In case of a medical emergency, if the patient is aged 15 or older, it is okay to treat in my absence

Health History

History of Chief Complaint

Past Medical/Personal History

History of Neuropathy? Or Neuropathy Symptoms

Please list surgery history.

Please circle the area(s) of pain and or discomfort.

To the best of my knowledge, the questions on this form have been accurately answered. I
understand that providing incorrect information can be dangerous to my health. It is my
responsibility to inform the doctor’s office of any changes in my medical status. I also
authorize the healthcare staff to perform the necessary services I may need.

ASSIGNMENT OF HEALTH PLAN BENEFITS AND RIGHTS
AS WELL AS AN APPOINTMENT AND/OR DESIGNATION
AS MY PERSONAL REPRESENTATIVE
AND AN ERISA/PPACA REPRESENTATIVE AND BENEFICIARY

I understand and agree that (regardless of whatever health insurance or medical benefits I have), I am
ultimately responsible to pay Midwest Pain Relief Center as well as all employees, employers, representatives,
and agents thereof, (hereinafter collectively referred to as “Healthcare Provider”) the balance due on my
account for any professional services rendered and for any supplies, tests, or medications provided. I hereby
authorize payment of, and assign my rights to, any health insurance or medical plan benefits directly to
Healthcare Provider for any and all medical/healthcare services, supplies, tests, treatments, and/or medications
that have been or will be rendered or provided; as well as designating and appointing Healthcare Provider as
my beneficiary under all health insurance or medical plans which I may have benefits under. I hereby authorize
the release of any health status, conditions, symptoms or treatment information contained in your records that
is needed to file and process insurance or medical plan claims, to pursue appeals on any denied or partially paid
claims, for legal pursuit as to any unpaid or partially paid claims, or to pursue any other remedies necessary in
connection with same. I hereby assign directly to Healthcare Provider all rights to payment, benefits, and all
other legal rights under, or pursuant to, any health plan (including, but not limited to, any ERISA governed
plan/insurance contract, PPACA governed plan/insurance contract) rights that I (or my child, spouse, or
dependent) may have under my/our applicable health plan(s) or health insurance policy(ies). I also hereby
appoint and designate that Healthcare Provider can act on my/our behalf, as my/our Personal Representative,
ERISA Representative, and PPACA Representative as to any claim determination, to request any relevant claim
or plan information from the applicable health plan or insurer, to file and pursue appeals and/or legal action
(including in my name and on my behalf) to obtain and/or protect benefits and/or payments that are due (or
have been previously paid) to either Healthcare Provider, myself, and/or my family members as a result of
services rendered by Healthcare Provider, and to pursue any and all remedies to which I/we may be entitled,
including the use of legal action against the health plan, the insurer, or any administrator. I hereby also declare
that Healthcare Provider is my/our beneficiary regarding my/our health plan as contemplated by both ERISA
and PPACA, and that Healthcare Provider can pursue any and all rights that I/we may have under state and/or
federal law regarding my/our health plan. This assignment, appointment, and designation will remain in effect
unless revoked by me in writing. It is my intent that the effective date of this document shall relate back to
include all services, supplies, test, treatments, or medications that have been previously provided by Healthcare
Provider. A photocopy or scan or this document is to be considered as valid and as enforceable as the original.

HIPAA Notice of Privacy Practices

Midwest Pain Relief Center, LLC

1405 N. Argonia Road

Milton, KS 67106 - 620-478-2878

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED, DISCLOSED, AND HOW
YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY.
If you have any questions about the notice above, please contact Jannell Turner at our office.

OUR OBLIGATIONS

We are required by law to:

• Maintain the privacy of protected health information 
• Give you the notice of your legal duties and privacy practices regarding your health information. 
• Follow the terms of our notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION 

Described as follows are ways we may use and disclose health information that identifies you (Health Information). Except for the following purposes, we will use and disclose health information only with your written permission. You
may revoke such permissions at any time by writing to our practice’s privacy officer.

TREATMENT: We may use and disclose health information for your treatment and to provide you with treatment related health care services. For example, we may disclose health information to doctors, nurses, technicians, or other personnel, including people outside of our office who are involved in your medical care and need the information to provide you with medical care.

PAYMENT: We may use and disclose health information so that we or others may bill and receive payment from you, an insurance company, or a third party for treatment and services you receive. For example, we may give your health plan information so that they will pay for your treatment.

HEALTH CARE OPERATIONS: We may use and disclose health information for health care operation purposes. These uses and disclosures are necessary to make sure that all of our patients receive quality care to operate and manage our office. For example, we may use and disclose information to make sure the care you receive from our office is of the highest quality. We may also share information with our entities that have a relationship with you for their health care operation activities (for example, your health plan).

APPOINTMENT REMINDERS, TREATMENT ALTERNATIVES, HEALTH RELATED BENEFITS AND SERVICES: We may use and
disclose health information to contact you and remind you of your appointment with us. We may also use and disclose health information to tell you about treatment alternatives, health related benefits and services that may be of interest to you.

