INTEGRITY PAIN MANAGEMENT CENTERKERRY C. LATCH, M.D. / CHRISTIAN SAMUELSON, M.D.ASSIGNMENT OF BENEFITS: I hereby authorize payment directly to INTEGRITY PAIN MANAGEMENT CENTER of any andall medical benefits applicable and otherwise payable to me. I understand that I am financially responsible to INTEGRITY PAIN MANAGEMENTCENTER for charges not covered by this assignment. I understand that should I bill my managed care insurance directly, I am not entitled to anyfurther discounts.RELEASE OF INFORMATION: I hereby authorize INTEGRITY PAIN MANAGEMENT CENTER to furnish my insurance company orcompanies, or their representatives with any and all information that may be contained in their medical records.LIFETIME MEDICARE B SIGNATURE AUTHORIZATION: I authorize any holder of medical or other information about meto release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carriers, or to the billing agent of INTEGRITYPAIN MANAGEMENT CENTER any information needed for this or a related Medicare claim. I permit a copy of this authorization to be used on place of theoriginal, and request payment of medical benefits be made to the holder of the assignment of my behalf. I understand that I am responsible for any health deductiblesand coinsurance.LIABILITY / INSURANCE WAIVER: I hereby state that I wish INTEGRITY PAIN MANAGEMENT CENTER to submit my claim formedical services to for services rendered for the accident date of: . I am not filing thisclaim with any other liability insurance and will not be making any claim to any other general liability insurance or company. I also understand that if I do submitthis to any other general liability insurance or company that will have to be refunded immediately and the total amountoriginally charged for the services rendered will become due and payable by me. Filing your liability insurance does not constitute and assignment. If this is a legalcase, we do not accept assignment pending the outcome of your case. You are responsible for your bill in its entirety.LIABILITY / ATTORNEY - MEDICAL RECORDS RELEASE:I authorize INTEGRITY PAIN MANAGEMENT CENTER torelease my medical records to my attorney: (name)address: phone #:WORKER’S COMPENSATION: This authorizes my physician to furnish written reports and communicate orally with any representative, attorneyfor, or investigator from my Worker’s Compensation carrier regarding my examination, diagnosis, treatment, and prognosisconcerning injuries sustained as a result of an accident occurring on the day of , 19 .IF PATIENT IS UNDER 18: I hereby give my permission for to betreated by Dr. .Patient NameSignature / Telephone VerificationWitnessDateI have reviewed the Notice of Privacy Practices from Integrity Pain Management Center concerning how theuse or disclosure of Protected Health Information will be handled by the practice. I give Integrity PainManagement Center consent to use or disclose my Protected Health Information for purposes of treatment,payment, and restrictions and to revoke this consent.THESE AUTHORIZATIONS MUST BE SIGNED IN ORDER TO EXPEDITE THE FILING OFYOUR INSURANCE CLAIMPatient Name (Please Print):Patient Signature: Date:Name of Custodial Parent or Legal Guardian (Please Print):Parent/Guardian’s Signature: Date:Witness:Date:

INTEGRITY PAIN MANAGEMENTKERRY C. LATCH, M.D. / CHRISITAN SAMUELSON, M.D.PATIENT RIGHTS & ADVANCE DIRECTIVESWe recognize that you have the right to participate in and to make decisionsregarding your health care, including the right to refuse medical treatment asprovided by state law and regulations.You have the right to express your wishes related to your care through“Advanced Directives” as provided by state law and regulations. “AdvancedDirectives”are written statements which specify what kind of treatment you want ordo not want under special and serious circumstances when you may not be able totell your doctor or other caregiver how you want to be treated.“Advanced Directives” may be in the form of a “living will” and/or bydesignating a third party ( relative, friend, etc. ) to make decisions on your behalfusing a durable power of attorney or other forms allowed by the state.Integrity Pain Management Center does not discriminate against clients inadmissions to care or services offered on the basis of the presence or absence ofadvanced directives and will comply with state law. However, it is important that weknow if you have formulated an advanced directive so your wishes can be honored. Itis also important that you provide a copy of your advanced directive to yourphysician so that the appropriate care can be ordered.If you have already formulated an advanced directive, if you execute anadvanced directive in the future, or if you change or revoke and advanced directive, itis important that your physician and the surgery center be informed.If you indicate below that you have an advanced directive, the facility willretain the information in your clinical record, will contact your clinical record, willcontact your attending physician for orders to comply with the terms of yourinstructions, and will notify Integrity Pain Management Center staff who providesyour care. Likewise, if you formulate, change or revoke an advanced directive later,you must notify us and your physician. We will include the information in yourclinical record, contact your physician for orders, and notify us and your physician.We will include the information in your clinical record, contact your physician fororders, and notify Integrity Pain Management Center staff of the changes.I have prepared and advanced directive regarding my health care.I have not prepared an advanced directive regarding myhealthcare.I have received written information regarding my right to makedecisions concerning medical care, including the right to accept orrefuse medical or surgical treatment, and the right to formulateadvanced directives under state law.Patient Signature:Date:

HIPAA Privacy Authorization FormAuthorization for Use or Disclosure of Protected Health Information(Required by the Health Insurance Portability and Accountability Act – 45 CFR Parts 160and 164)1. I hereby authorize Pikes Peak Spine and Joint to use and/or disclose theprotected health information described below for .[Name of Individual]2. Authorization for Release of Information. Covering the period of health care from to OR all past, present and future periods:a. I hereby authorize the release of my complete health record (including recordsrelating to mental health care, communicable diseases, HIV or AIDS, and treatment ofalcohol/drug abuse).ORb. I hereby authorize the release of my complete health record with the exception ofthe following information: Mental health records Communicable diseases (including HIV and AIDS) Alcohol/drug abuse treatment Other (please specify): .3. This medical information may be used by the person I authorize to receive thisinformation for medical treatment or consultation, billing or claims payment, or otherpurposes as I may direct.4. I understand that I have the right to revoke this authorization, in writing, at any time. Iunderstand that a revocation is not effective to the extent that any person or entity hasalready acted in reliance on my authorization or if my authorization was obtained as acondition of obtaining insurance coverage and the insurer has a legal right to contest aclaim.5. I understand that my treatment, payment, enrollment or eligibility for benefits will notbe conditioned on whether I sign this authorization.6. I understand that information used or disclosed pursuant to this authorization may bedisclosed by the recipient and may no longer be protected by federal or state law.Signature of Patient or Personal RepresentativeDatePrint Name of Patient or Personal RepresentativeRelationship to Patient

INTEGRITY PAIN MANAGEMENTKerry C. Latch, M.D. / Christian Samuelson, M.D.We thank you for choosing our office for your medical care. In order to better serve you we kindly ask thatyou review our office policies. Our professional relationship will be enhanced by your clear understanding ofour office policies. Thank you for your review and acceptance of these policies.PAYMENT FOR SERVICE: All applicable fees such as: deductible, co-insurance and co-pays mustbe paid at the time services are rendered. Our office accepts cash , checks, debit and MasterCard or Visa.Payments returned to our office for insufficient funds, closure of account and/or credit card contestment willresult in an assessment of 35. Each office visit and procedure accrues it own fees.HMO/REFERRALS: If your insurance policy requires a written authorization/referral from our office,you must notify us in advance to ensure that the authorization/referral is received prior to your visit with thespecialist.INSURANCE VERIFICATION: As the policy holder, it is your responsibility to call your insuranceand verify that Kerry C. Latch, MD, Christian Samuelson, M.D. are participating providers with yourinsurance. Our office makes every attempt to obtain current benefit information from your insurance carrier atyour initial appointment; however as the insured member, you are ultimately responsible forunderstanding your benefits structure. At the time of your initial visit and each year, our office willrequest a copy of your current medical card and updated patient information form. Please notify our officeimmediately of any changes to your medical insurance policy so that we may take the necessary steps to assistyou in obtaining your maximum level of benefits.MEDICATION REFILL: When requesting a prescription refill, please contract your pharmacy firstand they will contact us with the required information. Refills are handled by the end of the clinic day andyour request for such may be delayed due to your insurance, holidays or weekends. Please plan appropriateadvance notice of your refill requests. Prescriptions for narcotic medications will not be filled after clinichours, weekends and/or holidays.URINE DRUG SCREENING: The best treatment plan often includes urine screening, an essentialtool that enables us to manage your pain and reduce medication cross-reactions. We do these randomly asneeded for care. All results are fully confidential.CANCELLATIONS: If you must cancel or reschedule your appointment, please notify our office atleast 24 hours in advance. You may call after hours and leave a message on the receptionist voicemail box.Cancellations or no shows within 24 hours of the scheduled appointment time will result in a 50cancellation fee. Your insurance will not cover this charge. All fees must be paid in full prior to or on theday of your next appointment. This allows us adequate time for other patients to be assisted.FORMS: Our office charges for letters and forms which need to be filled out and signed. Theminimum charge will be 50 per form/letter. There is a 25 charge for patients who want copies of theirmedical records.NOTE TO PATIENT: Please understand that the insurance carriers/attorneys do not guarantee anypayments for services rendered. Payment is not made until the claim is reviewed and accepted; therefore, youwill be responsible for the total balance if no payment is made by your insurance/attorney. Any and allpayments received from your insurance/ attorney will be credited to your account.Patient SignatureDate


