New Patient Form

Step 1 of 24 - Patient Information

Patient Information

Name(Required)

First Middle Initial Last

Date of Birth(Required)

MM slash DD slash YYYY

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Gender(Required)

Male

Female

Social Security #

Home Phone

Cell Phone(Required)

Work Phone

Email(Required)

Marital Status

Single

Married

Divorced

Widowed

Race/Ethnicity

American Indian

Hispanic/Latino

Asian

African American

White

Other

Is your visit related to an Auto Accident?(Required)

Yes

Is there a legal case/litigation?(Required)

Yes

Is your visit related to a Work Accident?(Required)

Yes

Is there a legal case/litigation?(Required)

Yes

Is your visit related to a Slip & Fall?(Required)

Yes

Is there a legal case/litigation?(Required)

Yes

Describe the event(s) in detail, including the date(s) of the event(s)(Required)

EMERGENCY CONTACT INFORMATION

Name

Relationship

Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Work Phone

Name

Relationship

Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Work Phone

Primary Care Physician

Name(Required)

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

Phone Number

Fax

Address

Street Address Address Line 2 City State ZIP Code

Cardiologist

Name(Required)

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

Phone Number

Address

Street Address Address Line 2 City State ZIP Code

Referral Source(Required)

Primary Physician

Friend/Family

Specialist

Chiropractor

Online Search

Primary Physician(Required)

Friend/Family(Required)

Advertisement(Required)

Specialist(Required)

Chiropractor(Required)

Online Search(Required)

Health Insurance Information

Person Responsible

Self

Other

Relationship to Patient

Name

Social Security #

DOB

MM slash DD slash YYYY

Insurance Company

ID Number:

Insurance Phone

Group #

Additional Insurance

Person Responsible

Self

Other

Relationship to Patient

Name

Social Security #

DOB

MM slash DD slash YYYY

Insurance Company

ID Number:

Insurance Phone

Group #

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.

Signature of Patient of Legal Guardian(Required)

Date(Required)

MM slash DD slash YYYY

Social History

Occupation

When was the last time you worked?(Required)

Occupation Status(Required)

Employed

Temporary Disability

Permanent Disability

Retired

Unemployed

Alcohol Use(Required)

Social Use

Daily use of alcohol

Never

History of alcoholism

Current alcoholism

Tobacco Use(Required)

Current user

Former user

Never used

How long has it been since you stopped smoking(Required)

Packs per day(Required)

How many years(Required)

Illegal Drug Use(Required)

Denies any illegal drug use

Currently uses illegal drugs

Formerly used illegal drugs

Have you ever abused narcotic or prescription medications?(Required)

Yes

Family History

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

Arthritis

Diabetes

Cancer

Headaches/Migraines

High Blood Pressure

Kidney Problems

Liver Problems

Osteoporosis

Rheumatoid arthritis

Seizures

Stroke

Past Medical History/Treatment

LIST OF SURGERIES AND HOSPITALIZATIONS

Hospital Name

Reason

Date

MM slash DD slash YYYY

Hospital Name

Reason

Date

MM slash DD slash YYYY

Hospital Name

Reason

Date

MM slash DD slash YYYY

Hospital Name

Reason

Date

MM slash DD slash YYYY

Hospital Name

Reason

Date

MM slash DD slash YYYY

Hospital Name

Reason

Date

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)

Anemia

Heart Attack

Coronary Artery Disease

Stroke/TIA

Heart Valve Disorder

Peripheral Vascular Disease

Presence of stent/pacemaker/defibrillator

High Blood Pressure

None of the above

Gastrointestinal(Required)

GERD ( Acid Reflux)

IBS

Gastrointestinal Bleeding

Crohn's's Disease

Stomach Ulcers

None of the above

Neurological(Required)

Multiple Sclerosis

Seizures

Balance Disorder

Peripheral Neuropathy

Head Injury

Headaches

Migraine

None of the above

Urological(Required)

Chronic Kidney Disease

Kidney Stones

Urinary Incontinence

Dialysis

None of the above

Respiratory(Required)

Asthma

Bronchitis/Pneumonia

Emphysema/COPD

None of the above

ENT(Required)

Glaucoma

Vertigo

Hearing Problems

Nosebleeds

None of the above

Musculoskeletal/Rheumatologic(Required)

Bursitis

Osteoarthritis

Osteoporosis

Fibromyalgia

Carpal Tunnel Syndrome

Rheumatoid Arthritis

Chronic Joint Pains

None of the above

Endocrinology(Required)

Diabetes

Hyperthyroidism

Hypothyroidism

None of the above

Diabetes - Type(Required)

Psychological(Required)

Depression

Anxiety

ADD/ADHD

Schizophrenia

PTSD

Bipolar Disorder

Other

None of the above

Other - Type(Required)

Other Diagnosed Conditions(Required)

Press + to add additional diagnosed conditions.

