Consents & Acknowledgments

Thank you for choosing Allied Pain & Spine Institute (Allied) for your pain care needs. We consider it a privilege to serve you. This form contains important information that needs to be read closely, understood, and consented to. Please address any questions you may have with our friendly staff.

As a patient of Allied, we will need you to authorize Allied and its associated multi-disciplinary staff and healthcare providers to provide and perform such medical and surgical care, medication management, tests, therapies (physical therapy, chiropractic, acupuncture, and psychotherapy), procedures, supplies and other services (including alternative and complementary) as are considered advisable for your health and well-being. If you are not willing or able to comply with the medical program of care provided or recommended by our physicians or designated alternate(s), you will absolve your physician(s), designated alternate(s), associated medical staff, and Allied of all responsibility resulting from your decided course of action.


By undersigning, you hereby authorize Allied and associated staff and agencies to gather, maintain, and release any and all healthcare information that may be required for the processing of any and all claims for third-party payers (including but not exclusive of private insurance, Medicare, Tricare, Disability, Workman’s Compensation, etc.) and for the purpose of best practice correspondence with involved primary care physicians and other providers.

You authorize Allied to communicate protected health information, where necessary, through the use of mail, email, phone, and voicemail. This may include electronic communication, such as announcements or appointment reminders via text messages or automated calls.


It is important that you understand your financial responsibilities for the services you receive. The changing healthcare environment puts more of this responsibility in your hands.

If you have Insurance:
Our office participates in a variety of insurance plans. As a courtesy, we will verify your coverage and bill carriers on your behalf. It is your responsibility to: ) bring your insurance card with you to every visit and make us aware of any changes in coverage, 2) bring a valid driver’s license or state-issued ID to confirm identity, 3) check with your insurance plan to verify that Allied is in you Preferred Provider Organization (PPO) Network, and 4) if your insurance company requires a physician referral, it is your responsibility to ensure that one has been obtained. If a valid referral is not on file, you will be asked to pay in full for the office visit via check, credit card, or CareCredit.

*Co-payments and Deductibles: You are responsible for paying any co-payments, deductibles, or co-insurances at the time of your appointment.

*Secondary Insurance: Initial filing to your secondary insurance will be billed as a courtesy. You are responsible for the follow-up with your secondary insurance after it is initially filed by Allied.

Balance Billing – Allied will bill you for any services not covered by your insurance company. You have the right to appeal the decision directly with your insurance company. While in the appeal process, payment is required.

If you do not have Insurance:
Payment is due at the time of your appointment. Information regarding fees and payment plans is available through our staff representatives.

Payment Options:
We accept cashier’s checks, personal checks, debit cards, and credit card payments for your convenience. Upon request, Care Credit is also available and must be processed in person in the Blossom Hill location.

Financial Statements: 
For your convenience, Statements will be sent electronically via text unless you request otherwise.

Motor Vehicle Accidents or Liability Cases:
We can file claims to your Automobile Insurance Company in cases where medical payment coverage is available from your Automobile Insurance Company to cover medical treatment/services rendered through Allied. In cases where such Med-Pay Insurance is not available and/or sufficient to cover medical expenses, within our standard guidelines, we will accept Letters of Guarantee and Liens to receive payment(s) when cases settle.

Worker’s Compensation:
We do accept Worker’s Compensation patients and file all claims to the carrier. There will be no balance billing to the patient for approved cases. Should Worker’s Compensation employer/carrier deny your claim, you will be fully responsible for payment. If you have received the authorized service at another clinic, as well as at our clinic, you will be fully responsible for the payment of that service. To increase convenience, efficiency, and control of pharmacologic care, insurance, and statute notwithstanding, we may be able to dispense certain recommended medications and durable medical equipment directly to you from Allied at the time of your doctor visit. As the injured party, you reserve the right to decline medication(s) and medical equipment(s) offered through Allied and obtain written prescriptions for equivalents to fill elsewhere. Allied will not knowingly collect or attempt to collect the payment of a charge for medical services or products (covered under Worker’s Compensation insurance) from a patient or the patient’s estate or family members. Allied cannot see an injured worker for two dates of injury (DOI) on the same day. A visit on a separate day is required for each date of injury (DOI) in each modality.