INDIVIDUALS INVOLVED IN YOUR CARE OR PAYMENT FOR YOUR CARE: When appropriate, we may share health information with a person who is involved in your medical care, such as your family or close friend. We may also notify your family about your location or general condition or disclose such information to an entity assisting in a disaster relief effort.

RESEARCH: Under certain circumstances, we may use and disclose health information for research. For example, a research project may involve comparing the health of patients who receive one treatment to those who receive a different treatment for the same condition. Before we use or disclose health information for research, the project will go through a special approval process. Even without special approval, we may permit researchers to look at records to help them identify patients who may be included in their research project or for other similar purposes.

SPECIAL SITUATIONS: As required by law, we will disclose health information when required to do so by international, federal, state, or local law. To avert a serious threat to health or safety, we will disclose health information when necessary to prevent a serious threat of health or safety to you, the public, or another person. However, disclosure
will be made only to someone who may be able to help and/or to provide treatment.

BUSINESS ASSOCIATES: We may disclose health information to our business associates who perform functions on our behalf or to provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than that as specific in our contract.

ORGAN AND TISSUE DONATION: If you are an organ donor, we may use or release health information to organizations that handle organ procurement or other entities engaged in procurement; banking or transportation of organs, eyes or tissues to facilitate organ, eye, or tissue donation and transplantation.

MILITARY AND VETERANS: If you are a member of the army forces, we may use or release health information as required by military command authorities. We may also release health information to the appropriate foreign military authority if you are a member of a foreign military.

WORKER’S COMPENSATION: We may release health information for worker’s compensation or similar programs. These programs provide benefits for work-related injuries or illnesses.

PUBLIC HEALTH RISKS: We may disclose health information for public health activities. The activities generally include disclosure to prevent or control disease, injury, or disability; report child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using; inform a person who
may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and report to the appropriate government authority if we believe a patient has been a victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required by law.

HEALTH OVERSIGHT ACTIVITIES: We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

LAWSUITS AND DISPUTES: If you are involved in a lawsuit of a dispute, we may disclose health information in response to a court or a court administrator order. We may also disclose health information in response to s subpoena, discover request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

LAW ENFORCEMENT: We may release health information if asked by a law enforcement official in the information is 1) in response to a court order, subpoena, warrant, summons, or similar process; 2) limited information to identify or locate a suspect, fugitive, material witness, or missing person; 3) about the victim of crime even if, under certain circumstances, we are unable to obtain the person’s agreement; 4) about a death we believe may be the result of criminal conduct; 5) about criminal conduct on our premises and; 6) in an emergency to report a crime to the location of the crime if victims, or the identity, description, or location of the person who committed the crime.

CORONORS, MEDICAL EXAMINERS, FUNERAL DIRECTORS: We may release health information to a coroner or medical examiner. For example, this may be necessary to identify a deceased person or determine the cause of death. We may also release health information to funeral directors as necessary for their duties.

NATIONAL SECURITY AND INTELLIGENCE ACTIVITIES: We may release health information to authorized federal officials
so they may provide protection to the President, other authorized persons, or foreign heads of state, or to conduct special investigations.

PROTECTIVE SERVICES AND INTELLIGENCE ACTIVITIES: We may release health information to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state, or to conduct special investigations.

NMATES OR INDIVIDUALS IN CUSTODY: If you are an inmate of a correctional institution or other custody of a law enforcement official, we may release health information to the correctional institution or law enforcement official. This release would be made if necessary 10 for the institution to provide you with health care; 2) to protect your health and
safety or the health and safety of others; 3) for the safety and security of the correctional institution.

YOUR RIGHTS

You have the following rights regarding health information we have about you.

RIGHT TO INSPECT AND COPY: You have the right to inspect and copy health information that we may use to make decisions about your care or payment for your care. This includes medical and billing records, other that psychotherapy notes. To inspect and copy this information, you must make your request in writing to our privacy officer.

RIGHT TO AMEND: If you feel that health information we have is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for our office. To request and amendment, you must make your request in writing to our privacy officer.

RIGHT TO AN ACCOUNTING OF DISCLOSURES: You have the right to request a list of certain disclosures we made of health information for purposes other than treatment, payment, and health care operations or for which you provided written authorization. To request an accounting of disclosures, you must make a request in writing to our privacy officer.

RIGHT TO REQUEST RESTRICTIONS: You have the right to request a restriction or limitation on the health information we use or disclose for treatment, payment, or health care operation. You also have a right to request a limit on the health information we disclose to someone involved in your care or the payment for your care, like a family member or friend. For example, you can ask that we not share information about your particular diagnosis or treatment with your spouse. To request a restriction, you must make your request in writing to our privacy officer. We are not required to agree with your request. If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment.

