Registration Guide. Bring this packet to all appointments. This packet belongs to:

Transcription

1 Registration Guide Bring this packet to all appointments. This packet belongs to:

2 We're ready to welcome you Now that you ve made the decision to reclaim your life, Laser Spine Institute is ready to give you the quality medical care you deserve. Since 2005, we ve had the privilege of providing our special blend of compassionate care to more than 75,000 patients. And with each passing year, we ve strengthened our commitment to those who seek our care by refining the way we deliver it. From our thoughtfully appointed state-of-the-art facilities to our highly skilled team of surgeons, Laser Spine Institute is dedicated to making the time you spend with us engaging and efficient. It s why we provide those we serve with their very own Care Management Team, infusing respect and dignity as we guide you on your personalized path to relief. Carrying the burden of chronic neck or back pain is something no one should have to go through alone. That s why we re so grateful you ve trusted us to help you regain your life.

3 Your personalized path to relief At Laser Spine Institute, you re never alone on your journey to relief. Here s how our dedicated team of professionals will help you take back your life from chronic neck or back pain. Speaking with your Patient Empowerment Consultant Your consultant will help you understand your care pathway, overcome any concerns you may have, review insurance and financial options and be your dedicated point of contact leading up to surgery. Meeting your highly skilled physicians and surgeons You ll undergo a full medical evaluation in our state-of-the-art facility to ensure it s safe for you to have surgery in our outpatient setting. Once cleared, you ll meet with a dedicated, boardcertified + surgeon, who is trained in our minimally invasive spine procedures, to address your specific spine condition and customize your anesthesia and surgical plan. Our goal is simple to give you relief from your painful condition. Discuss your path Initial medical screening Meet with your surgeon SURGERY Discussion with your dedicated Care Team This team will conduct your medical assessment before you arrive, make recommendations regarding which tests may be necessary, collect your medical records, provide details on travel and schedule your surgical procedure. Staying in touch To ensure you are healing as planned, your Care Team will check in with you throughout your recovery to monitor your path to relief. + For more information, visit LaserSpineInstitute.com/surgeons. 2

4 Before you arrive As you prepare for your visit to Laser Spine Institute, know you ll be greeted with the warmest of welcomes, comforting amenities and a state-of-the-art facility that s second to none. Our Care Team To ensure your experience is as productive as possible, Laser Spine Institute will provide you with a dedicated Care Team to guide you on your personalized path to relief. Their goal is to: Conduct your medical assessment Schedule your surgical procedure Assist with travel information Make recommendations regarding which tests may be necessary Collect your medical records What to bring to our facility: Your most recent MRI or images Copies of your medical records Insurance card and driver s license or government issued ID 3

5 1. 2. Our seven state-of-the-art facilities Tampa Scottsdale Philadelphia Oklahoma City Cleveland St. Louis Cincinnati

6 Comforting amenities Relax, refresh and refuel in our pleasant lounges where convenient food and beverage options are available for purchase to all our guests during their stay. A place to connect Stay in touch with loved ones by connecting to our Wi-Fi during your time with us. Tampa facility featured on this page 5

7 Upon your arrival Preoperative appointments Evaluation Upon your arrival at Laser Spine Institute, our team of medical professionals will perform a full physical examination to determine if you can safely undergo surgery in our outpatient facility. During this exam, we ll review your medical history, go over any medications you are taking and discuss prior surgeries. Your exam may include blood work, electrocardiogram (EKG) and additional testing. Testing and imaging Before your minimally invasive surgical procedure, we may require you to have another MRI or more X-rays at our facility or with a local provider. Our medical team will then review your images. In some cases, you may be asked to undergo an additional diagnostic test that will locate the area your pain is coming from so you can enjoy maximum relief. MRI discussion You ll meet with one of our physicians to go over your medical history, document your symptoms and confirm your specific condition. If you are a confirmed candidate for surgery, a surgical order will be issued. Coordination Our Care Team will now review your upcoming appointments. This is the time to ask any questions you may have about our payment agreement, billing process and the filing of insurance claims. Plan to make a full payment to Laser Spine Institute based on the agreed amount at the end of this meeting. 6

