IRPC RULES FOR PATIENTS

IRPC RULES FOR PATIENTS TO

FOLLOW

01

Will NOT attempt to obtain pain medication from any physician other than my pain physician

02

Will not, UNDER ANY CIRCUMSTANCE, take more medication than prescribed. “Running out early” will not be tolerated and NO EARLY REFILL will be GIVEN.

03

Agrees to consent for random urine drug screening at my provider’s request

04

Will not use any illegal substances, such as cocaine, Methamphetamine, Heroin etc

05

Will not give, share, sell or trade my medications for any reason

06

Will keep medications in a safe place and protect them against loss or theft. I understand that lost or stolen medications will not be replaced regardless of circumstances

07

Failure to keep appointments or rescheduling appointments more than 3 times will result in dismissal from the clinic. After 3 consecutive no shows, A NO SHOW fee MUST be paid prior to being seen again. Fees for 3 consecutive no show follow up appointments or procedures are $40/$100 respectively. New patients who no show 3 times will need to wait 6 months before they will be scheduled again

08

Will not undergo any pain management procedures or injections elsewhere without the consent of my IRPC pain management doctor. I understand I am free to transfer my pain management care at any time. If I choose to transfer care, I understand the new physician will assume all responsibility for my prescribed pain medications

09

Understands that an important part of my pain management program will include non-drug treatment modalities (physical therapy, injection therapy, psychiatric therapy, etc.) If I fail to follow through with my doctor’s entire treatment program, I understand that pain medications may be withdrawn

10

Understands that my treatment goals are reduction in pain and improvement in overall function and quality of life. Should it become evident that these goals are not being met, I agree to stop pain medications.

11

Will not exercise any disruptive behaviors to my physician or staff. I will follow medication refill policy as described

12

Violation of any of the above rules more than two times can result in dismissal

13

Lost/Stolen medications will not be replaced regardless of circumstances

IRPC will not make any exceptions for the following

  • No narcotics for any pregnant women
  • No narcotics to anyone under 21 years of age
  • No early replacement prescriptions for
    lost or stolen medicine
  • No early refills
  • No narcotics to anyone with a history of
    buying or selling illegal drugs

IRPC PAIN MANAGEMENT AGREEMENT

Please click the attached pain management agreement for schedule drugs and narcotics policies and make sure to read and understand completely before signing it. Any intentional hiding or false statement can result in immediate termination

IRPC NEW PATIENT

PACKAGE

Please click the attached new patient package and make sure to fill it completely before signing it at the end. Please bring it with you at the time of initial visit.

PATIENT INFORMATION:

Due to high volume of patients needing appointments at our clinics, we have a wait time of about two-three weeks for appointments. With this in mind, it’s important for our patients to provide us with notice if they need to cancel their appointments so we can provide care to others who are waiting to be seen.
In order to provide the highest quality care for each of our patients, we’re asking for all patients of IRPC to keep their appointments unless it’s absolutely necessary to cancel.

All co-pays and deductibles are due at the time of service. For your convenience we gladly accept cash and credit cards. You must have your insurance card at time of check-in.

IRPC accepts all major insurance carriers (including Medicare, Medicaid and most other insurances). We also will pre-certify any insurance requirements as a courtesy for our patients. Please have all insurance cards, photo ID and copays ready at each and every visit. If we are unable to verify your insurance information then you will be expected to pay full cash price for services rendered.

IRPC is proud to provide a flexible cancellation policy for our patients. If you need to cancel your appointment at one of our clinics, please provide at least 24 hours’ notice. Feel free to reschedule your appointment for a date that works for you.

YEARLY UPDATE PATIENT’S INFO

Please click the attached form to update your data on yearly basis.