Financial Arrangement for Surgery:
If your treatment includes surgery, Allied and affiliated ambulatory surgery center(s) will make attempts for pre-certification with your insurance carrier. We will also verify insurance benefits, obtain coinsurance and/or deductible information, and may request payment in advance.

Minor Patients:
A parent or legal guardian must accompany patients 17 years old and younger and sign as a responsible party below (Exception: patients 17 years and younger declared emancipated minors). It is the parent or guardian’s responsibility to bring the necessary referrals and insurance card(s) and make payment at the time of service.

Non-Insured Services:
Our physicians will recommend medically appropriate treatment in all cases. In the event your health plan deems a service(s) medically unnecessary, experimental, non-covered, and/or inclusive as the responsible party, you agree to pay for any amounts not covered by the carrier. We attempt to be familiar with the limitations of health plans; however, the patient/insured is principally responsible to know all his or her plan’s specific provisions.

Prior Authorizations:
Our physicians want our patients to be able to access the ancillary services, procedures, and diagnostic services that they feel you need to provide the best possible care and outcome. When a patient is using commercial insurance, workman’s comp, personal injury claims, or other forms of coverage, we must partner with those payors to approve the services in advance of treatment. Our office will advocate for you with the payors to complete the required prior authorizations for your treatment plan. Sometimes the authorization process can be completed very quickly, but sometimes due to circumstances beyond our control, there may be delays, denials, and appeals that are required, which can delay your treatment. Allied Pain & Spine will complete prior authorizations as a courtesy, and we ask for your patience and participation in the process.

Returned Checks:
Allied will charge a $35.00 NSF fee for each returned personal check. This charge will be applied to the patient’s account. If two (2) checks are returned, only a cashier’s check or a credit card will be accepted for future services.

Translation Services:
If you require translation services, you are strongly encouraged to ask a friend or family member or your legal team to provide this assistance. If you cannot do so and require assistance while in our office, we will use a third-party translation service to assist you. The cost of this service is $30 per 15 minutes of use. The cost will be collected at the time of requesting the service.

Accepted Payment Methods:
Allied Pain & Spine accepts personal checks, credit cards, debit cards, and Care Credit. APSI does not accept cash payments.

Medical Fees:
Our charges are determined by what is usual and customary to our specialty and area. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates. Some treatment recommendations and services will not be covered by some insurance companies and will be the sole responsibility of the patient. If you have any questions about your billing statement, please ask to be referred to our billing department. Specific coverage issues, however, should be directed to your employer or insurance company’s member services department (the number found on the back of your insurance card).

Acupuncture and Chiropractic Fees:
Our charges are determined by the services the provider deemed would be most important for your care and by what is usual and customary for our ancillary providers in our area. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates. Some treatment recommendations and services will not be covered by some insurance companies and will be the sole responsibility of the patient. If you have any questions about what will be charged, please review with the provider before treatment begins.

Mental/Behavioral Health Assessments:
As part of Allied’s holistic and integrated approach to the management of pain, you will be asked regularly by your providers to complete mental/health evaluations. Insights from these questionnaires are used by physicians at Allied to determine the impact of pain on your psychological well-being and to devise more personalized treatment approaches when addressing your problem(s). Allied will submit a claim to your insurance carrier for these periodic assessments.

Finance Charge:
Allied will charge a 1.5% finance charge on balances over 120 days.

Last-Minute Cancelation and Rescheduling Fee & No-Show Fee:
Allied requires 24 business hour notice if a patient needs to cancel or reschedule an appointment. If an appointment falls on a Monday, patients must advise Allied of any changes on Friday before 2:00 pm. Failure to provide 24-hour notice will result in a charge of $84 to a credit card that we will ask to keep on file. Failure to have a ride to your appointment or your “ride did not show up” is not a valid reason, and the no-show fees will be charged to your account. Allied will charge a $84 NO SHOW Fee for any missed appointment not canceled within 24 business hours of the appointment time. The charge for EMG/NCS Test last-minute cancelation, rescheduling, or NO SHOW is $289. The charge for a psychology appointment, last-minute cancelation, rescheduling, or NO SHOW is $289.

