History and Physical

PLEASE COMPLETE THIS FORM BEFORE YOUR VISIT. USE BLUE/BLACK INK ONLY

NAME: ____________________________________________ AGE: _________

SEX: M F REFFERED BY Dr.______________________________________

I. Chief Complaint (CC) On the diagrams below, shade the area(s) where you feel pain. Mark the areas which hurt the most with an “X”.

II. Check the word(s) which describes your pain.

Burning Pulling Sensitive Stabbing Aching Hot Poker Tiring Heavy Stinging Sharp Penetrating Electric Throbbing Jabbing Gnawing Numbing Itching Shooting Pins & Needles

III. When does your pain occur?

Constantly Occasionally Without warningWith stress At the same time each day When I move a certain way

IV. History of Present Illness (HPI)

When did the pain begin?

What do you feel caused the pain?

Patients please do not write here: Doctor’s Note (optional)

INTENTIONALLY LEFT BLANK NO bladder or bowel incontinence NO saddle anesthesia NO focal weakness

GPS Score: __________

Page 1Rev: 21 AUG 2019

History and Physical

Instructions: For each question, please indicate your level of pain by circling a number from 0 to 10.

Global Pain Scale

YOUR PAIN:

My current pain is ............................................. No pain: 0 1 2 3 4 5 6 7 8 9 10 :Extreme pain

During the past week, the best my pain has been is ............................... No pain: 0 1 2 3 4 5 6 7 8 9 10 :Extreme pain

During the past week, the worst my pain has been is ............................. No pain: 0 1 2 3 4 5 6 7 8 9 10 :Extreme pain

During the past week, my average pain has been ................................... No pain: 0 1 2 3 4 5 6 7 8 9 10 :Extreme pain

During the past 3 months, my average pain has been ................................... No pain: 0 1 2 3 4 5 6 7 8 9 10 :Extreme pain

YOUR FEELINGS: During the past week I have felt:

Afraid ................................................ Strongly Disagree: 0 1 2 3 4 5 6 7 8 9 10 :Strongly Agree

Depressed .......................................... Strongly Disagree: 0 1 2 3 4 5 6 7 8 9 10 :Strongly Agree

Tired .................................................. Strongly Disagree: 0 1 2 3 4 5 6 7 8 9 10 :Strongly Agree

Anxious ............................................. Strongly Disagree: 0 1 2 3 4 5 6 7 8 9 10 :Strongly Agree

Stressed ............................................. Strongly Disagree: 0 1 2 3 4 5 6 7 8 9 10 :Strongly Agree YOUR CLINICAL OUTCOMES: During the past week:

I had trouble sleeping ........................ Strongly Disagree: 0 1 2 3 4 5 6 7 8 9 10 :Strongly Agree

I had trouble feeling comfortable ...... Strongly Disagree: 0 1 2 3 4 5 6 7 8 9 10 :Strongly Agree

I was less independent ....................... Strongly Disagree: 0 1 2 3 4 5 6 7 8 9 10 :Strongly Agree

I was unable to work (or perform normal tasks) ................. Strongly Disagree: 0 1 2 3 4 5 6 7 8 9 10 :Strongly Agree

I needed to take more medication….. Strongly Disagree: 0 1 2 3 4 5 6 7 8 9 10 :Strongly Agree YOUR ACTIVITIES: During the past week I was NOT able to:

Go to the store ................................... Strongly Disagree: 0 1 2 3 4 5 6 7 8 9 10 :Strongly Agree

Do chores in my home ...................... Strongly Disagree: 0 1 2 3 4 5 6 7 8 9 10 :Strongly Agree

Enjoy my friends and family ............. Strongly Disagree: 0 1 2 3 4 5 6 7 8 9 10 :Strongly Agree

Exercise (including walking) ............ Strongly Disagree: 0 1 2 3 4 5 6 7 8 9 10 :Strongly Agree Participate in my favorite hobbies .... Strongly Disagree: 0 1 2 3 4 5 6 7 8 9 10 :Strongly Agree

Scoring: Add up the total score and divide by 2. Each subset is worth 25 points. The maximum total score is 100.

