Office Policies

Please review our current policies. These are subject to change from time to time.


Patients are expected to pay any outstanding balances to the practice in a timely fashion. If you have questions regarding an existing bill or potential financial obligations related to your medical treatment, please call us at 317-706-7246 and ask for the billing office.

We are unable to offer self pay or other reduced rates for medical treatment. We do, however, recognize that medical care is expensive and unexpected circumstances do arise, so we offer a variety of payment plans. Any reduction in fees or balances can be made only on the basis of legitimate financial hardship and require valid completion of a Financial Hardship Form and may require additional documentation. Our decision and the terms, if applicable, will be conveyed to you as soon as possible.

Appointment Cancellations

All appointments require a minimum 24-hour cancellation notice to avoid a “no show” fee. For a missed appointment or cancellation with less than 24 hours notice for an appointment scheduled with Alina M. Clavijo, PhD, HSPP, you will be charged the full $160.00 for the session missed. All other appointments cancelled with less than 24-hour notice will be charged a $25.00 fee. This charge is the responsibility of the patient, not the insurance carrier. Cancellation penalties are required to be paid in full at the time of your next appointment.

Please arrive on time for your appointments. If you are more than 15 minutes late for any appointment, you may be required to reschedule. Also please allow sufficient time for your appointment. We understand that your problem may not always fit into a 15 minute visit, and that is also true for the other patients under our care.

All procedure appointments are confirmed 24-hours in advance. We must have a valid daytime phone number for you to confirm these appointments in person. Please advise the office staff of a preferred phone number for appointment confirmations.

Disability Forms & Paperwork

Effective January 2016, the Center for Pain Management NO LONGER completes any NEW forms or paperwork in support of Long Term Disability for any patients. If we completed Long Term Disability forms or paperwork for a patient PRIOR to December 31, 2015, we will continue to complete Re-Certifications as long as the individual remains an active patient in good standing at our practice. In addition, the Center for Pain Management WILL continue to complete patient paperwork/forms for Short Term Disability and FMLA to cover the duration of their treatment.

  • There will be a charge that must be paid prior to the completion of paperwork/forms. This charge ranges from $15.00 to $400.00 depending on the complexity of the request. The charge for most forms is $25.00.
  • Ten working days will be required for the completion of paperwork/forms.
  • The completion of some paperwork/forms may require an office visit if additional assessment is required.
  • We reserve the right to refuse to complete paperwork/forms if it requires information that we do not have as a part of your treatment with us.

Medical Records

Certain medical records must be in our hands and reviewed by our medical director before an appointment is scheduled for you. These records include recent office visit notes with your primary care physician or other physician(s) who has been treating the condition for which you are requesting an appointment to see us, a complete list of current medications, notes from previous surgeries/procedures related to your pain, radiology reports from X-ray, MRI, or CT exams (films are helpful, as well), and insurance information. A referral from your primary care physician is required if deemed necessary by your insurance carrier. Additionally, if you have been treated at a pain facility before, we will need to have those records for review.

Only once we have these records on hand and reviewed will we be able to schedule your appointment. No patient will be scheduled for an initial visit without providing all of the appropriate records first. It is your responsibility to make arrangements to get us the complete list of records; our office staff is not responsible for procuring your medical records.

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