NOTE: You are legally responsible for your account at Allied and all costs associated with its collection. Account balances after insurance must be paid in full within 30 days of patient billing unless other payment arrangements have been made to avoid collection agency action. A collection fee, attorney fee, or other fees that Allied may incur to collect payment will be added to any outstanding balance.


California law and Medicare Federal regulations require physicians and other health care providers to make certain disclosures to the patient(s) when referring patient(s) to a facility where a physician or physician’s family member may have a financial interest. We support these laws to help patients make reasoned decisions concerning their medical care. In compliance with the requirements of these laws, you are hereby informed that Allied Pain and Spine specialists at Allied, Drs. James Petros and Parish Vaidya have an ownership interest in Allied Pain & Spine Institute and Trinity Surgery Center, a Medicare-certified ambulatory surgery center. Notably, although our physicians hold Trinity Surgery Center as their optimal environment in providing required medical-surgical services, selection of a specific healthcare provider or facility always rests with the patient, and you may choose to be referred to an alternative setting if you so desire.


The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at


At Allied, we follow industry best practices for managing chronic pain, often drawing on various therapy disciplines (specialized in pain medicine) to achieve the best results.

By undersigning, you hereby authorize and consent Allied and its team of licensed subject matter experts to perform physical therapy, acupuncture, chiropractic, psychological treatment, and/or any combination thereof as may from time to time be medically indicated (per referral and discretion of attending physician or designated proxy) to help cure, alleviate, and/or manage pain problems and/or effects of injuries, for present condition and for any future condition(s) for which pain care may be sought at Allied.

Although it is highly recommended that therapy services be completed as recommended by your Allied provider, you have the right to withdraw consent at any time. In such an event, it is important that you have a final session with your therapist to enable appropriate closure and/or transition plan.

You acknowledge that while this document describes the major risks of the below-stated therapies, other side effects and risks may occur and that clinical staff cannot be reasonably expected to anticipate and explain all possible risks and complications associated with treatment.

You understand fully that therapy (ancillary) services provided at Allied play an integral role in the optimal management of pain and restoration/preservation of function but that pain relief cannot be predicted and/or guaranteed.

As with all medical records, you understand that therapy records will be kept confidential (exceptions, as stated below, notwithstanding) and will not be released without your written consent or where it may be required by law or court order.

If you have questions or concerns regarding the content in this section, please do not hesitate to ask for clarification.

Methods of physical therapy may include manual therapy, massage, traction, electrical muscle stimulation, joint mobilization, heat/cold therapy, and light therapy. Although generally safe, risks of treatment may include increased pain, falling/fractures, disc injuries, dislocations, and sprains.

Methods of acupuncture may include but are not limited to the insertion of sterilized filiform surgical needles into the skin, cupping (creating a vacuum on the external surface of the skin with heat or suction), infrared heating lamp, and electro-stimulation. Although generally safe, common side effects may include bruising, bleeding, and temporary numbness or tingling near the needling sites that may last a few days. Rare complications may include dizziness, fainting, spontaneous miscarriage, nerve damage, organ puncture (including lung puncture), infection, and burns and/or scarring are potential risks of cupping.

Methods of chiropractic may include but are not limited to, spine/joint adjustments, tissue release, traction, massage, and physiotherapy. I understand, and I am informed that in the practice of chiropractic, there are risks of treatment that may include increased pain, fractures, disc injuries, strokes, dislocations, and sprains. I do not expect the doctor to anticipate and explain all possible risks and complications of treatment and wish to rely on the doctor for expert judgment during the course of treatment, which the doctor thinks at the time, based upon all facts then known, is in my best interest. 

