Call Us: 317-776-7028

Medication refill calls are handled between 9 am and 4 pm. After hours medication-related calls including prior authorization or pharmacy changes will be answered on the following business day. Please allow a minimum of three business days for your refill to be processed.

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PATIENT REGISTRATION FORM

*

GUARANTOR (person responsible for all balances on the account)

INSURANCE INFORMATION

EMERGENCY CONTACT

CONSENT TO TREAT

I request and give my consent to my physician to provide and perform such medical/surgical care, tests, procedures, drugs, and other services and supplies as are considered necessary or beneficial by my physician for my health and well being. I acknowledge that no representations, warranties or guarantees as to the results or cures have been made to me or relied upon.

RELEASE OF MEDICAL INFO AND AUTHORIZATION TO PAY INS BENEFITS: I authorize my physician to release information from my medical record to my insurance carrier(s), or government agency for the processing of claims for medical benefits. I request that my insurance company honor my assignment of insurance benefits applicable to the services and pay all assigned insurance benefits directly to my physician on my behalf. I authorize Central Indiana Pain Management to obtain medical information for the purpose of referrals.

Complete this area only if you have Medicare coverage

MEDICARE CERTIFICATION: I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize my physician who treats me to release information from my medical record to the Social Security Administration and/or the Medicare program or its intermediaries or carriers. I request that payment of authorization benefits be made directly to my physician treating me, on my behalf.

ADVANCED DIRECTIVE

3.REQUIRED TO BE COMPLETED: Please indicate below who you are appointing as your personal representative to receive medical information. If you choose to indicate NONE, please do so on the first line.

I give my consent and authorization for this person or persons listed below to act as my personal representative and to receive any and all information from my medical records, or discuss any and all aspects of my medical care. I also give consent and authorization for the person or persons to be notified any time I have an appointment. I also understand that I may revoke this privilege at any time by submitting my request in writing to this office.

HIPPA PRIVACY ACKNOWLEDGEMENT

I have been offered a copy of the privacy policy from Medical Pain & Spine Care of Indiana (MPSCI).

I give my consent and authorization for the medical or billing staff of MPSCI to leave protected health care information about me or for me on my answering machine or voice mail via the telephone at the number I have provided. I understand I may revoke this privilege at any time by submitting my request in writing to this office.

FINANCIAL POLICY

Thank you for choosing Medical Pain and Spine Care of Indiana (MPSCI) and Dr. Peter Klim as your health care provider!

We are committed to providing you with quality health care. Please read our policies below and ask us any questions you may have, and sign in the space provided. A copy will be provided to you upon request.

1.Insurance. We participate in many insurance plans including some types of Medicaid. If you are not insured by a plan we do business with, payment in full is expected at each visit. If you are insured by a plan we do business with, but do not have an up to date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.

2.Co-payments and deductibles. All co- payments and deductibles must be paid at the time of service. This is part of your contract with your insurance company. Failure on our part to collect co-pays and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-payment at each visit.

3.Non-covered services. Please be aware that some and perhaps all (tangible and non-tangible) of the services you receive may not be covered or not considered reasonable or necessary by Medicare or other insurers. You must pay for these services in full at the time of visit.

4.Proof of Insurance. All patients must complete our patient information before seeing the doctor. We must obtain a copy of your current valid insurance information in a timely manner, you may be responsible for the balance of a claim.

5.Claims submission. We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.

6.Coverage changes. If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. If your insurance company does not pay your claim in 45 days, the balance will be billed to you.

7.Nonpayment. If your account is more than 90 days past due, you will receive a letter stating that you have 14 days to pay your payment in full. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency. The agency will bill you for the amount and any court costs up to $250. If your account is sent to collections you and your immediate family have 30 days to find alternative care. During that 30-day period, our physicians will only be able to treat you and your family on an emergency basis.

8.Missed appointments. We reserve the right to charge patients and discharge them from the practice if missed appointments are not canceled within 24 hours before the scheduled visit. These charges will be your responsibility and billed directly to you. Please help us serve you better by keeping your regularly scheduled appointments.

9.Forms. There is a charge for all forms requiring a physician and/or medical staff person to complete. Fees will need to be paid prior to the forms being completed.

I have read and understand the financial policy and agree to abide by it’s guidelines. I consent to treatment by, and authorize insurance benefits to be paid directly to Medical Pain & Spine Care of Indiana. I agree that I am responsible to pay 1) for services not covered by my insurance company 2) co-payments and deductibles 3) any expense associated with the collection of a debt owed to them by me (e.g. attorney fees, court costs or collection agency fee). I also consent to the release of pertinent medical information to my insurance carrier for the purpose of processing health care claims.

PATIENT HISTORY FORM

CURRENT MEDICATIONS

Please list any medications that you are now taking. Include non-prescription medications & vitamins or supplements:

LIST ANY OTHER MEDICATIONS YOU TAKE

PAST MEDICAL HISTORY

PERSONAL HISTORY

FAMILY HISTORY

EXTENDED FAMILY PSYCHIATRIC PROBLEMS PAST & PRESENT

SYSTEMS REVIEW

In the past month, have you had any of the following problems?

GENERAL

NERVOUS SYSTEM

PSYCHIATRIC

MUSCLE/JOINTS/BONES

STOMACH AND INTESTINES

EYES

SKIN

THROAT

BLOOD

HEART AND LUNGS

KIDNEY/URINE/BLADDER

Women Only

WOMENS REPRODUCTIVE HISTORY

SUBSTANCE USE HISTORY

DRUG CATEGORY:STIMULANTS(Cocaine, crack,Methamphetamine—speed, ice, crank)

DRUG CATEGORY:AMPHETAMINES/OTHER STIMULANTS(Ritalin, Benzedrine, Dexedrine)

DRUG CATEGORY:AMPHETAMINES/OTHER STIMULANTS(Ritalin, Benzedrine, Dexedrine)

DRUG CATEGORY:SEDATIVES/HYPNOTICS/BARBITURATES(Amytal, Seconal, Dalmane, Quaalude,Phenobarbital)

SUBSTANCE USE HISTORY

DRUG CATEGORY:HEROIN

DRUG CATEGORY:STREET OR ILLICIT METHADONE

SUBSTANCE USE HISTORY

DRUG CATEGORY:ALCOHOLINHALANTS(Glue, gasoline, aerosols, paint thinner,poppers, rush, locker room)

DRUG CATEGORY:OTHER

Patient Agreement to Participate in Medically Assisted Treatment (MAT)

DAST

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

(Circle the number to indicate your answer)

0 = Not at all 1 = Several days
2 =More than half the days
3 = Nearly every day

Patient
Testimonials

Good overall experience every time, even if I have to wait,. I know Dr Klim will give me the time he gives his other patients when they need it.
-- L.O

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Contact Us
18077 River Road, Suite 200, Noblesville, IN 46060
317-776-7028
Fax
317-773-7910

Map & Directions

Peter Klim, DO, MS, is the medical director of Medical Pain & Spine Care of Indiana, specialists in the most advanced interventional pain treatments available, located at 18077 River Road, Suite 200, in Noblesville, IN 46060. Dr. Klim and his team help people from all over Noblesville, Westfield, Fishers, Carmel, Indianapolis and the surrounding Indiana communities. Call 317-776-7028 for an appointment.