8 Surgery day Preparing for surgery Estimated time: 90 minutes On the morning of your surgery, you and your Care Partner will arrive at Laser Spine Institute, receive a warm welcome and be shown where to sign in. You and your Care Partner will then be guided to our preoperative area to meet with your anesthesiologist, surgeon and registered nurse. This team will go over your surgical order and ask you to sign consent forms. We will then escort your Care Partner to our lounge to relax as you get set to take back your life from chronic pain. Our medical staff will administer an IV and prepare you for surgery. Surgery Estimated time: one to four hours, depending on your procedure Our surgical team specializes in making your minimally invasive procedure as seamless as possible. As they take you into the operating room, they ll comfortably position you on the operating table. Your anesthesia team will consult with your surgeon to customize your anesthetic and monitor your vital signs throughout your surgery. Rest and recovery Estimated time: one to two hours After surgery, you ll be taken to our recovery area where our nurses will monitor your vital signs and provide medications to alleviate any discomfort. Once you feel alert and are able to use the restroom, your Care Partner will be invited to join you as you change into your clothes and begin the discharge process. The two of you will then receive postoperative instructions, including a discussion with your surgeon about your surgical procedure and your future appointments at Laser Spine Institute. 7

9 Recovery After-surgery assessment How are you healing? That s what we ll find out during your appointment 24 to 48 hours after surgery. Here s what you can expect us to do during this visit: Check your surgical dressing Provide more specific recovery instructions per your surgical order Answer your questions After-surgery reminders Remember, the road to relief is a partnership. We help guide you, and you take the steps to get there. You'll receive detailed postoperative instructions while you're at our facility for your procedure. To make sure you stay the course, we ve created this list of simple reminders: Slow down and take it easy. Take your medications as directed. Stay hydrated by drinking plenty of water. Limit activity (bending, lifting, twisting) that applies added weight to the spine. Wear your brace for the time recommended by your surgeon for your surgery type. Bend from your hips if you ve had a lumbar procedure. DO NOT bend from your spine. DO NOT reach overhead if you ve had a cervical procedure. Ask for assistance. Schedule an appointment with your local Laser Spine Institute clinic or your primary care provider to have your incision checked two weeks after your surgery. 8

10 Postoperative contact information Have medical concerns relating to your surgical procedure? We re here 24 hours a day, seven days a week to provide answers. We ll call you after surgery to check on your progress and see how we can help. SPINE LINE 9 Tampa Scottsdale Philadelphia Oklahoma City Cleveland St. Louis Cincinnati

11 I remember walking through the front door and I was greeted with, 'Hi! You must be Dwylett. We've been waiting for you. Dwylett M. Actual Patient 10

12 Commonly asked questions Imaging and scans Q: What s your policy for MRI or CT scans? A: Patients may have their diagnostic imaging, including MRI films and CT scans, done prior to their visit. If choosing this option, the following items are required before seeking evaluation and/or treatment at Laser Spine Institute: ** CD with DICOM images of your MRI and/ or hard copies (typically 14 inches by 17 inches) of your MRI/CT films. A reference/slice chart with your MRI films. Ask your facility to include this. Films/CD with a date of six months or less from the date of your scheduled surgery. MRI or CT scans that are hand delivered by you or your Care Partner on the day of your first appointment at Laser Spine Institute. A copy of the radiologist report. This can be obtained from the radiologist/ physician who ordered the film. Even if this report was previously sent to Laser Spine Institute, another copy must be brought in with the film. Patients not complying with the above requirements may be subject to postponement of the appointments and/or surgery. Any costs incurred by noncompliance with this policy will be the responsibility of the patient. Preparing for your visit Q: Why do I need to have a Care Partner? A: Laser Spine Institute requires all patients to be accompanied by someone who is at least 18 years of age, competent to attend all preoperative and surgical appointments and who is able to assist you for at least the first 24 to 48 hours after your surgery. We do this to ensure you receive the best care possible. Q: Why am I required to stay so close to the surgery center? A: We require all patients stay within a 15- mile radius of our state-of-the-art facilities to meet their medical needs in a timely manner. We partner with area hotels to make this as simple as possible. Q: How much time should I request off from work? A: We recommend you take at least two weeks off work after your surgery depending on your job description and individual recovery. Some patients may need six to 12 weeks. Insurance and billing Q: How does your billing process work? A: Laser Spine Institute will bill your insurance for our usual and customary fees. We cannot, however, determine the amount that your insurance carrier pays as each carrier differs. **This policy does not apply to patients scheduled for an MRI or CT scan upon arrival. 11