Medication History

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

Yes

Which ones?(Required)

Aspirin

Plavix

Coumadin

Lovenox

Other

Other(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

Name

Address

Street Address Address Line 2 City State ZIP Code

Phone

Mail Order Pharmacy

Name

Address

Street Address Address Line 2 City State ZIP Code

Phone

Do you have any drug/medication allergies?(Required)

Yes

If so, please list all allergies and symptoms if known

Medication Name

Symptom

Press + to add additional allergies and symptoms.

Topical Allergies

Latex

Iodine

Tape

IV Contrast

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)

Yes

Name of Patient (Please Print)(Required)

Signature of Patient of Legal Guardian(Required)

Date(Required)

MM slash DD slash YYYY

Consent to Release Medical Information to Personal Representative

Consent(Required)

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.(Required)

Consent Checkboxes(Required)

Appointment times

Medical Information

Billing/Demographic Info

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

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.

Signature of Patient of Legal Guardian(Required)

Date(Required)

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:

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).
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.
This authorizaon shall be in force and effect during my enre care at NeuSpine Instute LLC.
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.
I understand that my treatment, payment, enrollment, or eligibility for benefits will not be condioned on whether I sign this authorizaon.
I may request to receive and inspect a copy of the informaon being used and disclosed pursuant to this Authorizaon form.
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.

Patient Name(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Patient Signature(Required)

Date(Required)

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

Insurance Carrier(Required)

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.

Patient Signature(Required)

Patient Name(Required)

Date(Required)

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)

Fever

Chills

Sweats

Weakness

Fatigue

Decreased Activity

Malaise

Unexplained Weight Loss

Unexplained Weight Gain

Low Sex Drive

Difficulty Sleeping

None of the above

Eyes(Required)

Blurriness

Double Vision

Pain

Visual Disturbance

Visual Change

None of the above

Ear, Nose, Throat(Required)

Hearing Problems

Ear Pain

Sore Throat

Sinus Problems

Nose Bleeds

None of the above

Respiratory(Required)

Sputum Production

Shortness of Breath

Cough

Wheezing

None of the above

Integumentary(Required)

Rash

Itching

Lesion

Bruising

None of the above

Musculoskeletal(Required)

Back Pain

Neck Pain

Joint Pain

Muscle Pain

Muscle Cramp

Muscle Spasm

Gait Disturbances

Joint Stiffness

Joing Swelling

Trauma

None of the above

Neurological(Required)

Abnormal Balance

Confusion

Numbness

Tingling

Dizziness

Headaches

Loss of Coordination

Memory Loss

Seizures

Tinnitus

Tremors

Vertigo

None of the above

Cardiovascular(Required)

Chest pain

Palpitations

Swelling in Feet

Bleeding Disorder

Blood Clots

Fainting

Shortness of Breath During Sleep

None of the above

Psychiatric(Required)

Feeling Anxious

Depressed Mood

Suicidal Thoughts

Hallucination

Stress Problems

Suicidal Planning

Thoughts of harming others

None of the above

Hematological(Required)

Anemia

Blood Clots

Easy bruising/bleeding

Swollen Legs

Transfusion

None of the above

Gastrointestinal(Required)

Nausea

Vomiting

Diarrhea

Constipation

Heartburn

Abdonminal Pain

None of the above

Genitourinary/Nephrology(Required)

Painful Urination

Blood in urine

Change in Urine Stream

Unusual Discharge

Flank Pain

Urinary Incontinence

None of the above

Endocrine(Required)

Cold Intolerance

Heat Intolerance

History of Diabetes

Thyroid Disease

None of the above

Immunologic(Required)

HIV Exposure

Hives

Persistent Infections

None of the above

Pulmonary(Required)

Chest Pain

Cough

Coughing up blood

Shortness of breath

Sputum production

Wheezing

None of the above

Pain History

Chief complaint (Reason for your visit today):(Required)

Previous SPINAL or Brain/Head Surgeries

Where

When

Who

Press + to add additional spinal or brain/head surgeries.

Onset of Symptoms

Approximately, when did this pain begin?

What caused your current pain episode?

Was this due to a motor vehicle accident?(Required)

Yes

When(Required)

Was this due to a Slip & Fall?(Required)

Yes

When(Required)

Did this happen at work?(Required)

Yes

When(Required)

How did your current/most recent symptoms or pain begin?(Required)

Gradually

Suddenly

Since your pain began, how has it changed?(Required)

Improved

Worsened

Stayed the same

Pain Description

What time of day is your pain at its worst?(Required)

How often does the pain occur?(Required)

Constant

Changes in severity but always present

Intermittent

Nature of your pain?(Required)

Dull

Achy

Burning

Numbness

Tingling

Sharp

Stabbing

Shooting

Electrical

Radiating

Weakness

Other

Other(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)

Sitting

Standing

Bending

Twisting

Stretching

Walking

Exercise

Daily Activities

Working

Sneezing

Other

Other(Required)

How your pain is relieved?(Required)

Sitting

Elevating legs

Lying down flat

Exercise

Massage

Stretching

Topical Meds

Oral Meds

Other

Other(Required)

Does the pain radiate? If so where?

