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  • OUR PRACTICE
    • Neurosurgeons
    • Interventional Pain
    • APRN/PA
  • CONDITIONS WE TREAT
    • Neck Pain
    • Back Pain
    • Pelvic Pain
  • SERVICES
    • Minimally Invasive Surgery
    • Pain Management
    • Educational Videos
  • DOCTORS ADVICE
  • PATIENT RESOURCES
  • LOCATIONS
  • MAKE APPOINTMENT
NeuSpine Institute LogoNeuSpine Institute Logo
  • OUR PRACTICE
    • Neurosurgeons
    • Interventional Pain
    • APRN/PA
  • CONDITIONS WE TREAT
    • Neck Pain
    • Back Pain
    • Pelvic Pain
  • SERVICES
    • Minimally Invasive Surgery
    • Pain Management
    • Educational Videos
  • DOCTORS ADVICE
  • PATIENT RESOURCES
  • LOCATIONS
  • MAKE APPOINTMENT
NeuSpine Institute LogoNeuSpine Institute Logo
  • OUR PRACTICE
    • Neurosurgeons
    • Interventional Pain
    • APRN/PA
  • CONDITIONS WE TREAT
    • Neck Pain
    • Back Pain
    • Pelvic Pain
  • SERVICES
    • Minimally Invasive Surgery
    • Pain Management
    • Educational Videos
  • DOCTORS ADVICE
  • PATIENT RESOURCES
  • LOCATIONS
  • MAKE APPOINTMENT

New Patient Form

New Patient Formkeys.darrell@gmail.com2024-04-09T18:14:02-04:00

Step 1 of 24 - Patient Information

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Patient Information

Name(Required)
MM slash DD slash YYYY
Address(Required)
Gender(Required)
Marital Status
Race/Ethnicity
Is your visit related to an Auto Accident?(Required)
Is there a legal case/litigation?(Required)
Is your visit related to a Work Accident?(Required)
Is there a legal case/litigation?(Required)
Is your visit related to a Slip & Fall?(Required)
Is there a legal case/litigation?(Required)

EMERGENCY CONTACT INFORMATION

Address
Address

Primary Care Physician

If you do not have one, enter N/A.
Address

Cardiologist

If you do not have one, enter N/A.
Address
Referral Source(Required)

Health Insurance Information

Person Responsible
MM slash DD slash YYYY

Additional Insurance

Person Responsible
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I, the Patient, recognize and agree that neither NeuSpine Institute nor its healthcare providers must bill any insurance available to me (except as required by Florida PIP laws) when the cause, in whole or part, of my condition(s) for which I seek any service(s) from NeuSpine Institute is a tort (the negligence of another), be it a motor vehicle collision, slip or trip and fall, or any other tort event, and in a tort setting NeuSpine Institute is hereby authorized not to bill any health insurance source available to me, including but not limited to Medicare, Medicaid, or other governmental insurance source. Regardless of whether there is any other possible payer (other than me) that may be available to NeuSpine Institute as a source for payment of my medical bills in whole or part, no matter what the cause of my condition(s) for which I seek any services from NeuSpine Institute, I, the Patient, hereby agree that I shall remain liable to NeuSpine Institute for payment of the full amounts charged to me by NeuSpine Institute for the services rendered by NeuSpine Institute, I have no right to seek or compel NeuSpine Institute to reduce any bill to me, and in any event, I hereby waive any alleged right I may have to seek or compel NeuSpine Institute to reduce any bill to me.

Cancellation/No Show Policy

Any Follow-up appointment cancellation or no-show in which a 24-hour notice is not provided, will result in a $50 charge. Any Injection appointment cancellation or no show in which a 24-hour notice is not provided, will result in a $75 charge.

After three occurrences, you will be terminated from NeuSpine Institute. 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, the Patient, recognize and agree that even if NeuSpine Institute terminates its relationship with me, I shall remain liable for payment of the full amount of all charges billed to me by NeuSpine Institute.