13 Commonly asked questions Q: Will my surgery be covered by insurance? A: Laser Spine Institute works with a variety of insurance companies to provide a costeffective way to help our patients find relief. We verify your benefits prior to your visit, including any coinsurance, deductibles, outof-pocket maximums and policy limitations or precertifications as provided by your insurance policy. Some of our services will require precertification. Because each individual insurance policy has varying levels of coverage, we may not know the exact amount of your financial responsibility until after your claim has been filed and we receive the explanation of benefits from your insurance carrier. Q: I was quoted a fee for surgery. What does it cover? A: The fee we collect from you depends on your specific insurance policy. It is applied toward the cost of surgery. You may also receive a statement or invoice for services if you have not met your deductible, coinsurance or copay. Q: Who will file my insurance? A: Laser Spine Institute will file your claims on your behalf with most insurance carriers. If we are not in network with your insurance provider, you may receive correspondence from them directly. If this happens, call immediately so we can work with your insurance carrier to expedite the processing of your claims. Q: I received a payment from my insurance carrier. What should I do? A: If we are not in contract with your insurance carrier, the payment intended for us might be sent directly to you instead. If this happens, per your agreement please forward the payment you received and any attached correspondence to: Attn: RCC, Laser Spine Institute 5332 Avion Park Drive Tampa, FL To request a pre-paid postage envelope, call and speak with a Recovery Care Consultant. Doing so will ensure accurate accounting and handling of your claims. Payment options Q: What types of payments does Laser Spine Institute accept? A: We accept the following forms of payment: Credit cards Bank cards Money orders (Payable to Laser Spine Institute) Cashier s check (Payable to Laser Spine Institute) Wire transfers (Please contact your Patient Concierge for instructions) Laser Spine Institute CANNOT accept: Personal checks (Personal checks from credit cards or home equity lines of credit are not acceptable forms of payment.) Business checks 12

14 Commonly asked questions Q: Can I pay in advance for services I ll receive? A: Any patient willing to pay services upfront should sign a Charge Authorization Form. You may obtain this by contacting your Patient Concierge. Q: How will my patient deposit be applied? A: All patients will be responsible for a nonrefundable deposit when scheduling surgical or diagnostic appointments at Laser Spine Institute. This deposit is not an additional fee and will be credited toward the cost of your surgery. If your visit is canceled for medical or surgical reasons prior to your arrival, your deposit will be refunded. In the event your procedure is canceled after diagnostic or evaluation services have been rendered, your deposit will be retained and applied to your patient responsibility. If your patient responsibility is more than your deposit, you will be responsible for this balance. If your plan is in network and your patient responsibility is less than your deposit, you will be refunded by a cashier s check after all claims have processed through your insurance carrier. If your appointments are canceled without rescheduling and prior to any diagnostic or evaluation services being rendered, your deposit will be retained but applied to any future appointments should you choose to reschedule. Financing options Q: Is there a way to make my surgery more affordable? A: To help our patients manage costs, Laser Spine Institute is pleased to partner with CareCredit to offer low-interest financing options and affordable terms. We also offer supplemental options to assist our patients with financing the surgical procedures they need. For more information, please contact your Patient Empowerment Consultant. Requesting medical information Q: How do I request my medical records? A: To obtain a copy of your medical records, call , ext. 140, and ask for a Medical Release Form or Physician Release Form (if one of your regular physicians referred you to Laser Spine Institute). This will allow us to make a courtesy call to your physician with your permission and then send him or her information about your surgery. Q: How can I get a return-to-work letter? A: You must request it from our Patient Support Department (PSD) by calling the SPINE LINE as they will not be sent to you automatically. Once we receive your request, we will complete it within three business days. If you need a return-to-work letter sooner than that, please request it during your postoperative visit. 13

