TF MEDICAL GROUP LLC

Authorization to obtain your healthcare records

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to disclose  health information regarding the client referenced herein. I understand that the information disclosed pursuant to the this authorization may be subject to re-disclosure by the the recipient and that it is no longer protected by the federal privacy regulations.
 
Information to be disclosed to: tf  (or Top Flight) Medical Group, P O Box 330760 Nashville, Tennessee 37203, whose phone  contact number  is 615.340.3436 and whose electronic mail addresses (email addresses)  are: topflightmedical@meditouchehr.com or info@topflightmedical.com, and whose fascimile is 877.472.3945
 
Purpose of use of this information: Assistance in providing medical care/continuity of medical care. I understand that unless I revoke the authorization earlier, this authorization will automatically expire 12 months after the date that this authorization is signed. Use of copies: A copy of this authorization may be utilized with the same effectiveness as an original.
I certify that I am the (please check one) *
LEGIBLE signature of client/patient or representative *
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If signature is NOT the patient's, complete the following please

WE DO NOT PRESCRIBE OPIOID MEDICATIONS FOR LONG-TERM MANAGEMENT

WELCOME TO  TF MEDICAL  GROUP. WE ARE EXCITED ABOUT THE OPPORTUNITY TO SERVE YOUR HEALTHCARE NEEDS. PLEASE TAKE  TIME  TO  COMPLETE OUR  PRE- APPOINTMENT FORM. DON'T FORGET TO  PRESS THE SUBMIT BUTTON. (PLEASE NO PERIODS  OR  COMMAS OR  OTHER PUNCTUATION MARKS. SEPARATE DATES BY SPACES)

PLEASE  NOTE THAT WE  WANT  TO PROVIDE THE  SAFEST  AND MOST APPROPRIATE  MEDICAL CARE  AVAILABLE. IN ORDER  TO DO SO, WE  HAVE FOUND IT  IMPORTANT  TO HAVE  CERTAIN POLICIES APPLICABLE TO ANY NEW CLIENT.  WE WILL NOT BE ABLE TO SEE YOU IF YOU ARE USING ANY ILLEGAL DRUGS.  YOU MUST BE ABLE TO PASS A URINE DRUG  SCREENING  TEST   AT THE  TIME  OF YOUR FIRST VISIT WITH US.   EXCEPTIONS: (If you have a  prescription medication card and prescription for medicinal marijuana or if you are been prescribed medications which may contain cannabis)

WE  DO NOT  WRITE  PRESCRIPTIONS  FOR NARCOTIC OR  ANY PAIN MEDICATIONS  FOR  MANAGEMENT OF CHRONIC  NON-MALIGNANT PAIN   ALSO, WE  MUST HAVE YOUR  APPROPRIATE  MEDICAL RECORDS PRIOR  TO  WRITING  ANY PRESCRIPTION MEDICATIONS AT ALL.

WE HOPE THAT YOU SHARE OUR ZERO TOLERANCE POLICY FOR ILLEGAL SUBSTANCES

PLEASE SAVE YOUR FORM NOW!!!

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PLEASE READ THROUGH THE NEXT FEW PARAGRAPHS WHICH  STATE  MANY OF OUR IMPORTANT GROUP POLICIES. THEN, IF YOU AGREE, CHECK THE APPROPRIATE  AREA (BOX). IF NOT, YOU CAN SIMPLY  DISGARD THE ONLINE FORM:
IF THIS FORM IS NOT BEING COMPLETED 7-30 DAYS PRIOR TO YOUR SCHEDULED VISIT, PLEASE STOP HERE AND CONTACT OUR GROUP BEFORE YOU ATTEMPT TO COMPLETE THE FORM. AGAIN, THIS FORM SHOULD COMPLETED AT LEAST 7 DAYS AND NO MORE THAN 30 DAYS PRIOR TO YOUR FIRST APPOINTMENT WITH US. YOU WILL NEED SPECIAL AUTHORIZATION IN ORDER FOR THE FORM TO BE ACCEPTED FOR THIS VISIT. EVEN IF YOU COMPLETE THE FORM LATE, IT WILL NOT BE ACCEPTED WITHOUT AUTHORIZATION.
 
