Welcome!

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Our procedures are considered Same Day or Out Patient procedures. You can expect your first visit to last one hour to one-and-a-half hours from the time you check in until the time you leave. If you have a procedure performed the same day as the initial visit, the appointment time will most likely be one-and-a-half hours. At this first visit the doctor will conduct an assessment of your pain problem and then will develop a treatment plan for you. It may be possible to begin injection therapy the same day as the first appointment.

What to bring to the first appointment:

  • a list of your current medications
  • your insurance card(s)
  • a driver

Please notify us if:

  • You are taking a blood thinning medication such as Coumadin, Plavix, Warfarin, Aggrenox, Prodaxa or Pletal
  • You are diabetic
  • You have a latex or dye allergy
  • You have a pacemaker or defibrillator

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Follow-up of our patients is very important to us. If you have unresolved pain problems after your course of treatment, it may be necessary to re-evaluate your situation with your physician and have another appointment made for you.

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THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY.

Your Health Care Information - Protecting Your Privacy
It is your right as a patient to be informed of the privacy practices of your health care provider as well as to be informed of your privacy rights with respect to your personal health information. This Notice of Privacy Practices is intended to provide you with this information.

Pain Clinic of Northwestern Wisconsin’s Responsibilities
It is your right as a patient to be informed of Pain Clinic of Northwestern Wisconsin's legal duties with respect to protection of the privacy of your personal health information.
Pain Clinic of Northwestern Wisconsin is required to:

  • Maintain the privacy of your health information
  • Provide you with a notice of the legal duties and privacy practices regarding protected health information collected and maintained about you
  • Abide by the terms of this notice

Pain Clinic of Northwestern Wisconsin reserves the right to change the terms of the notice of privacy practices and make the new notice provisions effective for all protected health information that it maintains. Pain Clinic of Northwestern Wisconsin also reserves the right to change the terms of its notice with respect to any applicable more limited uses and disclosures.

Pain Clinic of Northwestern Wisconsin will promptly revise and distribute its notice whenever Pain Clinic of Northwestern Wisconsin makes a substantial change to any of its privacy practices. Pain Clinic of Northwestern Wisconsin will not use or disclose your health information without your authorization, except as described in this notice.

Your Health Information Rights
You have the right to request restrictions on certain uses and disclosures of protected health information, even if the restriction affects your treatment or Pain Clinic of Northwestern Wisconsin’s payment or health care operation activities. However, Pain Clinic of Northwestern Wisconsin is not required to agree to your requested restriction. For example, if you are an employee of the clinic and you receive health care services in the clinic, you may request that your health care record not be maintained in the general record filing area.

Receive Confidential Communications
You have the right to request that Pain Clinic of Northwestern Wisconsin communicate your health information to you by alternative means or at alternative locations. Pain Clinic of Northwestern Wisconsin shall accommodate reasonable requests. For example, you may request to be contacted at a phone number that is different from the phone number listed in your health care record.

Inspect and obtain a copy of your health record
You have the right to inspect and obtain a copy of your health care record. This request for access to your health care record must be submitted in writing. This right may not apply to certain types of psychotherapy notes and Pain Clinic of Northwestern Wisconsin may charge you a reasonable fee for a copy of your health care record. For example, you may request a copy of your health care record from your physician.

Amend your health record
You have the right to request an amendment to your health care record if you believe your health information is incorrect or incomplete. You may be asked to make this request in writing and state the reason why your health record should be changed. If Pain Clinic of Northwestern Wisconsin did not create the health information you believe is incorrect or if Pain Clinic of Northwestern Wisconsin disagrees with you, Pain Clinic of Northwestern Wisconsin may deny your request. For example, if you believe that information in your medical history is incorrect, such as your birth date, you may request that this information be amended. 

Obtain an accounting of disclosures of your health information
You have the right to an accounting of disclosures of your health information that Pain Clinic of Northwestern Wisconsin has made in compliance with state and federal law. The accounting will describe the dates of each disclosure, a brief description of information disclosed and the reason for disclosure. Upon request, you will receive one accounting per year at no charge and Pain Clinic of Northwestern Wisconsin may charge you a reasonable fee for each subsequent request. For example, you may request an accounting of disclosures made from your health record in the last year to the State for disease reporting.

Obtain a paper copy of the notice upon request
You have the right to obtain a paper copy of the notice upon request. For example, if you received the notice electronically, you may request that Pain Clinic of Northwestern Wisconsin provide a paper copy of the notice.