Mental health services provided by clinical psychologists at Allied may include psychological testing, diagnostic procedures, cognitive behavioral therapy, other psychological techniques, psychological clearances before procedures, and other appropriate services as needed. For Personal Injury patients, we are unable to provide psychological treatment; we can only offer evaluation/assessment,

By undersigning, you understand that there are limits to the confidentiality of psychological records and testing results as it may pertain to lawsuits, Workers’ Compensation claims, instances where disclosure of records is court-mandated or otherwise required by law, instances where there is a believable threat to patient self-harm (will require 72-hour hospitalization), instances where harm may be done to others, and instances of suspected abuse or neglect of minors, older adults (65 or older), or dependent adults. (Please note that all psychologists are legally obligated to report cases that may result in harm and/or abuse of any party to proper authorities).

Although psychotherapy and other services may pose significant benefits, you understand and acknowledge that psychotherapy may also pose the risk of eliciting uncomfortable thoughts and feelings.

We provide psychological pain evaluation/consultation and treatment to our patients, but our service does not include participating in depositions or any court procedure.  

By checking this box, I agree to use electronic records and signatures and I acknowledge that I have read the related consumer disclosure. (required)

We understand that unforeseen circumstances can arise, leading to the need for last-minute rescheduling or cancellations of procedures at Trinity Surgery Center, a partner of Allied Pain & Spine.

However, we must balance this need with the operational efficiency of our operating rooms and the schedules of our dedicated providers. As such, we have implemented a policy to reduce last-minute cancellations and ensure fair access to our services for all patients.

By signing below, you acknowledge that for any procedures scheduled at Trinity Surgery Center, we will require your credit card details on file at the time of scheduling if you are a PPO or Medicare patient. This will not be charged unless a procedure is canceled without providing at least 24 business hours notice. In such cases, a cancellation fee of $420 will be charged to your card.

For those seen under a Personal Injury lien, instead of charging a credit card, we will send a claim to your attorney for the cancellation fee of $420, which will be added to your lien.

We hope you understand that this policy is in place to keep our operating rooms available for patients who need them and to respect our providers’ time. We appreciate your cooperation and understanding in this matter.

By checking this box, I agree to use electronic records and signatures and I acknowledge that I have read the related consumer disclosure. (required)


Our organization proudly offers Chronic Care Management (CCM), Principal Care Management (PCM), and Behavioral Health Integration (BHI) to allow for more optimal and organized patient care.

Chronic Care Management (CCM) was created in 2015 by the Centers for Medicare and Medicaid Services (CMS) to allow for care coordination services outside of the regular clinic visit. Eligible patients for CCM are those who are 65 years of age or older with multiple (two or more) chronic conditions (expected to last at least 12 months) that pose risks for significant morbidity and mortality, acute exacerbation/decompensation, or functional decline. CCM services are typically non-face-to-face and may include the following, for at least 20 minutes per month: 1) personalized assistance from a dedicated health care professional(s), 2) collaboration with patients to create and execute specific care plans, 3) coordination of care between pharmacy, physicians, testing centers, hospitals, and more, 4) 24-hour access to a health care professional, 5) expert assistance in setting and meeting health goals. Pharmacy medication discounts are also typically available for CCM enrollees. (Note: Worker’s Compensation cases are also eligible for CCM).

We are also pleased to provide our patients with Principal Care Management (PCM). Beginning in 2020, the Centers for Medicare and Medicaid Services (CMS) created PCM to help provide more in-depth care to patients with a single chronic condition (with additional criteria otherwise similar to CCM).

Finally, we proudly offer Behavioral Health Integration (BHI) services. Integrated behavioral health connects our medical and behavioral health clinicians together to collaborate with each other and patients (and their families) to address medical conditions and related behavioral health factors that affect health, well-being, and pain management.

Because we consider CCM, PCM, and BHI integral to our ability to provide better and safer care, we encourage participation by all eligible patients.

Please note that the above services will trigger a separate, covered claim to the insurer on record. By undersigning, you understand and agree to reconcile any associated copays and deductibles.

