American Board Certified in Pain Medicine
American Board Certified in Anesthesia
Phone: 808-244-4564
Fax: 877-234-3819 (new)
Email: mpc@mauipainclinic.net
1063 Lower Main St.
Suite C-213
Wailuku, HI 96793
Dear Patients and Physicians
1. Our clinic currently has very limited clinic hours on Saturdays with most of our procedures being performed on Wednesdays at the hospital. As a result, some initiation of medications and early fine tuning of medications can be done at our office, however C-2 narcotics which must be written for every 30 days as required by law can only be initiated at this clinic and can not refilled due to the lack of having a clinic day in the near range of 30 day intervals. If the physician expressly wants only medical recommendations, but not to begin medications, please express this in the physician's referral forms.
2. Our clinic believes that pain management is a multidiscipline approach requireing the skills of often multiple specialties and services. Thus, a pain patient can require additional referrals to other physicians for consultation and management services.
3. We do not see patients without a physician referral, perferrably from their primary care physician. This policy is directly related to our belief that primary care physicians are the most important physicians in the treatment of chronic pain as they are most likely to develop a long term, deeper understading of their patient's needs than a consultant can ever achieve. Also, medical management of pain patients requires the input of a primary care physician.
Maui Pain Clinic is not accepting Quest or Medicaid for insurance reimbursement.
Dear Patient:
Please review our office policies below:
We believe patient education about their pain is the most powerful tool in their decision making regarding the type of care they choose. We strongly encourage and at times will require a patient to read about the treatment therapies we are recommending. Please visit our useful links page to further understand your pain condition and possible treatments.
Maui Pain Clinic does everything possible to minimize the cost of medical care. You can help a great deal by eliminating the need for us to bill you. The following is summary of our payment policy.
Patient policy Aggreement (As signed by patient in patient's pain questionaire):
I, _____________________________________ filled this questioner form truthfully and at the best of my knowledge.
I agree to proceed with a pain consultation and treatment with Maui Pain Clinic.
I agree to keep my appointment with my primary physician and/or referral physician for care of my general health problems.
I understand that Dr. Kern at Maui Pain Clinic will make recommendations to primary care or other referring physician for narcotics, but Dr. Kern will not be providing narcotics for patients on a regular basis since long term care is not possible at Maui Pain Clinic. Primary Care or other referring physician will make the final decision as to the appropriateness with regards to prescribing narcotics on a long tern basis and all narcotics will be written for my one and only one physician as part of your agreement to be seen at Maui Pain Clinic. In the rare instance that Dr. Kern refills my narcotic prescription or starts a narcotic prescription, this will not imply that Dr. Kern will continue prescribing narcotics to me. Ultimately, your primary care or referring physician will determine if long term use of narcotics is most appropriate for you.
I authorize the release of any medical or other information necessary for my medical care and to process this insurance claim.
I assign all medical benefits to include major medical benefits to which I am entitled, including Medicare, Private insurance, and third party payors to Dr. Kern, Maui Pain Clinic, LLC. A photocopy of this assignment is considered valid as original. I hereby authorize said assignee to release all information necessary, including Medical Records, to secure payment.
I also certify I have read “Notice of Privacy Practices” as well as Policies of Maui Pain Clinic from www.mauipainclinic.net and agree with its content. If I had any questions they were answered to my satisfaction.
I understand that Maui Pain Clinic only bills my Insurance as a courtesy. For any reason, if my insurance does not pay for Dr. Kevin Kern’ services provided to my medical care, I will be personally responsible for all of these medical charges. I understand that Dr. Kern, Maui Pain Clinic requires payment for my estimated share to be made when services are rendered to me.
If my insurance carrier does not remit payment within 60 days, the balance will be due in full from me. From time of billing I have 30 days to pay my bill in full. If payment is not made in 30 days a 5% monthly late charge will be bill to my account until the bill is paid in full. If there is no payment to my account within 120 days of my first statement the account will be sent to a collection agency. I understand that I am responsible for any court costs, collection agency fees, and/or attorney fees needed to collect monies owed to Dr. Kern, Maui Pain Clinic. In the event that my insurance company requests refund of payments made, I will be responsible for the amount of money refunded to my insurance company.
If any payment is made to me for services billed by Dr. Kern, Maui Pain Clinic, I recognize an obligation to promptly remit same to Dr. Kern Maui Pain Clinic.
The above does not apply for those of patients that area considered Worker’s Compensation. However, be advised if you claim Worker’s Compensation benefits are subsequently denied such benefits, I may be responsible for the total amount of charges for service rendered to me.
**** I understand a $35 cancellation fee is charge for appointments missed without 24 hour notice*****
**** I understand a $25 fee for any returned checks *********
I understand the above statements and my signature below represents my understanding and agreement of above statements. Any questions I have had regarding these statement have been answered to my satisfaction.
.
Billing Questions
If you should need any assistance or have questions, please call our clinic between 8:00 a.m.—4:00 p.m., Monday through Friday at 808.244.4564.
Refunds
Overpayments will be refunded upon written request to the responsible party within 30 days of our office confirmation.
Missed Appointments /Untimely Cancellations
Missed appointments represent a cost to us, to you and to other patients who could have been seen in the time set aside for you. If you are unable to keep your appointment, please give 24-hours notice to avoid charge. We reserve the right to charge for missed or untimely canceled appointments in the amount of $25.00 and collection fee if applicable. Excessive abuse of scheduled appointments may result in discharge from the practice.