Uses or Disclosures of Your Protected Health Information Permitted Without Your Authorization
Without your written authorization, Pain Clinic of Northwestern Wisconsin may use or disclose your health information for the following purposes:

  • Treatment
    Pain Clinic of Northwestern Wisconsin may use or disclose your health information in the provision, coordination or management of your health care.
    Example: Your information may be disclosed from one physician to another if they are consulting each other in relation to your care and treatment.
  • Payment
    In order for an insurance company to pay for your treatment, we must submit a bill that includes information that identifies you, your diagnosis and your treatment.
    Example: Pain Clinic of Northwestern Wisconsin may use or disclose your information to your insurer to receive payment for providing health care services.
  • Health Care Operations
    Pain Clinic of Northwestern Wisconsin may use or disclose your health information to improve the quality or cost of care we provide. These activities may include evaluating the performance of your doctors, nurses, and other health care professionals, or examining the effectiveness of the treatment provided to you when compared to patients in similar situations.
    Example: Pain Clinic of Northwestern Wisconsin may review your health record to determine the efficacy of the services provided to you.

As Required by Law:
Sometimes we must report some of your health information to legal authorities such as law enforcement officials, court officials, or government agencies. For example, we may have to report abuse, neglect, domestic violence or certain physical injuries, to respond to a court order.

Public health:
As required by law, Pain Clinic of Northwestern Wisconsin may disclose your protected health information to the State of Wisconsin for the purpose of statutory reporting.

Pain Clinic of Northwestern Wisconsin may disclose your protected health information (excluding mental health, alcohol or drug abuse or developmental disabled or HIV test result) to a state or federal public health agency for the purpose of preventing or controlling disease injury or disability.

Pain Clinic of Northwestern Wisconsin may disclose your protected health information (excluding your HIV test result) to a county agency investigating child abuse.

Pain Clinic of Northwestern Wisconsin may disclose your protected health information (excluding mental health, alcohol or drug abuse or developmental disabled or HIV test result) to the Food and Drug Administration (FDA). 

Pain Clinic of Northwestern Wisconsin may disclose your HIV test result to a person that may have sustained a contact that carries a potential for transmission of HIV.

Pain Clinic of Northwestern Wisconsin may disclose your protected health information that is reasonably related to a work related illness or injury if an application for workers’ compensation has been filed.

Victims of abuse, neglect or domestic violence: Pain Clinic of Northwestern Wisconsin may disclose health information (except for an HIV test result) if we reasonably believe that an individual is a victim of child or elderly abuse.

Health oversight activities:
Pain Clinic of Northwestern Wisconsin will not disclose HIV test results to health care oversight agencies without an authorization. Pain Clinic of Northwestern Wisconsin may disclose your mental health, alcohol or drug abuse or developmental disability related health information to the Department of Health and Family Services, to the county for coordination of human services and to a representative of the board on aging and long-term care. The remainder of your protected health information may be disclosed without your authorization to a state or federal agency.

Judicial and Administrative Proceedings:
Pain Clinic of Northwestern Wisconsin may disclose your protected health information in response to a court order. Pain Clinic of Northwestern Wisconsin may disclose your protected health information (excluding mental health, alcohol or drug abuse or developmental disabled or HIV test result) in response to a subpoena from a state or federal agency.

Law enforcement:
Pain Clinic of Northwestern Wisconsin may disclose your protected health information (except for HIV test results) to county law enforcement officials for the reporting and investigation of elderly and/or child abuse. Pain Clinic of Northwestern Wisconsin may disclose your protected health information (except for mental health, alcohol or drug abuse or developmental disabled or HIV test results) to state and federal law enforcement officials. Pain Clinic of Northwestern Wisconsin may disclose mental health, alcohol or drug abuse or developmental disabled protected health information for limited law enforcement purposes as required by law. Pain Clinic of Northwestern Wisconsin may disclose your protected health information to a law enforcement official in response to a court order.

For activities related to death:
Coroner or Medical Examiner: Pain Clinic of Northwestern Wisconsin may use or disclose your protected health information that is not an HIV test result or related to mental health, alcohol or drug abuse and developmental disabilities to a coroner or medical examiner. 
Funeral Director: Pain Clinic of Northwestern Wisconsin may use or disclose your HIV test result a funeral director.
For organ, eye, or tissue donation purposes: Pain Clinic of Northwestern Wisconsin may use or disclose your protected health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation or cadaveric organs, eyes or tissue for the purpose of facilitating organ, eye or tissue donation and transplantation.
Research: Pain Clinic of Northwestern Wisconsin may use or disclose your protected health information for research purposes if the researcher has obtained your permission or fulfilled the stringent privacy requirements of state and federal law.

To avoid a serious threat to health or safety: Pain Clinic of Northwestern Wisconsin may disclose your protected health information under limited circumstances to law enforcement officials to avert a serious threat to health or safety.
Disclosures for specialized government functions: Pain Clinic of Northwestern Wisconsin may disclose protected health information (excluding mental health, alcohol or drug abuse or developmental disabled or HIV test result) for national security, for protection of the President and for medical suitability determination or of Armed Forces personnel to a state or federal agency.
Pain Clinic of Northwestern Wisconsin may disclose protected health information to limited staff of a correctional institution or a custodial law enforcement official for the provision of health care and the transport of inmates.