Late Policy:

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

MM slash DD slash YYYY

Social History

Occupation Status(Required)
Alcohol Use(Required)
Tobacco Use(Required)
Illegal Drug Use(Required)
Have you ever abused narcotic or prescription medications?(Required)

Family History

Mark all appropriate diagnoses as they pertain to your parents and siblings(Required)

Past Medical History/Treatment

LIST OF SURGERIES AND HOSPITALIZATIONS

MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
I have NEVER had any surgical procedures performed.

**Mark the following conditions/diseases that you have been treated for in the past**

Cancer/Oncology

Cancer-Type
Press + to add additional cancer types.

Cardiovascular/Hematologic

Cardiovascular/Hematologic(Required)
Gastrointestinal(Required)
Neurological(Required)
Urological(Required)
Respiratory(Required)
ENT(Required)
Musculoskeletal/Rheumatologic(Required)
Endocrinology(Required)
Psychological(Required)
Other Diagnosed Conditions(Required)
Press + to add additional diagnosed conditions.

Medication History

Are you currently taking any blood thinners or anti-coagulants?(Required)
Which ones?(Required)

Please list all medications you are CURRENTLY taking. Include all over the counter medications.

List Medications
Name
Dosage
Directions
Reason for Medication
 
Press + to add additional medications.

Pharmacy Information

Local Pharmacy

Address

Mail Order Pharmacy

Address
Do you have any drug/medication allergies?(Required)
If so, please list all allergies and symptoms if known
Medication Name
Symptom
 
Press + to add additional allergies and symptoms.
Topical Allergies
Please list all past pain medications that you have been on at any point for your current pain complaints. Include all over the counter medications.
Name
Dosage
Directions
Did this help you? Y/N
 
Press + to add additional pain medications.

ACKNOWLEDGEMENT AND CONSENT FOR NOTICE OF PRIVACY

Acknowledge of Receipt

I have reviewed the 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.

Patient Requested Copy(Required)
MM slash DD slash YYYY

Consent to Release Medical Information to Personal Representative

Consent(Required)
Consent Checkboxes(Required)
Do NOT release my information, except to health care providers and...(Required)
Name
Relationship
 
Press + to add additional individuals.

PATIENT AUTHORIZATION & CONSENT

I hereby voluntarily consent to medical treatment, including diagnosc procedures, surgical and other medical services, provided by NeuSpine Instute 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 collecon 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 aorney’s fees that may be incurred in such collecon efforts. I authorize but do not require NeuSpine Instute LLC physicians to submit claims to my insurance for services rendered by my medical providers. To be clear, NeuSpine Instute LLC is free to choose not to bill or seek payment from any insurance carrier of mine, except for PIP (as required by Florida law). I authorize the release of any medical informaon necessary to process this assignment on the claim. I authorize payment to be made to NeuSpine Instute LLC physicians for services provided by them if NeuSpine Instute LLC chooses to bill insurance.

MM slash DD slash YYYY

HIPAA Privacy Authorization Form

NEUSPINE INSTITUTE

HIPAA Privacy Authorization Form

Authorizaon for Use of Disclosure of Protected Health Information

(Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)

I Authorize NEUSPINE INSTITUTE LLC to use and disclose the protected health informaon described below.

By signing:

  1. I authorize the release of my complete health record (including records related to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse).
  2. This medical informaon may be used by the person I authorize to receive this informaon for medical treatment or consultaon, billing or claims payment, or other purposes as I may direct.
  3. This authorizaon shall be in force and effect during my enre care at NeuSpine Instute LLC.
  4. I understand that I have the right to revoke this authorizaon, in wring, at any me. I understand that a revocaon is not effecve to the extent that any person or enty has already acted in reliance on the authorizaon or if the authorizaon was obtained as a condion of obtaining insurance coverage and the insurer has a legal right to contest a claim.
  5. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be condioned on whether I sign this authorizaon.
  6. I may request to receive and inspect a copy of the informaon being used and disclosed pursuant to this Authorizaon form.
  7. I understand that informaon used or disclosed pursuant to this authorizaon may be disclosed by the recipient and may no longer be protected by federal or state law.
MM slash DD slash YYYY
MM slash DD slash YYYY