Please list any additional areas of pain

Treatment History

Interventional Pain Treatment History

Epidural Steroid Injection

Cervical

Thoracic

Lumbar

Joint Injection - Joint(s)

Medial Branch Blocks/Facet Injections

Cervical

Thoracic

Lumbar

Nerve Blocks - Area/Nerve(s)

Radio Frequency Nerve Ablation

Cervical

Thoracic

Lumbar

Spinal Cord Stimulator - Trial Only/Permanent Implant

Pain killers give complete relief from pain

Pain killers give moderate relief from pain

Pain killers give very little relief from pain

Pain killers have no effect on the pain and I do not use them

2. PERSONAL CARE (e.g. Washing, Dressing)

I can look after myself normally without causing extra pain

I can look after myself normally but it causes extra pain

It is painful to look after myself and I am slow and careful

I need some help but manage most of my personal care

I need help every day in most aspects of self care

I don’t get dressed, I was with difficulty and stay in bed

3. LIFTING

I can lift heavy weights without extra pain

I can lift heavy weights but it gives extra pain

Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned, i.e. on a table

Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned

I can lift very light weights

I cannot lift or carry anything at all

4. WALKING

Pain does not prevent me walking any distance

Pain prevents me walking more than one mile

Pain prevents me walking more than ½ mile

Pain prevents me walking more than ¼ mile

I can only walk using a stick or crutches

I am in bed most of the time and have to crawl to the toilet

5. SITTING

I can tolerate the pain I have without having to use pain killers

The pain is bad but I manage without taking pain killers

Pain killers give complete relief from pain

Pain killers give moderate relief from pain

Pain killers give very little relief from pain

Pain killers have no effect on the pain and I do not use them

6. STANDING

I can stand as long as I want without extra pain

I can stand as long as I want but it gives me extra pain

Pain prevents me from standing for more than one hour

Pain prevents me from standing for more than 30 minutes

Pain prevents me from standing for more than 10 minutes

Pain prevents me from standing at all

7. SLEEPING

Pain does not prevent me from sleeping well

I can sleep well only by using medication

Even when I take medication, I have less than 6 hrs sleep

Even when I take medication, I have less than 4 hrs sleep

Even when I take medication, I have less than 2 hrs sleep

Pain prevents me from sleeping at all

8. SOCIAL LIFE

My social life is normal and gives me no extra pain

My social life is normal but increases the degree of pain

Pain has no significant effect on my social life apart from limiting my more energetic interests, i.e. dancing, etc.

Pain has restricted my social life and I do not go out as often

Pain has restricted my social life to my home

I have no social life because of pain

9. TRAVELLING

I can travel anywhere without extra pain

I can travel anywhere but it gives me extra pain

Pain is bad, but I manage journeys over 2 hours

Pain restricts me to journeys of less than 1 hour

Pain restricts me to short necessary journeys under 30 minutes

Pain prevents me from traveling except to the doctor or hospital

10. EMPLOYMENT/ HOMEMAKING

My normal homemaking/ job activities do not cause pain.

My normal homemaking/ job activities increase my pain, but I can still perform all that is required of me.

I can perform most of my homemaking/job duties, but pain prevents me from performing more physically stressful activities (e.g. lifting, vacuuming)

Pain prevents me from doing anything but light duties.

Pain prevents me from doing even light duties.

Pain prevents me from performing any job or homemaking chore

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

Patient Signature(Required)

Date(Required)

MM slash DD slash YYYY

Patient Information

EMERGENCY CONTACT INFORMATION

Primary Care Physician

Cardiologist

Health Insurance Information

Additional Insurance

Cancellation/No Show Policy

Social History

Family History

Past Medical History/Treatment

Medication History

Pharmacy Information

ACKNOWLEDGEMENT AND CONSENT FOR NOTICE OF PRIVACY

Consent to Release Medical Information to Personal Representative

HIPAA Privacy Authorization Form

Review of Systems

Pain History

Treatment History

Spine Surgery

Physical Therapy

Chiropractic Care

Massage Therapy

Brace Therapy

Acupuncture

Hot/Cold Packs

TENS Unit

Other Physicians or Specialists

WHO WE ARE

LEARN MORE ABOUT US

CONTACT INFORMATION

SERVICES / PROCEDURES

SERVICES/PROCEDURES