IMPORTANT: If you are a Medicare beneficiary and elect to opt out of our automated CCM/PCM/BHI enrollment process, please advise our front desk staff accordingly. If you are an injured worker (claimant) and elect to opt out of our automated CCM enrollment process, please notify our front desk staff accordingly.


Telemedicine is the distribution of health-related services and information via electronic and telecommunication technologies, such as computers and mobile devices, to access and manage healthcare services remotely. Telemedicine may include technologies you use from home or that your doctor uses to improve or support health care services. Telemedicine allows out-of-office patient and clinician contact, care, advice, reminders, education, intervention, monitoring, and remote admissions. Examples of telemedicine include videoconferencing, teleconferencing, the transmission of images, e-health including patient portals. 

The BENEFITS of telemedicine include the following:

  • Make health care accessible to people who live in rural or isolated communities;
  • Provide long-distance clinical care;
  • Make services more readily available or convenient for people with limited mobility, time, or transportation options;
  • Obtain expertise of specialists;
  • Improve communication and coordination of care among members of a health care team and patient.
  • Provide support for self-management of health care;
  • Quick and efficient medical evaluation and management.

As with any medical care options, there are potential RISKS associated with the use of telemedicine. These risks include, but may not be limited to:

  • Information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision-making by the physician and assistant(s);
  • Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
  • Security protocols could fail, causing a potential breach of privacy and/or inadvertent disclosure of personal identifying information and/or protected health information;
  • Lack of access to complete medical records may result in adverse drug interactions, allergic reactions or other judgment errors;
  • Overuse of medical care;
  • Unnecessary or overlapping care.

By signing below: 1. You understand that the purpose of telemedicine is to provide health care services. 2. You permit your doctor and the doctor’s assistants to use telemedicine in your care where applicable, including for remote care management. 3. You recognize that telemedicine means using the phone and/or video to communicate with your healthcare team instead of seeing your care team in person (face-to-face). 4. You understand that reasonable efforts will be made to protect your privacy, though there may be a risk of inadvertent disclosure of your personal identifying information and/or protected health information. 5. You understand that you can ask questions and discontinue the use of telemedicine at any time you choose. 6. You understand that telemedicine does not replace other medical assessment and care types.


As part of our comprehensive suite of services, we are pleased to be able to provide our patients with “remote care management.” Healthcare insurers are moving towards remote care management to enhance your medical team’s ability to better monitor and manage your health. This new direction is “proactive” as opposed to “reactive” in the treatment of disease. Electronic assessments, digital exercise programs, and/or pain questionnaires may be provided to you on a routine basis and may be accessed/completed via smartphone, tablet, or desktop computer. 

Our goal with these offerings is to monitor and manage pain even between clinic visits.

Because we consider remote care management integral to our ability to provide better and safer care, we encourage participation by all eligible patients. 

Please note that this service will trigger a separate claim to the insurer on record. By undersigning, you understand and agree to reconcile any associated copays and deductibles. You further understand that you may discontinue this service at any time by informing your physician.

IMPORTANT: If you elect to opt out of our automated remote care management enrollment process, please advise our front desk staff accordingly.

By checking this box, I agree to use electronic records and signatures and I acknowledge that I have read the related consumer disclosure. (required)


Medical Records Copying Fees:
$37 fee for standard preparation.
$55 fee if requested for preparation within 48 hours (rush fee).
Payment is due before mailing or at the time of pick up.

There will be a $27 charge for each disability form and a seven to ten (7- 10) BUSINESS days waiting period for all disability forms.

Family Medical Leave Act Forms:
There will be a ($16) charge for each leave form and a seven to ten (7-10) BUSINESS days waiting period for all leave forms.

Handicap Parking Permits:
No charge.


