Imperial Pain Specialists

Patient Application

Our process is very thorough. However, this process helps to ensure that everything is obtained to provide the best possible care for our patients.

This is NOT the full patient application, and a full application will need to be completed prior to scheduling an appointment.

Our new patient application process is outlined as follows:

1. You must turn your application in and pay the $50.00 application fee. (Non-refundable)

2. We must have the last 3 office visits from your primary care provider and/or referring physician, the last 2 notes from your most recent pain clinic, if applicable, and written reports from radiology (MRI/CT) on your areas of pain. These images must be within the last 2 years.

3. We can obtain the above-mentioned records on your behalf. You can also submit these records to us with your application to help expedite the application process.

4. Once all records are received, your application will go for review. If approved by the Nurse Practitioner and Medical Director, you will be called with an appointment date and time.

Fees:

1. New Patient Visit: $325.00

2. Follow up Visit: $275.00

3. Application Fee: $50.00 (Non-Refundable; please call the office at (423)461-0021 for payment)

Imperial Pain Specialists does not take any form of Insurance. We do not accept cash or personal checks.

Please be prepared to pay with a credit/debit card or a cashier's check from your bank account.

Please be aware of the following:

1. We use an outside lab for drug testing. This lab will take your Insurance for your drug screens. You are given a drug test at every visit.

2. It is required that you keep an active phone number. You will be called in a minimum of 2 times per year for random urine screenings and medication counts. If you are not present at these appointments, you will be discharged. No exceptions.

3. You must keep a primary care physician and see them at minimum 1 time each year.

4. Per our policy, you may not be prescribed any benzodiazepine medication and be established at this facility. The FOA guidelines suggest that concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death. Exceptions may be considered. However, it will limit your dosage and the amount of opioid pain medication that you are prescribed.

5. Excessive phone calls hinder our ability to process your application in a timely manner. If you have questions regarding your application, please allow up to 2 weeks for processing time.

   
   

Imperial Pain Specialists

411 Princeton Rd Ste 101

Johnson City, TN 37601

Authorization to Release Medical Information

If you do not want certain portions of your medical records released, please initial:

I hereby authorize Imperial Pain Specialists and its physicians, employees, and agents to release or disclose to the below- named recipient, al l of my medica l records including especially protected records such as those relating to psychological or psychiatric impairments, drug abuse, alcoholism, sickle cell anemia, sexually transmitted diseases, or HIV/AIDS infection.

I understand I have the right to revoke this authorization by written notification to the Privacy Officer, except to the extent it has acted in reliance thereon before notice of revocation. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure which may not be protected by federal confidentiality rules. I understand that I may request a copy of this authorization. I hereby affirm that I have read and fully understand the above statements and consent to the disclosure of the medica l record for the purpose and extent stated above.

Patient Application

PLEASE COMPLETE THIS APPLICATION IN ITS ENTIRETY AND TO THE BEST OF YOUR ABILITY. DO NOT LEAVE ANY INFORMATION BLANK.

YOU MUST PROVIDE AT LEAST 2 PHONE NUMBERS WHERE YOU CAN BE REACHED.