15 Commonly asked questions Q: Will Laser Spine Institute help me fill out my FMLA paperwork? A: Yes. We will gladly complete your medical leave certification for FMLA and/or shortterm disability. A $20 fee will be charged for the completion of FMLA paperwork. Please bring these forms with you to your first evaluation day. We ll complete them three to five days after your postoperative appointment, following your surgery. FMLA/ disability medical leave will be certified for a maximum of 12 weeks postoperatively. Laser Spine Institute physicians do not certify for long-term disability/social Security. For more details on FMLA and disability please see page 20. Rest and recovery Q: Will I feel any residual pain after surgery? A: You may. That s because it s not uncommon to feel residual pain, such as swelling and inflammation, after surgery. This discomfort is the result of the nerves healing and should become progressively less over time. * Q: Should I avoid lifting after surgery? A: We recommend lifting no more than 10 to 15 pounds for at least four weeks and that you return to normal activities gradually to allow maximum healing. * Q: When can I resume my normal routine? A: You can gradually return to, then increase, your regular activity level two weeks after surgery based on how you feel, continuing this gradual progress for four to six weeks after your procedure. If you ve had a fusion procedure, it may be six weeks or more. Please avoid any prolonged postures and vary your activities and positions. * Q: When can I swim or enjoy the water again? A: It s best to wait until your incision is completely healed before getting into the pool, bathtub or other body of water. * You may begin a pool exercise program two weeks after surgery and increase to an active swimming program after four weeks. Q: When can I start driving again? A: Most patients can drive 24 to 48 hours after surgery, however, all patients must not drive while taking pain medications or muscle relaxers. Patients undergoing a minimally invasive stabilization procedure (or fusion) may not drive for up to two weeks after surgery. Q: Is it safe for me to travel after surgery? A: Yes, but to ensure your comfort, we recommend these tips: If traveling by car, stop every hour to stretch and walk. If returning home by plane, you should stand or walk around the cabin after the fastenseat-belt light has been turned off. *Each patient is different. Results may vary. 14

16 The people were great. And the outcome was even better. My back's as good as new. * Jerry J. Actual Patient *Each patient is different. Results may vary. 15

17 Care Partner information Care Partner requirements The person who you choose to come with you on your day of surgery plays a vital role in your healing process. That s why your Care Partner must be: At least 18 years old Able to drive Prepared to communicate in English with our medical team Able to assist you on surgery day Willing to care for you in the first 24 to 48 hours after surgery Because you may also need assistance with daily activities, Care Partners should be prepared to help you with: Driving Walking Getting in and out of the car Eating, drinking Getting in and out of bed Getting to and from the restroom Taking medications Changing clothing and/or bandages What to expect on surgery day The entire surgery process should take between six and eight hours. Your Care Partner will accompany you through the preoperative process but not surgery. During the preoperative appointment, you will review consent forms and instructions for after surgery. This could take 90 minutes to two hours. While you are in surgery, your Care Partner can relax in our patient lounge. If your Care Partner leaves the surgery center at any time, he or she must let a Hospitality Associate know and provide a contact number. We ll provide your Care Partner with updates on your progress throughout the day. Depending on the procedure, your surgery should take one to four hours. After surgery, you should be in the recovery room for one to two hours. Once you are alert and able to walk, your Care Partner will join you in recovery and receive instructions on how to care for you in the first 24 to 48 hours after surgery. This discussion should last one to two hours. For their safety, children under the age of 13 must be accompanied by an adult at all times. They are welcome in our lounges and main areas but are not allowed in clinical and surgical areas. 16