Assignment of benefits, liens, direct payment authorization, authorization to release

insurance information, and authorization to escrow unpaid medical & PIP benefits

NeuSpine Institute LLC

For and consideration of NEUSPINE INSTITUTE LLC agreeing to pursue the responsible person(s), which may include tortfeasor(s) and/or insurance carrier(s), for payment of benefits due and not requiring prepayment for services, I hereby irrevocably assign all rights and benefits to NEUSPINE INSTITUTE LLC for Medical Payment Coverage, and other benefits which I may have in accord with Florida Statutes §627.736. This includes any benefits from my insurance company and any other entity that may be responsible for medical expenses incurred. I further authorize NEUSPINE INSTITUTE LLC to collect payments & prosecute any necessary actions to collect payments for services as they see fit and allowable by law and contract. THIS DOCUMENT CONSTITUTES AN ASSIGNMENT OF RIGHTS AND BENEFITS.

This assignment concerns only the bills for NEUSPINE INSTITUTE LLC and those costs including, but not limited to, attorney’s fees, other costs, and interest necessary in procuring payment from the above-named insurance company and/or other entities. This assignment is not intended to assign any other causes of action that may belong to the undersigned patient. I agree to pay any applicable deductible or copayment not covered by any policy of insurance I may have. I understand that as a benefit and convenience to me, NEUSPINE INSTITUTE LLC may choose to bill or pursue collection against an insurance company or other responsible entity.. I hereby instruct and direct my insurance company that if billed by NEUSPINE INSTITUTE LLC to pay my benefits directly to NEUSPINE INSTITUTE LLC on the address provided on the bill. If my current policy prohibits direct payment to doctors, then I hereby instruct and direct my insurance company that if billed by NEUSPINE INSTITUTE LLC to make the check payable to me and mail it to NEUSPINE INSTITUTE LLC at the address on the bill. NEUSPINE INSTITUTE LLC’s medical care is being provided for a reasonable fee for treatment that I have sought out under my above-mentioned insurance carrier and is medically necessary from my perspective. I instruct my insurance carrier to pay these bills to the full extent of my available benefits under the insurance policy and Florida law. If any portion of the charge for these services is either reduced or denied in whole or in part, my insurance company is to place funds equal to the amount of the reduced or denied charges into escrow and hold the escrowed funds until agreement or resolution of legal action by NEUSPINE INSTITUTE LLC. I further instruct my insurance company that if billed by NEUSPINE INSTITUTE LLC, to make payment for charges thusly submitted by NEUSPINE INSTITUTE LLC in priority to any other request to escrow benefits, including a request by myself to reserve benefits for pending disability claims. I hereby give NEUSPINE INSTITUTE LLC limited power of attorney to endorse and sign my name on any draft for payment to either NEUSPINE INSTITUTE LLC or myself if said draft represents payment for charges related to services rendered by NEUSPINE INSTITUTE LLC.

I further direct my insurance carrier to provide information to NEUSPINE INSTITUTE LLC which is otherwise available to me including but not limited to the amount of copay of any applicable insurance policy, declaration page, all applicable endorsements, transcripts and/or copies of any recorded statements, examinations under oath and request for same, independent medical evaluations and requests for same, and peer review reports, this request includes the name of other medical providers to whom payments have been made under my policy of insurance. If any language within this agreement has the effect of invalidating this agreement , that language shall be deemed void and the remainder of the assignment shall maintain full force and effect. A photocopy of this assignment shall be considered as effective and valid as the original. Nothing in this agreement constitutes a delegation of any duties I may have under any policy of insurance to which I am a party.

If NEUSPINE INSTITUTE LLC elects to bill my insurance, I am responsible for copays, co-insurances, and deductibles prior to my office visits and surgery date if surgery is necessary.

MM slash DD slash YYYY

If patient is incapacitated or under the age of 18, please indicate the patient's name, guardian name and relation to patient and obtain guardian signature.

Review of Systems

Mark the following symptoms that you currently suffer from within the last 2 weeks

Constitutional(Required)
Eyes(Required)
Ear, Nose, Throat(Required)
Respiratory(Required)
Integumentary(Required)
Musculoskeletal(Required)
Neurological(Required)
Cardiovascular(Required)
Psychiatric(Required)
Hematological(Required)
Gastrointestinal(Required)
Genitourinary/Nephrology(Required)
Endocrine(Required)
Immunologic(Required)
Pulmonary(Required)

Pain History

Previous SPINAL or Brain/Head Surgeries
Where
When
Who
 
Press + to add additional spinal or brain/head surgeries.

