New Patient Form

Patient Information

Date format must be dd-mm-yyyy e.g. 31-12-1999
Date format must be dd-mm-yyyy e.g. 31-12-1999

Emergency Contact Information

Provider History

Primary Care Physician

Cardiologist

Other

Insurance Information

Primary Insurance

Date format must be dd-mm-yyyy e.g. 31-12-1999

Secondary Insurance

Date format must be dd-mm-yyyy e.g. 31-12-1999

Pharmacy Information

Local Pharmacy

Mail Order Pharmacy

Financial and Consent Agreement

ALL PROFESSIONAL FEES ARE DUE AT THE TIME OF SERVICE, UNLESS PREVIOUS ARRANGEMENTS HAVE BEEN MADE

Patient Information Form - Financial Agreement

  1. Services are rendered to the patient, not the insurance company. Our office will file your insurance if proper information is received.
    • You are responsible for Co-Pays, Deductibles, Non-Covered Services, Co-Insurance and items considered “not medically necessary” by insurance.
    • For unpaid claims over 45 days, it is your responsibility to follow up with your insurance company and the balance may be considered due and payable.
  2. It is your responsibility to notify our front desk of any insurance or address changes.
  3. You will be responsible for any changes that occur if your current insurance is not communicated at the time of service.
  4. Expenses incurred to collect patient-responsible debt may be charged to the patient or guarantor.
Date format must be dd-mm-yyyy e.g. 31-12-1999

MEDICAL INFORMATION

Please circle:

LIST OF SURGERIES AND HOSPITALIZATIONS

      
      
Date format must be dd-mm-yyyy e.g. 31-12-1999Date format must be dd-mm-yyyy e.g. 31-12-1999Date format must be dd-mm-yyyy e.g. 31-12-1999Date format must be dd-mm-yyyy e.g. 31-12-1999Date format must be dd-mm-yyyy e.g. 31-12-1999Date format must be dd-mm-yyyy e.g. 31-12-1999

Medications

Please list all medications you are taking or provide a list (Include all over the counter medications and medications taken within the last month)

If you are not currently taking any medications, please write N/A.
If you do not have any allergies, please write N/A.
Diabetes High Blood Pressure High Cholesterol Stroke or mini-stroke Aneurysm Chest Pain Heart Attack Congestive Heart Failure Abnormal Heart Rhythm Pacemaker or AICD Anemia Headaches Anxiety Depression Asthma Cataracts Pneumonia Emphysema or COPD Acid Reflux Ulcerative colitis or Crohn’s Disease Kidney failure/problems HIV or AIDs Hepatitis Bleeding or Clotting problems Hypothyroidism Hyperthyroidism Cancer Arthritis Osteoporosis Glaucoma Epilepsy

Acknowledgement and Consent For Notice of Privacy

Acknowledge of Receipt

I have reviewed NeuSpine Institute LLC Notice of Privacy, which explained how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document at no cost to me.

Date format must be dd-mm-yyyy e.g. 31-12-1999

Consent to Release Medical Information to Personal Representative

I, , hereby consent to have my information released to the following individuals. This consent will remain in effect until otherwise notified by me in writing.

Appointment times Medical Information Billing/Demographic Info

Do NOT release my information, except to health care providers and…

Date format must be dd-mm-yyyy e.g. 31-12-1999

Patient Authorization & Consent

I hereby voluntary consent to medical treatment, including diagnostic producers, surgical and other medical services, provided by NeuSpine Institute LLC or their authorized designees, as they may in their professional judgment be necessary to provide appropriate medical, surgical or emergency care. I agree to reimburse the fees of any collection agency, which may be based on a percentage at a maximum of 50% of the debt, all costs, and expenses, including but not limited to reasonable attorney’s fees that may incur in such collection efforts.

I authorize NeuSpine Institute LLC physicians to submit claims to my insurance for services rendered by my medical providers. I authorized the release of any medical information necessary to process this assignment on the claim. I authorize payment to be made to NeuSpine Institute LLC physicians for services provided by them.

Date format must be dd-mm-yyyy e.g. 31-12-1999

To All Patients:

In order to provide you with good service, it is of great importance we have your current address and phone number on file. Please be sure to contact us if your phone number and/or address changes. This information will be utilized to remind you of your appointment date and time.

Cancellation/No Show Policy:

Any cancellation, broken appointments, or no shows in which a 24-hour notice is not provided, after three occurrences, will result in termination from NeuSpine Institute.

Late Arrival Policy:

The clinic has limited waiting time for your appointment. If you are more than 15 minutes late, your appointment will be rescheduled.

If we terminate our service with you, we will be happy to transfer a copy of your medical records to your new physician upon receipt of a signed authorization to release records.

I have been informed and understand the policies listed above. I also understand if I fail to provide a 24-hour notice of a broken appointment, I will incur a service charge of $50.00.

Date format must be dd-mm-yyyy e.g. 31-12-1999

New Patient Information

Please make sure that a response is written in EVERY SPACE

Previous SPINAL Surgeries:

Previous Treatment (please answer yes/no and details as applicable)

Date format must be dd-mm-yyyy e.g. 31-12-1999

Have you seen any other providers since your last visit?

Please circle any symptoms you have experienced in the last two weeks:

Fever Night sweats Chills Appetite Change Fatigue
Swollen glands Rash Ulcer Laceration Hives Bruising Sores Hair loss Itching
Sore throat Ear Ache Sinus drainage Hoarseness Loss of hearing Jaw pain Neck Pain
Double vision Other visual changes Pain from bright lights Blind Spots
Shortness of breath Wheezing Chest pain Sputum Cough Coughing up blood
Chest pain Palpitations Swelling Fainting Shortness of breath
Nausea Vomiting Abdominal Pain Acid Reflux Difficulty Swallowing Choking Diarrhea
Painful Urination Incontinence Blood in urine Frequent Urination
Redness Pain Weakness Joint Swelling Prior Fractures
Fainting Seizure Memory loss Paralysis Prior head injury Numbness Weakness
Depression Anxiety Psychosis Delirium Fainting Seizure Paralysis
Easy Bruising Bleeding gums History of blood clots Nose bleed
Heat or cold intolerance History of Diabetes Thyroid Disease
Date format must be dd-mm-yyyy e.g. 31-12-1999

Analogue Scales

Upper Pain

Lower Pain

Add Symptoms for the parts mentioned below (Burning, Numbness, Stabbing Pain, Weakness, Aching)

Front Part of Body
Back Part of Body