed controlled medications at Med One. By signing this document, I have reviewed and agree to the drug screening protocol and standards set in place by Med One.