RIGHT TO REQUEST CONFIDENTIAL COMMUNICATION: You have the right to request that we communicate with you about your medical matters in a certain way or at a certain location. For example, you can ask that we contact you only by mail or at work. To request confidential communications, you must make your request in writing to our privacy officer. Your request must specify how or where you wish to be contacted. We will accommodate reasonable requests.

RIGHT TO A PAPER COPY OF THIS NOTICE: You have a right to a paper copy of this notice. You must ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice by contacting our office.

Changes to This Notice

We reserve the right to change this notice and make the new notice apply to health information we already have as we as any information we receive in the future. We will post a current copy of our notice at our office. The notice will contain the effective date on the first page, in the top right hand corner.

Complaints

If you believe your privacy has been violated, you may file a complaint with our office or the Secretary of the Department of Health and Human Services. To file a complaint with our office, contact our privacy officer. All complaints must be made in writing. You will NOT be penalized for filing a complaint.

By subscribing my name below, I acknowledge receipt of a copy of this notice, and my understanding and my agreement
to its terms.

MIDWEST PAIN RELIEF CENTER, LLC INFORMED CONSENT
Updated 8.2024

Introduction:

This consent form is designed to provide you with information about the nature and scope of treatment provided at our integrated medical office. It is important that you read this form carefully and ask any questions you may have before signing. By signing this form, you are giving your consent to receive medical care from our integrated team of healthcare professionals.

Nature of Integrated Medical Care:

Our integrated medical office combines various forms of healthcare to provide comprehensive care. This may include
conventional medical treatments, complementary therapies, and lifestyle modifications. Our healthcare team may consist of medical doctors, nurse practitioners, physician assistants, chiropractors, acupuncturists, nutritionists, and other healthcare professionals working together to optimize your health.

Treatment and Procedures

1. Assessment and Diagnosis: Our team will conduct an assessment, which may include physical examinations, medical history reviews, and diagnostic tests to understand your health condition.

2. Treatment Options: Based on the assessment, a treatment plan will be developed that may include: o Conventional medical treatments (e.g., medications, surgeries) o Complementary therapies (e.g., acupuncture, chiropractic adjustments) o Lifestyle and nutritional counseling.

3. Informed Consent: Each treatment or procedure will be explained to you, including the potential benefits, risks, and alternatives. Your consent will be obtained before any treatment is administered.

Risks and Benefits

All medical treatments and procedures carry some level of risk, and benefits are not guaranteed. We will discuss the potential risks and benefits of your treatment options with you. It is important to consider these factors and ask any questions you may have.

Patient Responsibilities

You are responsible for providing accurate and complete information about your medical history, current medications, and any other relevant health information. You should also inform us of any changes in your health status and follow the treatment plan as discussed.

Confidentiality

Your medical information will be kept confidential and will not be shared with outside parties without your consent, except as required by law or for purposes of treatment coordination among our healthcare team.

Consent

By signing this form, you acknowledge that you have read and understood the information provided, had the opportunity to ask questions, and voluntarily consent to receive medical care from our integrated medical office.

Midwest Pain Relief Center, LLC

1405 N. Argonia Road Milton, KS 67106
1-620-478-2878

Provider Statement of Patient/Client Rights and Responsibilities

•  Patients/Clients have the right to be treated with dignity and respect.
• Patients/Clients have the right to fair treatment, regardless of race, ethnicity, creed, religious belief, sexual orientation, gender, age, or health status. 
• Patients/Clients have the right to have their treatment and other patient information kept private. Only by law, may records be released without patient permission 
• Patients/Clients have the right to access care easily and in a timely fashion. 
• Patients/Clients have the right to a candid discussion about all their treatment choices, regardless of cost or coverage provided by their benefit plan. 
•  Patients/Clients have the right to share in developing their plan of care.
• Patients/Clients have the right to information about the organization, its providers, services, and role in the treatment process.
•  Patients/Clients have the right to information about provider’s work history and training.
•  Patients/Clients have the right to information about clinical guidelines used in providing and managing their care.
•  Patients/Clients have the responsibility to treat those who give them care with dignity and respect.
• Patients/Clients have the responsibility of giving providers the information they need, in order to provide the best care possible.  
• Patients/Clients have the responsibility to ask their providers questions about their care 
• Patients/Clients have the responsibility to help develop and follow the agreed-upon treatment plans for their care, including the agree-upon medication plan. 
• Patients/Clients have the responsibility to let their provider know when the treatment plan no longer works for them 
• Patients/Clients have the responsibility to tell their provider about medication changes, including medications given to them by others. 
• Patients/Clients have the responsibility to keep their appointments. Patients should call their providers as soon as possible if they need to cancel visits. 
•  Patients/Clients have the responsibility to let their provider know about their insurance coverage and any changes to it.
• Patients/Clients have the responsibility to let their provider know about problems with paying fees.  

I have read and understood my rights and responsibilities.