  • A cordial and cooperative tone will facilitate communication with our staff and providers. Allied has a zero-tolerance policy for aggressive or disruptive behavior toward its staff. Thank you for remaining calm and friendly.
  • All patients with pain perceive their symptoms to be special and urgent. We acknowledge that you may be experiencing physical and emotional distress. However, all patients referred to our Institute feel this same urgency to obtain treatment. Extra-special consideration cannot routinely be granted in scheduling your visits and treatments due to time, space, and staff limitations. Please know that we will do everything possible to serve you in a timely and effective manner within our limitations. Occasionally, a medical emergency or challenging case arises that may delay the day’s schedule – we appreciate your patience in these situations.
  • Chronic pain is not considered to be a medical emergency. Therefore, emergency access to our clinic is rarely indicated. You may be referred back to your primary care physician or to an emergency facility if we cannot accommodate your urgent needs. Please do not wait until the last minute to seek care for an escalating problem.
  • Arriving late for your appointment is disruptive and makes it nearly impossible to maintain our commitment to serving patients in a timely manner. Therefore, our office has a 15-minute late policy. If you arrive 15 minutes after your scheduled appointment, we will usually not be able to see you that day. We will reschedule your appointment for the next available time. Arriving late on a routine basis for your scheduled appointments may be reason for dismissal from our clinic. Out of courtesy, if you are running late, please call the office to confirm we can still see you.
  • We make every effort to give reminder texts for upcoming appointments, but it is ultimately the patient’s responsibility to keep all scheduled appointments or give appropriate notice for rescheduling or canceling.
  • Missed appointments will be rescheduled at the next available time (possibly up to 3-4 weeks). We will not refill medications in the interim, so try not to miss your scheduled appointment. Missing several appointments may be reason for dismissal from our Institute.
  • Video recording in the office is not allowed.
  • When you call our clinic, you may be routed to a voice mailbox. Please leave your message. We listen to our messages daily and will return your call as soon as we are able to do so. For quicker response, please consider texting our office or emailing us at
  • If opioids/narcotics or other potent medications to treat your pain are prescribed, you will be asked to enter into a formal agreement (see below) that outlines the rules, risks, and conditions of continued access to these medications. Please remember it is up to the physician’s discretion if opiate medications are prescribed on the first visit.
  • Before leaving the office, it is recommended that patients schedule their next appointment to avoid any last-minute requests for appointments that may be difficult to accommodate.
  • Provider extenders (Physician Assistants and Nurse Practitioners) may be asked to support your primary physician’s treatment plan through scheduled follow-up visits. Please know that these extenders regularly consult with the primary provider to ensure optimal care while at Allied.
  • At various points in your treatment journey at Allied, your providers may elect to refer you for ancillary services such as physical therapy, chiropractic, acupuncture, pain psychology, diagnostic testing, etc. For your convenience and to enhance/control the quality of care, we provide many of these services at Allied treatment sites as part of our comprehensive package of pain management services. Nonetheless, please be advised that you reserve the right to ask for an outside referral for any recommended service, at your discretion, at any time.
  • At various points in your treatment journey at Allied, your physicians and/or physician extenders may elect to provide you with medically-indicated durable medical equipment (DME)—for example, neck, back, and knee braces. For your convenience and better care through our integrated infrastructure, we can verify insurance benefits and dispense such equipment directly from our clinics as part of our comprehensive package of pain management services. Nevertheless, please be advised that you reserve the right to request DME prescriptions from your Allied provider(s) and fill outside Allied at any time.
  • For injured workers: At various points in your treatment journey at Allied, your physicians and/or physician extenders may determine that you are an eligible candidate for medication management. For your convenience and to expedite access to important medication, we can dispense medications directly to you from our in-house pharmacy during your clinic visit.  A claim is subsequently submitted to your worker’s compensation insurance to obtain retroactive authorization for the same.  Please be advised that you reserve the right to ask for a written prescription(s) to fill at an outside pharmacy vs. obtaining at Allied.
  • CONSENT FOR OBSERVATION, ASSISTANCE, AND/OR TREATMENT:  By signing below, you acknowledge and understand that Allied Pain and Spine Institute is a teaching institution and that its physicians may have affiliations with other academic, research, and training centers. I consent that fellows, residents, interns, nurses, physician assistants, medical and nursing students, and other healthcare professional students and trainees may observe, assist in, and perform my evaluation and treatment under the supervision of the staff physician(s). 