Page 2

Rev: 21 AUG 2019

NAME: ____________________________________________

History and Physical

Do you have: Numbness (location) _____________________________________________________________________

Tingling (location) _____________________________________________________________________

Weakness (location) _____________________________________________________________________

What makes your pain worse? (Please CHECK) coughing sneezing straining walking sitting lying down bending forward bending backward cold heat Other: ___________________________

Previous Treatments (mark the box if you have tried):

Chiropracter Physical therapy Accupuncture Massage

Injections or procedures (please list type of injection or procedure below)

Procedure Month / Year Body Location Physician

Medicines previously tried for pain (list each medicine, include over the counter medications):

____________________________________________________________________________________________________

Did any of the above treatments help your pain? _____________________________________________________________

What other physicians have seen you for this pain (please list below)? Physician Specialty Treatment Please list your primary care physicians and specialists (cardiology, neurosurgery, neurology, pulmonolory, rheumatology) Physician Specialty

Patients please do not write here: Doctor’s Note (optional) INTENTIONALLY LEFT BLANK

What makes your pain better? (Please CHECK) walking sitting lying down cold heat bending forward bending backward Other:____________________________________

Page 3

Rev: 21 AUG 2019

NAME: ____________________________________________

History and Physical V. Review of Systems (ROS)

Please CHECK all conditions YOU HAVE NOW. CIRCLE “Negative” if you have no complaints for that body system. General Questions Heart, Blood & Circulation Kidneys & Bladder Muscles, Bones & Joints Negative Negative Negative Negative Weight loss Chest pain Bloody urine Neck pain Weight gain Leg cramps / pain Dribbling after urination Back pain Fevers Ankle swelling Painful urination Gout Change in sleep patterns Shortness of breath at rest Poor bladder control Tendonitis Change in activity level Cold hands or feet Urinating frequently Swollen areas Brain & Nerves Heart defects Difficult starting urine Joint swelling Negative Heart murmurs Weak flow Morning stiffness Headaches Heart palpitations Ears, Eyes, Nose & Muscle aches Head injuries Varicose veins Throat Rheumatism Fainting spells, dizziness Blood clots in legs / lungs Negative Joint aches Blackouts or fainting Anemia Glaucoma Bursitis Memory Loss Nasal Polyps Skin Tremors Digestive System Allergy Negative Paralysis Negative Hoarseness Rashes Psychological Diarrhea Double vision Psoriasis Negative Constipation Eye problems Dry Skin Depression Nausea Hearing Loss Lumps Anxiety and worry Vomiting Ear discharge / pain Increased nail growth Emotional outburst Heartburn Ringing in your ears Increased hair growth Difficulty thinking Abdominal pain Sinus infections Skin color changes Racing Thoughts Problems swallowing Lungs & Breathing Shiny skin Difficulty falling asleep Vomiting blood Negative Females Only Hearing voices Black tarry stools Wheezing Negative Repetitive Habits Bloody bowel movements Prolonged cough PMS Male & Female Coughing up blood Endometriosis Negative Emphysema Heavy periods Painful sexual intercourse Shortness of breath Loss of sexual interest Lung infections VI. Past History (Medical, Surgical, Family, Social, Hospitalizations) Past Medical History: Please CHECK those that apply TO YOU (not your family) and describe if indicated.

Peripheral Neuropathy Easy Bruising/Bleeding Heart Attacks Heart Failure High Blood Pressure

Poor Circulation Irregular Heart Beat Arthritis Thyroid Disease Diabetes

High Cholesterol Stomach Ulcers Hepatitis Hiatal Hernia Reflux / GERD

Irritable Bowel Overweight Skin Disease Sleep Apnea AIDS or HIV +

Epilepsy/Seizures Depression/Anxiety Panic Attacks Bipolar Disorder Compulsive Disorder

Stroke(s)

SIDE: Rt Lt

Kidney Disease TYPE:

Spinal Disease TYPE:

Lung Disease TYPE:

Cancer

TYPE:

Osteoporosis Other:

Patients please do not write here: Doctor’s Note (optional) INTENTIONALLY LEFT BLANK

Page 4

Rev: 21 AUG 2019

NAME: ____________________________________________

History and Physical Past Surgical / Hospital History

Operation or Illness Month / Year Operation or Illness Month / Year

1) 6) 2) 7) 3) 8) 4) 9) 5) 10) Medication LIST:

Medication and Dose Doctor Medication and Dose Doctor 1) 6) 2) 7) 3) 8) 4) 9) 5) 10) Are you on a blood thinner? Yes No If you are, please list it here____________________________________________________

Allergies: Please list any drug, food, contact or environmental substances to which you have had an allergic or bad reaction.

Describe what happened: ____________________________________________________________________________

Family History Please check any FAMILY illnesses. Only include your parents and siblings (ie. sisters / brothers)

Illness Relationship Illness Relationship Illness Relationship Stroke Mom Dad Sib Panic Attacks Mom Dad Sib High cholesterol Mom Dad Sib

Epilepsy Mom Dad Sib Thyroid disease Mom Dad Sib High blood pressure Mom Dad Sib

Obesity Mom Dad Sib Back problems Mom Dad Sib Depression Mom Dad Sib

Cancer Mom Dad Sib Kidney disease Mom Dad Sib Bipolar / OCD Mom Dad Sib

Diabetes Mom Dad Sib Heart disease Mom Dad Sib Lung disease Mom Dad Sib

Other: OPIOID RISK TOOL: Please mark each box that applies Female Male 1. Does anyone in your family have history of substance abuse? Alcohol abuse Illegal drugs (including marijuana) Prescription drugs

1 3 2 3 4 4

2. Do you have a personal History of substance abuse? Alcohol abuse Illegal drugs (including marijuana) Prescription drugs

3 3 4 4 5 5

3. Age – Mark box if you are between 16 and 45 years of age 1 1 4. Do you have history of preadolescent sexual abuse? 3 0

5. Do you have history of any of the following psychological diseases? A) Attention deficit disorder (ADD), Bipolar disorder, Schizophrenia, or Obsessive compulsive disorder (OCD) B) Depression

2 2 1 1

TOTAL ____ ____

Page 5

Rev: 21 AUG 2019

NAME: ____________________________________________

History and Physical Social History

WHERE DO YOU WORK? Full time Part time Unemployed Disabled Retired

Marital / Alternative Status: Married Common Law Life Partner Widowed Single Separated Divorced Other: How many children do you have? males Females Number of marriages: Do all your children have the same biological parents? YES NO If no, how many partners have you had children

with? Do you care for children from another marriage? YES NO males females

Do you exercise regularly? YES NO What type? How often?

Do you smoke? YES NO I stopped smoking in: How much/how often? Packs/day Doctor’s Note (please do not write here, optional)

Do you drink alcohol? YES NO If YES, how much and how often do you drink?

Drinks/day

Days/wk

If YES, what do you drink? Beer Wine Hard Liquor Have you ever used alcohol to control your pain? YES NO

Do you use illegal drugs? YES NO

If YES, how much and how often? Times/day

Days/wk

If YES, which drug do you use? Have you ever used illegal drugs to control your pain? YES NO

Has your pain ever stopped you from working? YES NO

If YES, please explain:

Do you feel the reason for your pain is work related? YES NO

Any recent history of depression or unusual stress? YES NO

If YES, please explain:

Are you suing anyone about your pain problem? YES NO

All historical information reviewed with patient by Physician. If YES, please explain:

VII. Old Records and Data: Please list any X-Rays or other Diagnostic Tests done recently

Month / Year Body Location Physician X-Ray (s): CT (Cat Scans): MRI: EMG / NCV (Nerve Test): OTHER TEST:

Page 6

Rev: 21 AUG 2019

NAME: ____________________________________________

GENERAL WAIVER OF LIABILITY

I, _____________________________________________________, fully understand Please Print Full Name

that it is the responsibility of the patient and/or guarantor to provide proper billing

information. I also understand that I will be fully responsible for office visits, x-rays,

diagnostic studies and surgery/procedures that are not covered by my insurance

company.

