If the spouse is the primary card holder please write Spouse’s
IF IT IS AN ACCIDENT:
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I
understand that I am financially responsible for any balance. I also authorize New Jersey Pain, Spine and Sports Associates or
insurance company to release any information required to process my claims. In addition, I also understand and agree that if my
outstanding medical account is referred to a collection agency or attorney, a 20% service charge of the total owed will be added and
charged to me.
PATIENT CONSENT AND AUTHORIZATION
CONSENT FOR TREATMENT: I voluntarily consent to the rendering of care, including treatments, administration
of anesthetics and performance of diagnostic and/or surgical procedures. I understand that I am under the care and
supervision of the attending physician and it is responsibility of the staff to carry out the instructions of such
ASSIGNMENT OF BENEFITS: I hereby assign payment directly to the physician(s) accepting this assignment of
medical benefits applicable and otherwise payable to me but not to exceed the physician’s regular charges. I understand
that I am financially responsible for the charges not covered by this assignment or for any and all charges which the
insurance carrier declines to pay. It is further agreed that my credit balance resulting from payment of insurance or
other sources may be applied to any other accounts owed to said physician(s) by the insured or his/her family.
RELEASE OF INFORMATION: The Physician(s) may disclose all or part of the patient’s record to any person or
corporation which is or may be liable under a contract to the physician(s) or to the patient or to the Health Care
Financing Administration and/or the patient’s attorney, for all or part of the physician’s charges, including but not limited
to, patient insurance companies, worker’s compensation carriers, welfare funds, or the patient’s employer if a worker’s
LONG-TERM CONTROLLED SUBSTANCES THERAPY FOR CHRONIC PAIN: The purpose of this agreement is
to protect your access to controlled substances and to protect our ability to prescribe for you. The long-term use of such
substances as opioids (narcotic analgesics), benzodiazepine tranquilizers, and barbiturate sedatives is controversial
because of uncertainty regarding the extent to which they provide long-term benefit. There is also the risk of an
addictive disorder developing or of relapse occurring in a person with a prior addiction. The extent of this risk is not
certain. Because these drugs have potential for abuse or diversion, strict accountability is necessary when use is
prolonged. For this reason the following policies are agreed to by you, the patient, as consideration for, and a condition
of, the willingness of the physician whose signature appears below to consider the initial and/or continued prescription of
controlled substances to treat your chronic pain.
1. The medication must be safe and effective. The goal is to use the lowest dose that is both safe and effective.
2. The medication must assist me to functions better. If my activity level or general function gets worse, the
medication will be changed or discontinued. I will participate in other treatments that Dr. Abbasi (or his medical
associate) recommends and will be ready to taper or discontinue the opioid medication as other effective treatments
3. I will take my medications exactly as prescribed and will not change the medication dosage or schedule without
Dr. Abbasi’s (or his associate’s) approval.
4. I will keep regular appointments at NJ Pain, Spine and Sports Associates.
5. One doctor. All opioid and other controlled drugs for pain must be prescribed only by Dr. Abbasi (or his associate).
6. I give my permission to NJ Pain, Spine and Sports Associates to communicate with other physicians who are or
may be treating me.
7. If I have another condition that requires the prescription of a controlled drug (narcotics, tranquilizers, barbiturates or
stimulants) or if I am hospitalized for any reason, I will inform the NJ Pain, Spine & Sports Associates within one
8. I will designate one pharmacy where all my prescriptions will be filled.
Pharmacy name_________________________________________ Phone________________
9. I understand that lost or stolen prescription will not be replaced, and I will not request early refills.
10. I agree to abstain from all illegal and recreational drugs and will provide urine or blood specimens at the
doctor’s request to monitor my compliance.
11. Random blood testing at doctor’s discretion
AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION
Sexually Transmitted Disease (STD) as defined by law, RCW 70.24 et seq., includes herpes, herpes
simplex, human papilloma virus, wart, genital wart, condyloma, Chlamydia, non-specific urethritis, syphilis, VDRL, chancroid, lymphogranuloma venereuem, HIV (Human Immunodeficiency Virus), AIDS (Acquired Immunodeficiency Syndrome), and gonorrhea.
MEDICAL ASSESSMENT FORM