WE WOULD LIKE ALL PROSPECTIVE CHRONIC PAIN MANAGEMENT PATIENTS TO KNOW THAT WE DO REQUIRE A JOURNAL (PAIN DIARY) OF SOME SORT BE KEPT REGULARLY- PLEASE REVIEW THE INFORMATION AVAILABLE ON OUR WEBSITE IF YOU ARE NOT SATISFIED THAT YOU HAVE ENOUGH INFORMATION TO HELP YOU MAKE A DECISION ON A PROVIDER/PROGRAM IN THE PAIN MANAGEMENT AREA
 
PLEASE  NOTE THAT WE  WANT  TO PROVIDE THE  SAFEST  AND MOST APPROPRIATE  MEDICAL CARE  AVAILABLE. IN ORDER  TO DO SO, WE  HAVE FOUND IT  IMPORTANT  TO HAVE  CERTAIN POLICIES APPLICABLE TO ANY NEW CLIENT.  WE WILL NOT BE ABLE TO SEE YOU IF YOU ARE USING ANY ILLEGAL DRUGS.  YOU MUST BE ABLE TO PASS A URINE DRUG  SCREENING  TEST   AT THE  TIME  OF YOUR FIRST VISIT WITH US.   EXCEPTIONS: (If you have a  valid prescription medication card and prescription for medicinal marijuana or if you are been prescribed medications which may contain cannabis).
 
WE  DO NOT  WRITE  PRESCRIPTIONS  FOR NARCOTIC OR  ANY PAIN MEDICATIONS AT THE TIME OF YOUR FIRST VISIT  WITH US.  ALSO, WE  MUST HAVE YOUR  APPROPRIATE  MEDICAL RECORDS PRIOR  TO  WRITING  ANY PRESCRIPTION MEDICATIONS AT ALL.
 
BRING ALL CURRENT ACTIVE MEDICATIONS  IN THEIR RESPECTIVE BOTTLES/PLANNERS TO THE INITIAL VISIT
 
We are NOT able to see clients who have not completed the intake process in the manner described-7 days prior to your visit. Also, patients who are being evaluated for our chronic pain program who fail the first toxicology (drug) screen, will NOT be eligible a trial of opioid (narcotic) management
 
WE DO NOT PROVIDE PRESCRIPTIONS FOR CHRONIC PAIN MANAGEMENT AT INITIAL VISITS. PLEASE NOTE: YOU MUST HAVE VALID STATE OF TENNESSEE IDENTIFICATION
 
We are NOT able to see clients who have not completed the intake process in the manner described- A MINIMUM OF 7 days prior to your visit and a MAXIMUM of 30 days prior to the first visit. Also, patients who are being evaluated for our chronic pain program who fail the first toxicology (drug) screen, will NOT be eligible for a trial of opioid (narcotic) management at all.
 
WE NOW REQUIRE THE COMPLETION OF A SECOND RELEASE OF INFORMATION FORM FOR NEW PATIENTS. PLEASE BE SURE TO COMPLETE THE INDIVIDUAL RELEASE OF INFORMATION FORM WHICH IS LOCATED ON OUR WEBSITE ( LOOK FOR RELEASE OF INFORMATION LINK ON THE HOME PAGE). THIS HELPS US TO BE MOST EFFICIENT IN ALL THINGS
 
WE DO NOT PROVIDE PRESCRIPTIONS FOR CHRONIC PAIN MANAGEMENT AT INITIAL VISITS. ALSO, WE DO NOT REPLACE ANY LOST OR STOLEN PRESCRIPTION MEDICATIONS AT ALL.
 