If my insurance company requires a referral, I understand that it is my responsibility

to provide my healthcare practitioner with that referral for proper billing. If my

practitioner does not receive a referral at the time of my appointment, I will be

responsible for payment for the office visit and treatment for all services rendered. It

will be my responsibility to file a claim with my insurance company for

reimbursement.

______________________________________________________________

Patient and/or Guarantor Date

_______________________________ _______________________

Witnessed by Date

Rev: 21 AUG 2019

Pain Management Agreement

The purpose of this Agreement is to prevent misunderstandings about certain medicines you will be

taking for pain management. This is to help both you and your healthcare practitioner to comply with

the law regarding controlled pharmaceuticals.

I understand that this Agreement is essential to the trust and confidence necessary in a healthcare

practitioner/patient relationship and that my practitioner undertakes to treat me based on this

Agreement.

I understand that the physicians of Space City Pain Specialists may perform procedures at some

hospitals but do not round at hospitals.

I understand that if I break this Agreement, my practitioner will stop prescribing these pain-control

medicines.

In this case, my practitioner will taper off the medicine over a period of several days, as necessary, to

avoid withdrawal symptoms. Also, a drug-dependence program may be recommended.

I will communicate fully with my practitioner about the character and intensity of my pain, the effect

of the pain on my daily life, and how well the medicine is helping relieve the pain.

I will not use any illegal controlled substances, including marijuana, cocaine, etc.

I will not share, sell or trade my medicine with anyone.

I will not attempt to obtain any controlled medicines, including opioid pain medicines, controlled

stimulants, or anti-anxiety medicines from any other practitioner without informing my practitioner. I

also understand that as of September 1, 2011 it is a felony to Doctor Shop in the State of Texas.

I will safeguard my pain medicine from loss or theft. Lost or stolen medicines will not be replaced.

I agree to use ______________________________________________________________ Pharmacy,

located at

_______________________________________________________________________,

Telephone # ________________________________, for filling prescriptions for all of my pain

medicine.

PAGE 1Rev: 21 AUG 2019

I authorize the healthcare practitioner and my pharmacy to cooperate fully with any city, state or

federal law enforcement agency, including this state’s Board of Pharmacy, in the investigation of any

possible misuse, sale or other diversion of my pain medicine. I authorize my healthcare practitioner to

provide a copy of this Agreement to my pharmacy. I agree to waive any applicable privilege or right

of privacy or confidentiality with respect to these authorizations.

I agree that I will submit to a blood or urine test if requested by my practitioner to determine my

compliance with my program of pain control medicine.

I agree that I will use my medicine at a rate no greater than the prescribed rate and that use of my

medicine at a greater rate will result in my being without medication for a period of time.

I will bring all unused pain medicine to every office visit.

I agree to follow these guidelines that have been fully explained to me. All of my questions and

concerns regarding treatment have been adequately answered. A copy of this document has been

given to me.

This agreement is entered into on this ___________________day of __________________20______.

Patient Name:______________________________________________________________________

Patient Signature: ___________________________________________________________________

Healthcare Practitioner Signature: ______________________________________________________

Witnessed by: ______________________________________________________________________

Pain Management Agreement

PAGE 2Rev: 21 AUG 2019

Patient Guidelines

OFFICE HOURS:

______ Office hours are from 9:00 AM to 5:00 PM Monday through Friday. All calls will be answered during these hours. Calls outside of these hours will be received at the office and answered the following business day. If a physician is needed in the event of an emergency, please go to the nearest emergency department.

CANCELLATIONS:

______ There will be a $35 charge for any office visit cancelled less than 24 hours in advance and a $50

charge for all procedures cancelled with less than 24 hours notice.

