New Patient Packet

Thank you for choosing Central States Pain Clinic for your pain care and management needs. Below you will find appointment information for your visit, a map with directions and contact information, and forms to be filled out.

• Please arrive 30 minutes prior to your scheduled appointment time to complete paperwork.
• Please bring your photo ID, insurance card(s), and co-pay (if applicable).
• Please bring a list of your current medications.

Thank you for the pleasure of allowing Central States Pain Clinic providers and staff to be involved in your pain care. We look forward to seeing you at your first appointment. If you have any questions please feel free to call us at 515-267-1819 during normal business hours. Our office is open Monday through Friday, 8:00 am — 4:30 pm.

Please check to be sure the date and time of your appointment works for you. If you find that you have a conflict with your scheduled appointment time, we ask that you contact our office as soon as possible. We would like the opportunity to reschedule a time that will work better for you. This will allow us to release the time saved for you so we can serve other patients.

If you would like to fill out additional forms before your appointment you can access those through our patient portal. If you received an email from us then follow the instructions below. If you haven’t received an email call our office and we can send you an invitation, 515-267-1819.

Portal Instructions

We have emailed you your personalized login and temporary password to access your patient portal account. Here’s how you do it:

1. Open your email. The subject will be “Your Physician’s office has Requested Information”
2. Click the blue box at the bottom of the email saying “Login to Patient Registration Site”
3. You will be rerouted to the patient portal where you enter the information given to you in the email.
   a. Login ID
   b. Temporary password
4. The portal will prompt you to change your password
5. Then you will be asked for a “4 digit PIN” which is your 4 digit YEAR of birth i.e. 1976.

Location

Just off the 22nd Street exit off of interstate 235.
Just north of the interstate.
There is a Walgreens on the corner of 22nd and Westown.
We are just west of the Walgreens. 

Financial Policy

Central States Pain Clinic (CSPC) is committed to providing you the best possible care. Your clear understanding of our Financial Policy is important to our professional relationship. Please ask if you have any questions regarding our policy or your responsibility. Please inform us within 48 working hours of any insurance changes.

1. COPAYMENTS / DEDUCTIBLES / COINSURANCE: It is your responsibility to understand your insurance plan benefits and your responsibility for co-payments, co-insurance, and any deductible amounts for services you receive. Copayments are due at the time of service. If you are unable to make your payment at the time of service, CSPC reserves the right to reschedule your appointment until such time that you are able to make your payment. Payment plans are available. Please call the office to set one up.
2. FINANCIAL RESPONSIBILITY: Your insurance policy is a contract between you and your insurance carrier. You are ultimately responsible for payment in full for all medical services provided to you. Any charges not paid by your insurance carrier will be your responsibility.
3. COVERAGE CHANGES AND TIMELY SUBMISSION: It is your responsibility to timely inform us of any change to your billing or insurance information. Your insurance carrier places a time limit within which CSPC can submit a claim on your behalf. If CSPC is unable to process your claim within this period due to your providing incorrect insurance information or not responding to insurance carrier inquiries, you will be responsible for all charges.
4. INSURANCE PLAN PARTICIPATION: CSPC has specific network agreements with many insurance carriers, but not all insurance carriers. It is your responsibility to contact your insurance carrier to verify that your assigned provider here participates in your plan. Your insurance carrier’s plan may have out of network charges that have higher deductibles and copayments, which you will be responsible for.
5. WORK COMP / MOTOR VEHICLE ACCIDENT: If you are here as a result of a work related injury or motor vehicle accident, we will require information regarding your employer’s Workers’ Compensation insurance carrier or responsible party’s motor vehicle insurance. If we cannot verify that the carrier responsible for this service, then the patient will receive the bill.
6. SELF PAY: If you do not have health insurance your charges will be based on our current self-pay fee schedule. Payment is due in full at the time of service.
7. PRIOR AUTHORIZATIONS AND NON COVERED SERVICES: CSPC may provide services that your insurance carrier’s plan excludes or requires a prior authorization. CSPC as a courtesy to our patients, will make a good-faith effort to determine if services we provide are covered by your insurance carrier’s plan, and, if so, determine if prior authorization for treatment is required. If determined that a prior authorization is required, we will attempt to obtain such authorization on your behalf. Ultimately, it is your responsibility to ensure that services provided to you are covered benefits and authorized by your insurance carrier.
8. UNPAID ACCOUNTS: IF you have an outstanding balance over 120 days old and have failed to make payment arrangements or become delinquent on an existing payment plan, we may turn your balance over to a collection agency and will require payment for services provided on the day of service.
9. RETURNED CHECKS: YOU will be charged a $40 dollar returned check fee.
10. REFUNDS: Refunds for overpayment are processed only after full insurance reimbursement of all medical services has been received. If you believe you have a refund please call the office.

I have read and understand the financial policy and agree to abide by its guidelines.