WE DO NOT REPLACE LOST OR STOLEN PRESCRIPTIONS OR MEDICATIONS *

WE DO NOT PRESCRIBE OPIOID MEDICATIONS FOR LONG-TERM MANAGEMENT

SOME THINGS ABOUT YOU

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WHAT IS YOUR  CURRENT LEGAL MARITAL STATUS *
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WHICH OF THE FOLLOWING DO YOU USE OR HAVE ACCESS TO *

WE HOPE THAT YOU SHARE OUR ZERO TOLERANCE POLICY FOR ILLEGAL SUBSTANCES

WE DO NOT PRESCRIBE OPIOID MEDICATIONS FOR LONG-TERM MANAGEMENT

FIRST COMPLAINT THIS IS YOUR MAIN COMPLAINT

MANY OF OUR CLIENTS HAVE MORE THAN ONE (1) COMPLAINT. (EXAMPLES WOULD LOWER BACK PAIN AND UPPER BACK PAIN, OR BACK PAIN AND HIP PAIN, OR EVEN SHOULDER PAIN, NECK PAIN, AND RIGHT LEG WEAKNESS) SO, IF YOU HAVE  MULTIPLE COMPLAINTS OR PROBLEMS, USE THE EXTRA SPACES PROVIDED TO LIST THEM AND GIVE US THE DETAILS

HAVE YOU HAD ANY SURGERY RELATED TO YOUR COMPLAINT *
IF YOU HAD SURGERY  RELATED TO YOUR COMPLAINT DID IT HELP

SECOND COMPLAINT

HAVE YOU HAD ANY SURGERY RELATED TO YOUR COMPLAINT
IF YOU HAD SURGERY  RELATED TO YOUR COMPLAINT DID IT HELP

THIRD COMPLAINT

HAVE YOU HAD ANY SURGERY RELATED TO YOUR COMPLAINT *
IF YOU HAD SURGERY  RELATED TO YOUR COMPLAINT DID IT HELP

YOUR AND YOUR FAMILY'S MEDICAL AND SURGICAL PAST HISTORY

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ALLERGIES

MIND SPIRITUAL WELL BEING

SOCIAL HISTORY

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CHECK EACH YOU'VE  HAD TREATMENT FOR OR BEEN TOLD YOU NEEDED TREATMENT, N/A IF NONE *
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 CHECK  THE     THINGS THAT YOU CAN DO   FOR YOURSELF *

YOUR PREVIOUS TREATMENT FOR YOUR COMPLAINTS

WHICH TREATMENTS/THERAPY  FOR YOUR  COMPLAINT  HAVE YOU HAD
WHICH MEDICATIONS/REMEDIES HAVE YOU TAKEN TO HELP PAIN RELATED TO YOUR PROBLEM * 

GENERAL SYSTEM REVIEW

TODAY DO YOU HAVE ANY NEW

Over the last two weeks, how often have you been bothered by any of the following problems- select one choice only

LITTLE INTEREST OR PLEASURE IN DOING THINGS *
FEELING DOWN, DEPRESSED, OR HOPELESS *
TROUBLE FALLING OR STAYING ASLEEP, OR SLEEPING TOO MUCH *
FEELING TIRED OR HAVING LITTLE ENERGY *
POOR APPETITE OR OVEREATING *
FEELING BAD ABOUT YOURSELF - OR THAT YOU ARE A FAILURE OR HAVE LET YOURSELF OR YOUR FAMILY DOWN *
TROUBLE CONCENTRATION ON THINGS, SUCH AS READING THE NEWSPAPER OR WATCHING TELEVISION *
MOVING OR SPEAKING SO SLOWLY THAT OTHER PEOPLE COULD HAVE NOTICED? OR THE OPPOSITE-BEING FIDGETY OR RESTLESS THAT YOU HAVE BEEN MOVING AROUND A BIT MORE THAN USUAL *
THOUGHTS THAT YOU WOULD BE BETTER OFF DEAD, OR OF HURTING YOURSELF ON SOME WAY *