PRESCRIPTIONS:

______ All patients requiring controlled medications (narcotics, sedatives or relaxants) as a part of their

therapy will receive their prescriptions during physician clinic visits only. Controlled medications

will not be dispensed over the phone. All patients requiring long-term treatment with controlled

medications will have regular physician visits to monitor progress in treatment. During periods of

controlled medication trials, use of other controlled medications not obtained from this clinic is

prohibited. This will constitute a breach of your relationship with us and further therapy of this

nature may be discontinued. For specific patients, prescriptions of further controlled medications

may be contingent upon enrollment in a detoxification program. Medications for all other illnesses

not specifically related to your pain problem (example: diabetes, flu, etc.) may be prescribed by your

family or treating physician.

GOALS:

______ Chronic pain affects individuals in all aspects of their life. The suffering involved may not be

understood by family, friends or associates. While we wish we could alleviate all pain, this is often an

unrealistic goal. Our program is designed to help restore our patients to a more functional life and

reduce their level of pain through a multi-disciplinary and multi-therapeutic approach.

I have read the above patient guidelines for Space City Pain Specialists, L.L.P. and I understand these

guidelines.

Please write the above sentence in your own handwriting:

________________________________________________________________________________________

_______________________________________________________________________________________.

____________________________________________________________________________

Signature/Other Legally Responsible Person Sign Date

Rev: 21 AUG 2019

Consent for Treatment

Initials

_____ Consent for Treatment

I hereby, authorize and consent to medical treatment by Dr. ____________________________, his assistants

or his designees as is necessary in his judgment. I am aware that the practice of medicine is not an exact

science and I acknowledge that no guarantees have been made to me as to the result of treatment or

examinations.

_____ Assignment of Benefits

I hereby, authorize payment directly to Space City Pain Specialists, L.L.P. of all benefits otherwise payable to

me, but not to exceed the total charges for the services rendered.

_____ Authorization to Release Information

I authorize Space City Pain Specialists, L.L.P. to release any and all information contained in my complete

medical and billing record (including patient demographics) to:

1. My primary insurance company, and secondary insurance company if applicable or its

representatives.

2. Other designated persons or entities financially responsible for my care or treatment.

3. The Medicare program and their fiscal intermediaries, if applicable or otherwise required or

permitted by laws, regulations, and/or Federal or state agencies, as required or permitted by law

or regulations.

4. Any other Physicians, Hospitals, Surgery Centers, Imaging and Physical Therapy facilities that

Space City Pain Specialists, L.L.P. practitioners may refer you to.

5. Day-to-day healthcare operations of the practice (Communications sent to you or your designated

representative via email/text reminders/confirmations of appointments via online services).

6. I authorize Space City Pain Specialists, L.L.P. to communicate via email, text

reminders/confirmations of appointments via online services with another designated individual

approved by me. If approved by you, then please provide the authorized person’s information

below:

Authorized Person: ____________________________________Ph. #: ______________________________

Authorized Person’s Email Address: __________________________________________________________

____ Financial Responsibility

I understand that I am financially responsible to the Space City Pain Specialists, L.L.P. for all charges for the

services rendered to me. I hereby, promise to pay Space City Pain Specialists, L.L.P. for the services I

receive.

____ Copies

A photo static copy of this authorization is as valid as the original. It will remain in effect until I submit a

written request to revoke it.

My signature indicates I have read and understand all the preceding information.

Patient/Responsible Party Name: ____________________________________________________________

Rev: 21 AUG 2019

Witness: _________________________________________________ Date: ________________________

Signature: ________________________________________________ Date: ________________________

Medical Records Release Form

By signing this form, I authorize you to release confidential health information about me, by releasing

a copy of my medical records, or a summary or narrative of my protected health information. To the

person(s) or entity listed below.

Patient: ____________________________________________________________

Limitations on the information you may release subject to this Release Form are as follows:

______________________________________________________________________________

_________________________________________________________________________.

Release my protected health information to the following person(s)/entity:

Name: _______________________________________________________________________

Street: _______________________________________________________________________

City: ____________________________ State: ________________ Zip: ________________

The reasons or purposes for this release of information are as follows:

_____________________________________________________________________________

__________________________________________________________________________.

Patient Signature (or parent, guardian or legal representative):

______________________________________ Fax: ________________________

SS#: _________________________________ DOB: _______________________

Date: ________________________

I understand that you will provide this information within 15 days from receipt of request and

that a fee for preparing and furnishing this information may be charged according to rulings

set forth by the Texas State Board of Medical Examiners.