18 Checklist for your visit To-do list: Complete and return your registration forms, including photocopies of your insurance card and photo ID. Gather your conservative treatment records from the past year. These records include progress notes for treatment of your neck and back pain from a primary care doctor, physical therapist, pain management doctor, chiropractor or other treating doctor. Refer to the medication lists and instructions provided in this packet and stop all prohibited medications prior to arrival. Expect a member of our team to contact you one to three days prior to your visit to notify you of your evaluation appointment time. If necessary, request FMLA or short-term disability forms from your employer and bring them to the facility to be completed. Make arrangements for your stay: Identify a Care Partner over 18 years of age, in good physical and mental health, who can accompany you on your visit. He or she will need to meet the requirements on the Care Partner information sheet. Traveling to see us? We require that you stay within 15 miles of the facility on your surgery day. Ask for your Facility Guide to find our hotel partners nearby and their Laser Spine Institute booking rates. Bring with you to the facility: Original copy of your Registration Guide and your completed forms. Photo ID such as driver s license, passport or military ID. Insurance card. Any postoperative reports from previous spine surgeries and all conservative treatment records you ve gathered for treatment of your neck and back pain within the last year. MRI report and/or CT scan and images that are less than six months old. Any testing records less than 30 days old (bloodwork, EKG). Any FMLA or short-term disability paperwork you need completed. Several loose-fitting outfits and a two-week supply of all medications, including pain medications. Laser Spine Institute may not write prescriptions that have been ordered by your prescribing doctor(s). 17

19 Medication hold list If you are taking an over-the-counter medication not listed here and you are unsure of its actions, please consult your pharmacist or physician, or call Laser Spine Institute at , from Monday through Friday, 8 a.m. to 7 p.m. Eastern Standard Time. The following medications MUST BE STOPPED FIVE DAYS prior to your surgery. Advil Aggrenox Aleve Alka-Seltzer Amigesic Anacin products Anaflex Anaprox Ansaid Apo-ASEN Arco Pain Tablet Argeric Arthropan Arthrotec Ascriptin Aspergum Aspirin (all products containing aspirin) Aspir-Low Aspirtab Bayer Bayer time release Buffex Bufferin Bufferin Arthritis Buffinol Butalbital Compound Butazolidin Cama Arthritis Carisoprodol Compound Cataflam Clinoril Combunox Cope Daypro Diclofenac Diflunisal Disalcid Doan s Dolobid Easprin Ecotrin 81 Empirin Endodan Entrophen Equagesic Es Anacin Etodolac Excedrin Migraine Feldene Fenoprofen Fiorinal Flector Patch Floctafenine Flurbiprofen Glucosamine Goody s Halfprin Helidac Ibuprofen Indocin Indomethacin Instantine Kaopectate Kava Ketoprofen Ketorolac Lodine Lovaza Magan Magnaprin Marthritic Meclofenamate Meclomen Medipren Mefenamic acid Midol Mobic Mobiflex Momentum Mono-Gesic Motrin Nabumetone Nalfon Naprelan Naprosyn Naproxen Norgesic Forte Nuprin Ocuvite Oruvail Orudis Oxaprozin Pamperin-IB Pepto-Bismol Percodan Phenylbutazone Piroxicam Piroxicam PMS-ASA Ponstel Prevacid NapraPAC Relafen Robaxisal Roxiprin Salflex Salsalate Sine-Aid IB Sodium salicylate Soma Compound St. Joseph Aspirin Sulindac Suprofen Suprol Surgam Synalgos-DC Tandearil Talwin Compound Tenoxicam Tiaprofenic acid Tolectin Tolmetin Toradol Tricosal Trilisate Vanquish Vicoprofen Voltaren Zorprin We recommend you stop taking the following supplements at least five days prior to your scheduled surgery: St. John s wort, garlic, ginger, ginkgo biloba, ephedra (ma huang) and vitamin E. 18