PROSPECTIVE PAIN MANAGEMENT CLIENTS ONLY

HAVE YOU EVER BEEN TREATED BY A PAIN SPECIALIST *
IF YOU HAVE BEEN TREATED BY A PAIN SPECIALIST BEFORE HAVE YOU STOPPED SEEING THE PROVIDER *
WERE YOU RELEASED FROM A PAIN MANAGEMENT GROUP OR SPECIALIST PREVIOUSLY FOR VIOLATION OF POLICY *
RELEASED FROM MORE THAN ONE PAIN MANAGEMENT GROUP/SPECIALIST FOR VIOLATION OF POLICY *
WHICH STUDIES/TESTS HAVE  YOU HAD WITHIN THE LAST 12 MONTHS FOR YOUR COMPLAINT

WE DO NOT PRESCRIBE OPIOIDS FOR CHRONIC (LONG-TERM) PAIN MANAGEMENT

We recommend that you never discuss your medication or treatment with other persons in the facility except the providers . Also, keep your belongings, including your medications, documents, etc with you or your trusted guardian or representative at all times.

Please sign BELOW here if you are on a computer, or sign with stylus or your finger if you are on a mobile device. PLEASE MAKE SURE YOUR SIGNATURE IS LEGIBLE Thanks, and we look forward to meeting you very soon

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PLEASE BRING ALL CURRENTLY PRESCRIBED MEDICATIONS TO THIS VISIT INCLUDING RECENT EMPTY BOTTLES

WOMEN IF THERE IS ANY CHANCE THAT YOU ARE CURRENTLY PREGNANT TELL US NOW PLEASE

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POTENTIAL PAIN MANAGEMENT CLIENTS

For those  potentially  participating in our pain management programs, please  begin keeping some sort of  daily journal (diary). And,  in this  journal please:
 
1. List  daily activities  such as  exercising house chores, cooking , laying around, yard  work, shopping, etc..
 
2. List  the times throughout the day that you actually are taking  your medications for  pain  control 
 
3. List  the location of your  painful areas  as  you experience throughout the day
 
4. Write down  pain  levels that you  experience throughout the  day/night  0-10  with the 10 being  highest
 
You can start the journal keeping now or immediately after your first visit with us. This is  an expectation that  we have of you, unless we say otherwise
 
Many of  our patients use "apps" (applications typically downloaded to  a device such as phone  or tablet) in order to do this quite nicely. The information  can later be sent to  our  group  in a number of ways
 
 
The purpose of the journal is to monitor  and  keep a more accurate daily account of  lifestyle and activities as they may certainly affect chronic pain cycles. This is  not a "punishment"  or  just some  extra work for you (our healthcare team does  review these journals) we are quite serious about them. As well,  maintenance of these journals does  help to keep  some level of client and provider accountability  and responsibility  to the process of  long term management. Over the years this method  has really shown that a more thorough and effective approach  of and for management  is enabled.
 
The  journal   information really should be kept nearly daily
 
START KEEPING THE JOURNAL NOW. Please remember to  bring the journal  to each visit. It is an important  piece and  part to  your  visits with our providers . Please be sure to bring it along with  current medication(s) and  its bottles- even if the bottles are empty- to each appointment. 
 
Be sure to ask  any questions  that you may have about the journal, or anything   else  during  your apppointment time or via electronic or other messaging as available.
 
IF YOU ARE GOING TO NEED A WORK OR SCHOOL NOTE AFTER YOUR VISIT WITH US THIS TIME , PLEASE CHECK THE APPROPRIATE BOX

WE DO NOT REPLACE LOST OR STOLEN PRESCRIPTIONS OR MEDICATIONS

BE SURE TO GET GREEN CHECK MARK AND COPY YOUR REFERENCE NUMBER DOWN AFTER COMPLETING THE FORM

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TOP FLIGHT MEDICAL GROUP, LLC (CALL- 615.340.3436 GO TO OUR WEBSITE: tfmgglobal.com  OR  EMAIL  US AT
tfmg@topflightmedical.com  FOR ANY QUESTIONS)