HIV/ AIDS: I consent to the release of any positive or negative test result for AIDS or HIV

infection, antibodies to AIDS or infection with any other causative agent of AIDS with the rest of

my medical records.

Initial: ________________________ Date: ______________________

Rev: 21 AUG 2019

Urine Testing Agreement

The Purpose of this agreement is to inform, for purposes of consent, the Drug Screening policy of Space

City Pain Specialists. As part of the Pain Management Agreement you sign as a patient of Space City

Pain Specialists, you agree to submit to urine testing when requested by your practitioner. This

agreement is required in order for you to remain compliant with your pain control program.

▶ All new patients are required to submit to a urine test

▶ All existing patients are subject to random urine tests

▶ Space City Pain Specialists is advised, by the Drug Enforcement Agency, to have a drug screening

protocol

▶ I understand my insurance company will be billed for urine testing ordered by Space City Pain

Specialists; out of network charges may apply

▶ I understand that any portion of the cost of urine testing not covered by my insurance company

will be billed to me by the Lab the test is sent to for analysis

It is Space City Pain Specialists right to deny treatment to any patient who is non-compliant with the

urine testing policy.

I _________________________________________________ agree to submit to urine testing as part of

my compliance for treatment by the practitioners at Space City Pain Specialists.

Signature: ____________________________________________________________________________

Date: ________________________________________________________________________________

NAME: ___________________________________________________

Which of the following best describes your ethnicity? (PLEASE CHECK ONE)

Hispanic Origin

Non-Hispanic Origin

Unknown

Decline to provide information

Which of the following best describes your race? (PLEASE CHECK ONE)

American Indian

Asian

Black

Native Hawaiian/Pacific Islander

White/Caucasian

Unknown

What is your preferred language? (PLEASE CHECK ONE)

English

Spanish

Other: ___________________________________________________

Please tell us your current smoking status: (PLEASE CHECK ONE)

Current every day smoker

Current some day smoker

Smoker, current status unknown

Never smoker

Former smoker

Unknown, if ever smoked

Rev: 21 AUG 2019 – RESS Form

Page 1 of 5

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED

AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Effective Date: April 14, 2003

Our Promise to You:

We are required by law and regulation to protect the privacy of your medical information, to provide you with this notice

of our privacy practices with respect to protection of health information, and to abide by the terms of the notice of

privacy practices then in effect for our practice.

This practice uses and discloses health information about you for treatment, to obtain payment for treatment and for

administrative/operational purposes, and to evaluate the quality of care that you receive. This notice describes our

privacy practices. You can request a copy of this notice at any time. For more information about this notice or our

privacy practices and policies, please contact the person listed below.

Treatment, Payment, Health Care Operations:

Treatment:

We are permitted to use and disclose your medical information to those involved in your treatment. The

physician in this practice is a specialist. When we provide treatment, we may request that your primary care

physician share your medical information with us. Also, we may provide your primary care physician

information about your particular condition so that he/she can appropriately treat you for other medical

conditions, if any.

Payment:

We are permitted to use and disclose your medical information and collect payment for the services provided to

you. For example, we may complete a claim form to obtain payment from your insurer or HMO. The form will

contain medical information, such as a description of the medical service provided to you, that your insurer or

HMO needs to approve payment to us.

Health Care Operations:

We are permitted to use and disclose your medical information for the purposes of health care operations, which

are activities that support this practice and ensure that quality care is delivered. For example, we may ask

another physician to review this practice’s charts and medical records to evaluate our performance so that we

may ensure that only the best health care is provided by this practice.

Disclosures That Can Be Made Without Your Authorization:

There are situations in which we are permitted by law to disclose or use your medical information without your written

authorization or any opportunity to object. In other situations, we will ask for your written authorization before using or

disclosing any identifiable health information about you. If you choose to sign an authorization to disclose information,

you can later revoke that authorization in writing to stop future uses and disclosures. However, any revocation will not

apply to disclosures or uses already made or taken in reliance on that authorization.

