New Patient Form - NeuSpine Institute

Patient Information

Today’s Date:Date format must be dd-mm-yyyy e.g. 31-12-1999

Last Name:

First Name:

Middle Initial:

Address:

Gender:Male Female

Social Security #:

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

Home Phone:

Cell Phone:

Work Phone

E-mail:

Preferred Method of Contact:Phone E-mail

Marital Status:Single Married Divorced Widowed

Is your visit related to an Auto Accident?Yes No

Referring Physician (if applicable):

Emergency Contact Information

1. Name:

Relationship:

Address:

Home Phone:

Cell Phone:

Work Phone:

2. Name:

Relationship:

Address:

Home Phone:

Cell Phone:

Work Phone:

Provider History

Primary Care Physician

Name:

Phone Number:

Address:

Cardiologist

Name:

Phone Number:

Address:

Other

Name:

Phone Number:

Address:

Insurance Information

Primary Insurance

Person Responsible:Self Other

Relationship to Patient:

Name:

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

Social Security #:

Insurance Company:

ID Number:

Insurance Phone:

Group #:

Secondary Insurance

Person Responsible:Self Other

Relationship to Patient:

Name:

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

Social Security #:

Insurance Company:

ID Number:

Insurance Phone:

Group #:

Pharmacy Information

Local Pharmacy

Name:

Phone Number:

Address:

Mail Order Pharmacy

Name:

Phone Number:

Address:

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

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.
It is your responsibility to notify our front desk of any insurance or address changes.
You will be responsible for any changes that occur if your current insurance is not communicated at the time of service.
Expenses incurred to collect patient-responsible debt may be charged to the patient or guarantor.

Patient/Legal Guardian Printed Name

Patient/Legal Guardian Signature

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

MEDICAL INFORMATION

Please circle:

Do you smoke cigarettes?Yes No

How many per day?

Are you a former smoker?Yes No

Last used?

Do you drink alcohol?YesNo

How often?

Do you participate in recreational drug use?YesNo

What kind?

LIST OF SURGERIES AND HOSPITALIZATIONS

Hospital Name

Reason

DateDate 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)

Name

Dosage

Directions

Reason for Medication

If you are not currently taking any medications, please write N/A.

Please list all allergies and symptoms if known:

If you do not have any allergies, please write N/A.

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.

Patient requested copy:Yes No

Name of Patient (Please Print)

Signature of Patient of Legal Guardian

DateDate 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…

Name

Relationship

Name

Relationship

Name

Relationship

Signature of Patient of Legal Guardian

DateDate 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.

Signature of Patient of Legal Guardian

DateDate 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.

Patient/Legal Guardian Printed Name

Patient/Legal Guardian Signature

DateDate 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

Name

Previous SPINAL Surgeries:

Where:

When:

Who:

When did it start?

Was there an event/injury that caused your pain to start?

What makes your pain worse?

What makes your pain feel better?

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

Bracing therapy

When

How long

Did it help

Physical Therapy

When

How long

Did it help

Chiropractor

When

How long

Did it help

Acupuncture

When

How long

Did it help

Massage Therapy

When

How long

Did it help

Pain Management

Doctor’s name

When

How long

Did it help

What did they do?

Injections

What part of body

What kind

When

How many

Did it help

Previous evaluated by spinal surgeon?(If so, who?)

Other tests/Doctors:

Are you on any blood thinners such as aspirin?

Name:

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

Pharmacy Name:

Pharmacy Phone:

Have you seen any other providers since your last visit?

Yes:

No:

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

Name:

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

Analogue Scales

Upper Pain

1) Mark your current NECK PAIN based on the scale below

2) Mark your current ARM PAIN based on the scale below

Lower Pain

1) Mark your current BACK PAIN based on the scale below

2) Mark your current LEG PAIN based on the scale below

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

Front Part of Body Neck

Back Part of BodyNeck

Right arm

Left arm

Back

Stomach

Right leg

Left leg