 

Workers compensation:
Pain Clinic of Northwestern Wisconsin may disclose protected health information reasonably related to a workers’ compensation injury.

Except for the situations listed above and treatment, payment or health care operation purposes, the use or disclosure of your health information requires Pain Clinic of Northwestern Wisconsin to obtain your written authorization. You may withdraw your authorization in writing at any time by submitting your written withdrawal to Pain Clinic of Northwestern Wisconsin’s Privacy Officer.

Patient Complaint Process
If you believe your privacy rights have been violated, you may file a complaint with Pain Clinic of Northwestern Wisconsin or with the Secretary of the Department of Health and Human Services. There will be no retaliation against you for filing a complaint.

To file a complaint with Pain Clinic of Northwestern Wisconsin please contact the Pain Clinic of Northwestern Wisconsin’s Privacy Officer who will provide you with the necessary assistance.

Questions or Concerns
If you have any questions or concerns regarding your privacy rights or the information in this notice, please contact:
Rhonda Shufelt
Pain Clinic of Northwestern Wisconsin
PO Box 1185
Eau Claire WI 54702
(715) 552-5346
fax: (715) 838-6596

 
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The Pain Clinic of Northwestern Wisconsin is an independent physician group whose services are provided in an outpatient setting. Most procedures and services are performed in the hospital, and patients are admitted to the facility where they are being treated. Other types of procedures and services are performed in an office setting in which the Pain Clinic of Northwestern Wisconsin rents office space from the hospital.

If you are being admitted through the hospital as an outpatient, you will receive two bills. One is from the Pain Clinic of Northwestern Wisconsin for the physician services provided; the second is for the facility charges from the hospital where you were seen. The Pain Clinic of Northwestern Wisconsin billing staff is happy to assist you with any questions you may have about your account or balance with us. If you have questions about a hospital bill, we would ask that you please contact the appropriate facility.

Our Responsibilities
We understand that health insurance can be confusing. Therefore, while it is ultimately your responsibility to know your insurance plan, we will make reasonable efforts to assist you by Scheduling you at a location covered by your insurance company.
Preauthorizing your visit if required. (Please see the section on Preauthorization.)
As a courtesy to you, our office will send bills for our services to your insurance company on your behalf.
We will bill your insurance company in a timely manner.
We will keep your personal medical and account information confidential according to state and federal law.

Patient Responsibilities
To help us bill your insurance accurately and in a timely manner, we will need some assistance from you. We would ask you provide our office with the following:

  • A copy of your current insurance card. We will ask for this at each visit.
  • Accurate demographic information (address, phone number, etc.)
  • If your visit is related to an injury, please provide appropriate information (date of injury, location, employer, worker’s compensation carrier, etc.)
  • Pay your bill on time (within 30 days of receiving a statement).
  • Know whether prior authorization from your insurance company is required in order for the insurance company to pay the bill.
  • Know whether or not our physicians and/or the facility where you are being seen are providers for your insurance plan.

Preauthorization
Preauthorization means getting approval from your insurance company before coming for your appointment. Not all insurance companies require a prior approval.
Sometimes insurance companies have special requirements for providing coverage for pain services. Some insurance companies require preauthorization for all types of services, while others require preauthorization only for certain procedures.
If our office is aware that you have an insurance plan that requires preauthorization, we will submit the appropriate information to your insurance company in order to get your visit and service approved. Also, there are some services that our office always preauthorizes, regardless of the insurance plan.
Please remember that it is up to you to understand the requirements of your individual insurance plan and that if a visit is not approved, your insurance company may not cover the service and you may be responsible for the bill.

Insurance Payment and Patient Responsibility
Most insurance companies do not cover 100% of the cost of services, and there is a portion that the patient is responsible for. There are several patient responsibility components that may apply to an insurance payment.
Deductible – A set annual amount that the patient is responsible for paying prior to his or her insurance making a payment.
Co-pay – A set dollar amount per office visit that is the patient’s responsibility.
Co-insurance – A percentage of the charge that the patient is responsible for.
Because of the contract you have with your insurance company, we are obligated to collect payment from you for your portion of the balance.

Payment Methods
We accept a variety of payment methods, including cash, check, money order, or credit card (Visa/MasterCard). Credit card payments may be accepted via phone, and the minimum credit card payment accepted is $15.
If you do not have insurance coverage and will be paying for the services yourself, a down payment may be required by the Pain Clinic of Northwestern Wisconsin and the facility where you are being treated.
We understand that there may be times and circumstances that come up where you are unable to pay your entire bill. In these situations it is VERY important that you contact our billing department so a representative can assist you in setting up a reasonable plan and to keep your account from being sent to a collection agency.

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