Public Health, Abuse or Neglect, and Health Oversight:

We may disclose your medical information for public health activities. Public health activities are mandated by federal,

state, or local government for the collection of information about disuse, vital statistics (e.g. births and deaths), or injury

by a public health authority. We may disclose medical information, if authorized by law, to a person who may have been

exposed to a disease or may be at risk for contracting or spreading a disease or condition. We may disclose your medical

information to report reactions to medications, problems with products, or to notify people of recalls of products they

may be using.

Rev: 21 AUG 2019

Page 2 of 5

We may also disclose medical information to a public agency authorized to receive reports of child abuse or neglect.

Texas law requires physicians to report child abuse or neglect. Regulations also permit the disclosure of information to

report abuse or neglect of elders or the disabled.

We may also disclose medical information to a health oversight agency for the activities authorized by law. Examples of

the activities are audits, investigations, licensure applications, and inspections which are all government activities

undertaken to monitor the health care delivery system and compliance with other laws, such as civil rights laws.

Legal Proceedings and Law Enforcement:

We may disclose your medical information in the course of judicial or administrative proceedings in response to an order

of the court (or the administrative decision-maker), or other appropriate legal processes. Certain requirements must be

met before the information is disclosed.

If asked by a law enforcement official, we may disclose your medical information under limited circumstances provided

that the information:

Is release pursuant to legal process, such as a warrant or subpoena;

Pertains to a victim of crime and you are incapacitated;

Pertains to a person who has died under circumstances that may be related to criminal conduct;

Is about a victim of crime and we are unable to obtain the person’s agreement;

Is released because of a crime that has occurred on these premises; or

Is release to locate fugitive, missing person, or suspected.

We may also release information if we believe the disclosure is necessary to prevent or lessen an imminent threat to the

health or safety of a person.

Workers’ compensation:

We may disclose your medical information as required by the Texas workers’ compensation law.

Inmates:

If you are an inmate or under the custody of law enforcement, your medical information may be released to the

correctional institution and/or the law enforcement official. This release is permitted to allow the institution to provide

you with medical care, to protect your health, the health and safety of others, or for the safety and security of the

institution.

Military, National Security and Intelligence Activities, Protection of the President:

We may disclose your medical information for specialized governmental functions such as: separation of discharge from

military service, requests as necessary by appropriate military command officers (if you are in the military), authorized

national security and intelligence activities, as well as authorized activities for the provision of protective services for the

President of the United States, other authorized government officials, or foreign heads of state.

Research, Organ Donation, Coroners, Medical Examiners, and Funeral Directors:

When an Institutional Review Board or privacy board has approved a research project and its privacy protections, we

may release medical information to researchers for research purposes. We may release medical information to organ

procurement organizations for the purpose of facilitating organ, eye, or tissue donation if you are a donor. Also, we may

release your medical information to a coroner or medical examiner to identify a deceased or a cause of death. Further, we

may release your medical information to a funeral director where such a disclosure is necessary for the director to carry

out his duties.

Required by law:

We may release your medical information where the disclosure is required by law.

Rev: 21 AUG 2019

Page 3 of 5

Your Rights Under Federal Privacy Regulations:

The United States Department of Health and Human Services created regulations intended to protect patient privacy as

required by the Health Insurance Portability and Accountability Act (HIPAA). Those regulations create several

privileges that patients may exercise. We will not retaliate against a patient that exercises their HIPAA rights.

Requested Restrictions:

You may request that we restrict or limit how your protected health information (PHI) is used or disclosed for treatment,

payment, or healthcare operations. We do NOT have to agree to this restriction, but if we do agree, we will comply with

your request except under emergency circumstances.

To request a restriction, please submit the following in writing: (a) the information to be restricted, (b) what kind of

restriction you are requesting (i.e. on the use of information, disclosure of information or both), and (c) to whom the

limits apply. Please send your request to the HIPAA Compliance person for our practice identified below.

We can automatically refuse provide some of the information you ask to inspect or ask to be copied if the information:

Includes psychotherapy notes.

