Appointment Policy

We require 24 hour notice for an appointment cancellation. Please be aware that there is a $50 fee for missing a scheduled appointment or procedure. These charges are your responsibility and will not be billed to your insurance company.

Patients with 3 or more non-canceled or no-show visits will be discharged from clinic. We ask that you help us in serving you better by keeping your scheduled appointments or giving 24 hour notice before any cancellation.

Financial Policy

All non-covered services and co-pays are payable at the time of service. We accept cash, checks and MasterCard, Visa, and Discover.

Fees for services provided and not paid for at time of service are due and payable within 60 days. You will receive a statement each month for any unpaid balances. We will charge a $20 service fee for all returned checks.

All procedures performed have physician and separate facility charges.

Many patients are covered by health insurance contracts, which provide for reimbursement for specific medical fees. If you are not familiar with your policy, it is suggested that you discuss coverage with your carrier before charges are incurred. All insurance policies are between you and your insurance carrier. Your doctor's bill is an agreement between you and your physician. Our fees may be more or less than the payment schedule used by your insurance carrier. You are personally responsible for full payment of fees, regardless of any insurance carrier. You are personally responsible for full payment of fees, regardless of any insurance company's arbitrary determination of Usual & Customary. Our physicians are "Preferred Providers" for certain HMOs and PPOs. The contracts that we have signed with these specific carriers supersede our Usual & Customary policy. For our patients who are subscribers to these insurance plans, you will not be billed for amounts above our negotiated fee schedule, with the exception of co-pays, co-insurances, and deductible amounts as stated per your contract.

As a courtesy, we will submit insurance claims for you. We accept Medicare assignment. If the patient's insurance requires that a referral is necessary, it is the responsibility of the patient to obtain one from their primary care physician prior to their appointment. We reserve the right to refuse service to any patient who does not have a valid referral in our office at the time of their appointment. Many of the services that our office provides requires pre-authorization, and we ask that you be patient with our office obtain this authorization. Many insurance companies require documentation prior to authorizing services and we will do our best to comply in a timely fashion with their requests. We reserve the right to charge a $25 fee if they fail to give at least a 24-to-48- hour appointment cancellation notice. This fee will be paid by the patient, regardless of insurance.

Extended payment plans can be arranged through our billing office. These plans are based upon financial circumstances of each patient. We invite you to discuss any financial difficulties by calling (262) 797-4053.

Prescription Policy

• Medication refill appointments must be scheduled at least two (2) weeks in advance. It is the patients' responsibility to keep track of the amount of medication remaining and to schedule appointments appropriately.
• All patients must refrain from excessive phone calls to our nursing staff. One phone call per 24 hours is appropriate.
• All narcotics must come from one physician. You must notify our doctors of any medication orders made by other physicians while under the care of Great Midwest Pain Center.
• All medications must be obtained at the same pharmacy.
• The prescribing physician has complete liberty to discuss fully all diagnostic and treatment details with the pharmacist at the dispensing pharmacy for purpose of maintaining accountability.
• Random urine toxicology screening may be done at any time. Failure to comply with random drug screens is reasonable cause for discharge from Great Midwest Pain Center.
• Medication will not be replaced if they are lost, fall into the toilet, are eaten by pets, left on the airplane, or any other reason. If your medications are stolen and you complete a police report regarding the theft, we may make an exception.
• All medications are to be kept in a safe place, especially away from children. They may be hazardous or lethal should they be inadvertently taken by any person other than who they were prescribed for.
• Take medications only as prescribed. Early refills will not be given. If you use a month's supply of medication in three weeks, the last week must be endured with no medication.
• Avoid the use of alcohol, which alters mental alertness, if receiving medication from our office. Refrain from the operation of an automobile and machinery while under the influence of medications that alter mental status. If you are unsure if the medication you are taking will alter mental status, check with our office.
• Script altering is a federal offense and we will report any violation to the proper authorities.
• Should your prescription need to be changed prior to your due date; all unused medication must be brought to our office prior to receiving a new prescription.
• We reserve the right to communicate with previous and present physicians that have cared for you and/or your previous or present insurance carriers.

If drug dependence, tolerance or addiction occurs, I agree to accept full responsibility for the risks taken secondary to my consent of narcotic consumption for the management of my pain. Should withdrawal symptoms be encountered, I will notify Great Midwest Pain Center. This medication should be stopped slowly with tapering. Medication is not to be stopped on your own without medical advice. Evidence of medication hoarding, increasing use of the medication without communication with pain clinic staff, refilling your prescription too frequently, getting the medication from multiple physicians or pharmacies, increasing amounts of medications, altering prescriptions, medication sales, unapproved use of other drugs (alcohol, sedatives, or street drugs) during narcotic analgesic treatment or other unacceptable behavior will result in tapering, discontinuing narcotic maintenance therapy, and potential discharge.

Side effects of narcotic medication may include drowsiness, dizziness, constipation, nausea, and/or confusion. Risk of psychological dependence with the use of these medications may occur. Physical dependence is frequently encountered in the use of long-term narcotic therapy. Medication needs to be withdrawn gradually to avoid uncomfortable withdrawal symptoms that may include excessive tearing, runny nose, dilated pupils, goose-pimple flesh, sweating, yawning, diarrhea, muscle aches, headache, and insomnia. Tolerance to the use of narcotic medication may occur, decreasing effectiveness.