Per the sole discretion and expert opinion of provider(s) at Allied, controlled medications (such as opioids) may be needed and prescribed to augment pain relief and function for specific conditions and clinical trajectories, at different time points and/or on a chronic basis, on a case-by-case basis, and per consent of the patient. Opioid trials/courses are intended to address moderate to severe pain that has not been well controlled by various means.

The purpose of this agreement, which will be effective for the duration of treatment at Allied, is to instruct on the rules of engagement and to prevent misunderstandings about medications prescribed through our office for pain management. Just as your provider must comply with laws regarding controlled medications, a patient accepting/receiving/continuing referenced medications will also have responsibilities.

By signing below, you understand and agree to the following tenets if provided with controlled substances from our Pain Center:

  • You will not use illegal substances while receiving controlled pain medications at Allied.
  • You will not drive or operate any machinery while using prescribed opioid medication.
  • You will not increase or decrease the dosage of your opioid medication without the consent of the prescribing physician. If you feel adjustments in medication dosage are required, you agree to contact the prescribing provider at APSI for an appointment.
  • You will not share or sell your opioid medications or take another person’s medication.
  • You will not receive any pain medications from any other doctors. If you are given a prescription for a controlled substance, you agree not to fill the prescription until you have contacted our office and have discussed it with one of our providers.
  • You acknowledge your responsibility to safeguard all medications prescribed.
  • Should your prescription or opioid medication be lost, stolen, or destroyed, under no circumstances will it be replaced.
  • You will not contact the office to schedule an earlier appointment for an early refill if you have over-taken opioid medication.
  • You understand that even though Allied may request medication for you, your insurance company and the pharmacy may determine that your refill is not ready to be picked up for any reason, and you must work directly with them to resolve any issues.  
  • You understand that the day you pick up the prescription from the pharmacy starts the clock for when you will be able to pick up the refill of that prescription, any delays in your picking up the RX, do not justify an early refill. 
  • You understand that there may be risks associated with the use of opioid medication, including the risk of death, respiratory depression, bowel and bladder dysfunction, sexual dysfunction, change of appetite with possible weight gain or loss, change of coordination (which may interfere with driving, operating machinery, and fine motor movement), birth defects, and others.
  • You acknowledge that continuation and dosage changes will be based on the tilt of balance between benefits and side effects.
  • You understand that the continuous use of opioid medication may result in dependence, addiction, change in personality, and sleep disturbance.
  • You agree to work with a designated provider(s) at Allied to wean chronic opioid medication if and whenever possible. You recognize after discussion with your treater that alternative and “best practice” adjunctive strategies are available for chronic pain treated with opioids, and hereby agree to referrals that may involve psychologists, acupuncturists, etc.
  • You will report any changes in mental state and other possible side effects from prescribed opioid medication.
  • You will not receive/use anti-anxiety medications known as benzodiazepines, or Soma unless decided jointly by a provider at Allied.
  • You agree to submit to random urine drug testing and/or pill counts at the request or need of the providers on an as-needed basis to monitor medication compliance with recommended treatment.
  • You recognize that sudden stoppage of pain medication can lead to rebound pain, withdrawal symptoms, seizures, and other symptoms. You are informed not to stop any pain medication suddenly unless decided jointly by a provider at Allied.
  • You agree to allow your pain provider to review any past medical or psychological records.
  • You agree to participate in remote care monitoring (to include weekly digital pain journaling) to optimize care and safety.
  • You understand that breaking this agreement will result in the termination of controlled substance prescriptions and potential discharge from Allied.


It is understood that any claim or dispute as to medical malpractice, that is, as to whether any medical services rendered were necessary or unauthorized or were improperly, negligently, or incompetently rendered or omitted, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to a court process. The arbitrator shall have the authority to award any remedy or relief that a court of the state of California could order or grant, but no other remedy relief. By signing below, you acknowledge this agreement. An arbitration agreement is effective as of the date of the provisions of the first care, ongoing care, or services of any kind.