Includes the identity of a person who provided information if it was obtained under a promise of confidentiality.

Is subject to the Clinical Laboratory Improvement Amendments of 1988.

Has been compiled in anticipation of litigation.

We can refuse to provide access to or copies of some information for other reasons, provided that we provide a review of

our decision on your request by another licensed health care provider who was not involved in the decision to deny

access.

Texas law currently requires that we are ready to provide you with copies or a narrative within 15 business days after

receiving your request. We will inform you when the records are ready or if we believe access should be limited. If we

deny access, we will inform you in writing. HIPAA permits us to charge a reasonable cost-based fee. The Texas State

Board of Medical Examiners (TSBMB) has set limits on fees for copies of medical records that under some

circumstances may be lower than the charges permitted by HIPAA. In any event, if we assess any charges for copying

your PHI records, we will charge you the lower of the fee permitted by HIPAA or the fee permitted by the TSMBB.

Amendment of Medical Information:

You may request that we amend your medical information in the designated records set. Any such request must be made

in writing to the person listed below. We will respond within 60 days of the date we have received your request. We may

take an additional 30 days extension, but we will notify you in writing. We may refuse to allow an amendment if the

information:

Was not created by this practice or the physician here in this practice

Is not part of your Designated Record Set

Is not available for inspection because of an appropriate denial (i.e. contains psychotherapy notes)

If the information is accurate and complete.

Even if we refuse to allow an amendment, you are permitted to include a patient statement about the information at issue

in your medical record which you sought to amend. If we refuse to allow an amendment, we will inform you in writing.

If we approve the amendment, we will inform you in writing, allow the amendment to be made and tell others that we

now have the correct information.

Accounting of Certain Disclosures:

You may request and we must provide an accounting of disclosures of your personal health information that are made

other than for treatment, payment, health care operations, or made via an authorization signed by you or your

representative. Your first accounting of disclosures (within a 12 month period) will be free. For additional requests

within that period we are permitted to assess charges to cover our costs of providing the list. If there is a charge we will

notify you and you may choose to withdraw or modify your request before we incur any costs.

Rev: 21 AUG 2019

Page 4 of 5

Appointment Reminders, Treatment Alternatives, & Other health-related Benefits:

We may contact you by telephone, email, text, mail or both to provide appointment reminders, information about

treatment alternatives, or other health-related benefits and services that may be of interest to you.

Contacting your Office Regarding HIPAA Requests:

To contact us for questions, requests or complaints under HIPAA, please do so in writing addressed as follows: Space

City Pain Specialist, 17448 Highway 3, Suite 136, Webster, TX 77598; Attn: Teri Whitt, HIPAA Compliance.

Making Complaints Regarding HIPAA:

If you are concerned that your privacy rights have been violated, you may contact the person identified by our practice as

in charge of HIPAA Compliance at the address for our practice set forth in this notice. You may also send a written

complaint to the United States Department of Health and Human Services. We will not retaliate against you for filing a

complaint with the government or us. The contact information for the United States Department of Health and Human

Services is:

U.S. Department of Health and Human Services

Office for Civil Rights

HIPAA Complaint, Region VI

1301 Young, Suite 1169

Dallas, TX 75202

Phone: 214.767.4056

Fax: 214.767.0432

NOTE: We may change our policies and this notice at any time and have those revised policies apply to all the protected

health information we maintain. If or when we change our notice, we will post the new notice in the office where it can

be seen.

Rev: 21 AUG 2019

Page 5 of 5

ACKNOWLEDGEMENT OF REVIEW OF NOTICE OF PRIVACY PRACTICES

I have reviewed this office’s Notice of Privacy Practices, which explains how my medical information will be

used and disclosed.

I understand that I am entitled to receive a copy of this document.

I, ____________________________________________, have received a copy of Space City Pain

Specialists, L.L.P. Notice of Privacy Practices.

____________________________________________________________________________

Signature of Patient or Personal Representative Date

NOTE: This form must be signed by you the patient. It becomes part of your permanent file.

Rev: 21 AUG 2019