Onset of Symptoms

Was this due to a motor vehicle accident?(Required)
Was this due to a Slip & Fall?(Required)
Did this happen at work?(Required)
How did your current/most recent symptoms or pain begin?(Required)
Since your pain began, how has it changed?(Required)

Pain Description

How often does the pain occur?(Required)
Nature of your pain?(Required)
If “0” is no pain and “10” is the worst pain, how would you rate your pain?(Required)
Current pain level
On your best day
On your worst day
 
What is your pain aggravated by?(Required)
How your pain is relieved?(Required)

Treatment History

Interventional Pain Treatment History

Epidural Steroid Injection
Medial Branch Blocks/Facet Injections
Radio Frequency Nerve Ablation

Please mark all of the following treatments you have had for pain relief.

Spine Surgery

Physical Therapy

Chiropractic Care

Massage Therapy

Brace Therapy

Acupuncture

Hot/Cold Packs

TENS Unit

Other Physicians or Specialists

OSWESTRY LOW BACK DISABILITY QUESTIONNAIRE

Instructions: this questionnaire has been designed to give us information as to how your back pain has affected your ability to manage everyday life. Please answer every section and mark in each section only the ONE box which applies to you at this time. We realize you may consider 2 of the statements in any section may relate to you, but please mark the box which most closely describes your current condition.

1. PAIN INTENSITY
2. PERSONAL CARE (e.g. Washing, Dressing)
3. LIFTING
4. WALKING
5. SITTING
6. STANDING
7. SLEEPING
8. SOCIAL LIFE
9. TRAVELLING
10. EMPLOYMENT/ HOMEMAKING

Disclosure for outstanding balances with active appointments.

Please be advised that Neuspine Institute is required to collect on any outstanding balances prior to appointments. It is the patient's responsibility to check what is owed from their insurance company's explanation of benefits (EOB) to determine what is outstanding. Any balances over thirty (30) days will need a full payment before being seen. In the event that no payment(s) can be made, then Neuspine Institute has the right to reschedule/cancel the appointment until the balance is paid in full or on an active payment plan is on file. Please keep in mind that payment plans for any accounts with balances over $500.00 will be considered after review.

By signing this form, you acknowledge that you are aware of the possibility for your appointment to be canceled or rescheduled due to the outstanding balance(s) and that a full payment may be needed to place you back on the schedule. If you have any question(s) regarding this disclosure, you may contact the Financial Counselor at 813-333-1186 ext. 425. Thank you for your cooperation on this matter.

Acknowledgement

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WHO WE ARE

At NeuSpine Institute, we specialize in diagnosing and localizing pain with a personalized treatment plan that fits your specific needs and pathology. Spinal surgery is a last resort, only to be undertaken after the failure of nonsurgical therapies such as physical therapy, interventional pain management, chiropractic, and spinal regenerative techniques.

LEARN MORE ABOUT US

CONTACT INFORMATION

  • Office
  • 813-333-1186

  • Fax
  • 844-691-5928
  • Wesley Chapel

  • 2590 Healing Way Suite 310
    Wesley Chapel, FL 33544

  • Zephyrhills
  • 38055 Arbor Ridge Dr.
    Zephyrhills, FL 33540
  • Odessa

  • 15141 Ogden Loop
    Odessa, FL 33556
  • Physical Therapy
  • 813-333-2060
  • Lakeland

  • 1507 Lakeland Hills Blvd Unit 107
    Lakeland, FL 33805
  • South Tampa

  • 2829 West De Leon St
    Tampa, FL 33609

  • Spring Hill

  • 8468 Northcliffe Blvd. Spring Hill, FL 34606

SERVICES / PROCEDURES

SERVICES/PROCEDURES

  • Minimally Invasive Surgery
  • Pain Management

© Copyright 2025 NeuSpine Institute | Privacy Notice

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