INTEGRITY PAIN MANAGEMENT CENTERPATIENT INFORMATIONPlease fill out the following information. This will make admission process quicker and will prevent answering the same questions repeatedly.PLEASE PROVIDE THE MOST APPROPRIATE ANSWERPATIENT NAME:Religious Preference:Language: Are you able to read? Are you able to write?Information obtained from:SELFOTHER (SPECIFY):1. List all previous surgeries, major illnesses and or major injuries:2. Have you or a member of your family ever had complications from an anesthetic: NOYESExplain if yes,3. Have you ever had any of the following illnesses?PLEASE CHECK YES OR NOYESNOYESNOAngina (Chest Pain)HIV PositiveHeart AttackKidney ProblemsStrokeHigh Blood PressureAsthmaBleeding ProblemsEmphysemaHead InjuryTuberculosisMuscle WeaknessDiabetesSleep ApneaHepatitisLiver DamageVision ProblemsNerve DiseaseContactsSeizuresGlassesDenturesHearing AidsHearing ProblemsPsychiatric History? If so, please explain:List any other illnesses:SUBSTANCE USEAlcohol NO YESDrugsNO YESTobacco NO YESHOW MUCH?HOW LONG?LAST USED?

INTEGRITY PAIN MANAGEMENTKERRY C. LATCH, M.D. / CHRISTIAN SAMUELSON, M.D.NAME:DOB:PERSONAL HISTORYHEIGHT: WEIGHTDO YOU HAVE CHILDREN? IF SO, HOW MANYHAVE YOU HAD ANMRIX-RAYS1. Are you allergic to any medications: NOList medications and type of reaction:EMGYES4. Do you take any prescription medication?LIST MEDICATIONSDOSENOFREQUENCYYESLAST DOSEDO YOU TAKE ANY OTHER MEDICATION?NOYESIF YES, LIST BELOWWORK HISTORYWHO WAS YOUR EMPLOYER AT THE TIME OF THE INJURYWHAT WAS YOUR JOB DESCRIPTIONARE YOU STILL EMPLOYED WITH THEM?IF NOT ARE YOU CURRENTLY EMPLOYED?YESYESORORNONOI understand that I have been referred to Integrity Pain Management Center for the purposes of determiningmy present status. Any information obtained during my visit will be used to determine that status. I,therefore, will give the most complete and honest answers possible. I understand that physical testing isnecessary and will give my best efforts during the tests.SIGNATURE DATE:

PHYSICIAN LIEN, PARTIAL ASSIGNEMENT OF CAUSE OF ACTION, ASSIGNMENT OR PROCEEDS, CONTRACTUAL LIEN ANDAUTHORIZATION (“Agreement”)I hereby direct any and all insurance carriers, attorneys, agencies , governmental departments, companies, individual, and/or other legalentities (“payers”), which may elect or be obligated to pay, provide or distribute benefits to me for any medical conditions, accidents,injuries, or illnesses, for which medical treatment or medical services were rendered hereunder (“condition”) to pay directly to andexclusively in the name of, Kerry C. Latch, M.D. (Dr. Latch, Dr. Samuelson and or Office) such sums as my be owing to Kerry C. Latch, M.D.and Christian Samuelson, M.D. for charges incurred by me at their office relating to my condition and pay directly to and exclusively in thename of Kerry C. Latch, M.D. and Christian Samuelson, M.D. such sums as may be owing to the doctors for charges incurred by me,including charges for treatment, narrative reports, depositions, testimony, and any other charges incurred by me at the office (“charges”).I further grant a contractual lien to Kerry C. Latch, M.D. and Christian Samuelson, M.D. in accordance with the definitions, rights andremedies of Texas Law including specifically, but not limited to, Texas Business & Commerce Code 9.102 and the comments there under,with respect to my charges, and outstanding medical balance. This lien shall apply to all payers and to the full extent of Texas law for thepurpose of the Agreement/ medical assignment and medical lien benefits shall include, but shall not be limited to, proceeds for anysettlement judgment or verdict, as well as any proceeds or recovery relating to commercial health or services benefits, no fault coverage,uninsured and underinsured motorist coverage, third-party liability distributions, malpractice proceeds, attorney retainer agreements,and any other benefits or proceeds payable to me for the purposed stated herein, regardless of whether such proceeds are related to mycharges or not.In addition I hereby assign to the Office, insofar as permitted by law, the following:All of my rights, remedies, and benefits to Kerry C. Latch, M.D. and Christian Samuelson, M.D. as well as any and all causes of action that Imight have against such payer to the extent of my charges, the right to prosecute such causes of action either in my name or in the Office’sname, and the right to settle or otherwise resolve such causes of action as the Office sees fit.In the event that I retain one or more attorneys to represent me in this manner, I hereby direct each attorney(s) to issue a letter ofprotection to this office regarding my charges. Upon issuance, I hereby agree that such letter(s) of protection cannot be revoked ormodified without the expressed written consent of the office. I further direct (and the Office hereby requests) each attorney to provideimmediate notice to the Office regarding any funds received by the attorney relating to my accident, to promptly pay the Office out of suchfunds and to provide a full accounting of such funds to the Office upon its request.I hereby direct all payers to release to Kerry C. Latch, M.D.and Christian Samuelson, M.D. any information regarding any coverage orbenefits which I may have including, but not limited to the amount of the coverage, the amount paid thus far and the amount of anyoutstanding claims.I authorize the Office to release any information regarding my treatment or pertinent to my case to all payers as defined above to facilitatecollection under this Agreement. I hereby direct this Office to file a copy of this Agreement together with any applicable charges with anyor all payers regardless of whether a claim has been established with said payers. I hereby authorize Kerry C. Latch, M.D. and ChristianSamuelson, M.D. to endorse/sign my name on any and all checks listing me as a payee, which are presented to this Office for payment ofan account relating to me, my spouse or any of my dependents. I further authorize Kerry C. Latch, M.D. and Christian Samuelson, M.D. toapply my credit balances on charges incurred by me to any other outstanding charges still owed by me, my spouse or my dependents,regardless of whether these other charges are related to my condition. In the event that I retain one or more attorneys to represent me fora recovery for injuries sustained which were the basis of the condition which I sought medical treatment, I direct each and every attorneyto issue a letter of protection for Kerry C. Latch, M.D. or Christian Samuelson, M.D. to protect the outstanding medical balance of Kerry C.Latch, M.D. or Christian Samuelson, M.D. Upon issuance I hereby agree that such letters of protection cannot be revoked or modifiedwithout the express written consent of Kerry C. Latch, M.D. or Christian Samuelson, M.D.I understand that I remain personally responsible for the total amounts due to Kerry C. Latch, M.D. or Christian Samuelson, M.D. for theirservices. This Agreement does not constitute any consideration for this Office to await payments and it may demand payments from meimmediately upon rendering services as its option. If this Office must take any action to collect and outstanding balance on my account, Iwill be responsible for payment and will reimburse Kerry C. Latch, M.D. or Christian Samuelson, M.D. for all costs of such collection effort,including, but no limited to all court costs and attorney fees.This Agreement shall not be modified or revoked without the mutual written consent of Kerry C. Latch, M.D. or Christian Samuelson, M.D.and myself. I hereby revoke any previously signed authorizations whether executed at this office or any other office to the extent that theterms of those authorizations conflict wit the terms of this Agreement.I agree that each and every provision of the Agreement is reasonably necessary for the protection of the rights and interests of Kerry C.Latch, M.D., Christian Samuelson, M.D. and myself. However, should any provision of the Agreement be found to be invalid, illegal orunenforceable or for any reason cease to be binding on any party hereto, all other portions and provisions of this Agreement shallnevertheless remain in full force and effect.Patient Name ( Please Print) : Patient Signature: Date:Name of Custodial Parent or Legal Guardian (Please Print):Parent/Guardian’s Signature : Date:

INTEGRITY PAIN MANAGEMENTKerry C. Latch, M.D./ Christian Samuelson, M.D.PATIENT SERVICE AGREEMENTGuarantor Statement:I hereby agree to assume financial responsibility for any and all reasonable charges inaccordance with service provided me or my dependent(s) at this facility.In the event my account becomes delinquent, I will assume total responsibility for anyreasonable collection expenses or attorney’s fee associated with the collection effort.Assignment of Benefits:I hereby agree to the authorization and assignment for payment to be made to the facilitynamed above, by any and all insurance claims regarding all professional services rendered.In the event that my insurance company pays me directly, I will upon receipt, remit the entireamount to the facility named above. It is understood that my account will not be consideredclosed until all remaining balances are paid, regardless of the amount of percent of insurancecoverage.Disclosure of Information:I hereby authorized and consent to the disclosure or release of any all medical records andfilms relative to my condition, care or treatment either by or to the facility named above, myreferring physician and all other physicians participating in my care.I agree that the conditions set forth in the above agreements have been explained to me andthat I agree to and understand its contents.SignatureDateWitnessDate

PAIN MANAGEMENT CENTER any information needed for this or a related Medicare claim. I permit a copy of this authorization to be used on place of the original, and request payment of medical benefits be made to the holder of the assignment of my behalf. I understand that I am responsible for any health deductibles