20 Medication alert list Continue these prescribed blood-thinning medications unless Laser Spine Institute has been provided with written approval/permission from your doctor that you can stop the medication. If you are on any of these prescribed medications and have not spoken with your Care Team, please contact your Patient Empowerment Consultant. WARNING: THESE MEDICATIONS CAN ONLY BE STOPPED WITH APPROVAL OF YOUR PRESCRIBING PHYSICIAN. Aggrenox (aspirin/ dipyridamole) Arixtra (fondaparinux) Aspirin (when prescribed by your physician) Brilinta (ticagrelor) Coumadin (warfarin) Eliquis (apixaban) Fragmin (dalteparin) Innohep (tinzaparin) Lovenox (enoxaparin) Plavix (clopidogrel) Pletal (cilostazol) Pradaxa (dabigatran etexilate) Xarelto (rivaroxaban) If you are diabetic: Consult with the doctor who treats your diabetes about your insulin dosage or other diabetic medication. You may experience an elevation in your blood sugar before, during and/or after surgery due to the stress of surgery and the steroid medications used during the surgery. Please have a plan to address this with your local doctor who treats your diabetes so you are ready to handle elevations in your blood sugar while you are at Laser Spine Institute. This could include additional checking of your blood sugar and additional insulin as needed. Our providers will check and treat your blood sugar before, during and after surgery. For your safety, we ask that you follow your regular doctor s instructions after you are released from Laser Spine Institute. Please closely monitor your dietary intake to prevent blood sugar fluctuations. Laser Spine Institute will inform you of the exact date of your surgery. Medication instructions will be given after we are able to obtain written permission from your prescribing physician. 19

21 Patient resources Family and Medical Leave Act (FMLA) and short-term disability Laser Spine Institute will gladly complete medical leave certification for FMLA and/or short-term disability. If you need medical documentation from us, please observe the following guidelines: A $20 fee will be charged for completion of FMLA paperwork. It is necessary for patients to provide Laser Spine Institute with the specific forms to complete. Please complete any employee/patient sections only; do not write in provider sections. An authorization form to disclose/release medical information will be necessary and may be included in your FMLA/Disability Claim Packet. If not, they are available when you arrive at Laser Spine Institute. It is important that you provide Laser Spine Institute with the name, phone number and fax number of the human resources/disability representative to whom we should send the completed forms. It is recommended that you bring forms on the first evaluation day at Laser Spine Institute and turn it in to the Hospitality team. They will be completed approximately three to five business days after the postoperative appointment. If you do not have your forms on arrival, they will be completed approximately three to five business days after they are sent to us. If you are scheduled for more than one procedure, the forms will be completed following the postoperative appointment for the last procedure. We generally recommend patients take at least two weeks off work postoperatively for proper recovery, though some patients may need six to 12 weeks, depending on job description and individual recovery. FMLA/disability medical leave will be certified for a maximum of 12 weeks postoperatively. Once forms are completed, we will fax or mail them to the third party designated on the release of information (ROI) form. A copy will be mailed to you. Without a completed ROI form all completed FMLA/disability forms will be returned to you, and you will then be responsible to ensure that your employer/insurance company receives your forms in order for you to receive benefits/coverage. Releases to return to work are handled by your Care Team when you are approaching readiness to return to work. You will need to request them, as they are not automatically sent. They will be completed within three business days after we receive a request. If you need written verification from Laser Spine Institute prior to treatment to show that you are tentatively scheduled for surgery, please contact your Patient Empowerment Consultant or Scheduling Concierge. If you need a return-to-work note for your employer by the time you are leaving Laser Spine Institute, please request from the Clinic Practitioner during your postoperative visit. Laser Spine Institute physicians do not certify for long-term disability/social Security. Statement on advance directives/living wills In an ambulatory care setting, where we expect to provide care to patients who are not acutely ill, admission to Laser Spine Institute surgery center indicates our belief that our patients will tolerate the procedure in the ambulatory setting without difficulty. If a patient should suffer cardiac or respiratory arrest or any life-threatening condition, the patient will be transferred to a more acute level of care most likely the closest hospital emergency room. If a patient who is to receive a procedure at Laser Spine Institute presents the staff with an advance directive/living will, the patient must be advised that Laser Spine Institute will not honor any advance directive/living will that does not allow resuscitation. It is the policy of Laser Spine Institute surgery center to transfer any patient requiring resuscitation to the hospital. The hospital can determine when to implement the advance directive/living will once the patient or others notify the hospital of the advance directive/living will. Patients who disagree with this policy must address the issue with the attending physician prior to signing the form acknowledging an understanding of the policy regarding advance directives/living wills. By regulation, Laser Spine Institute notifies all patients that it will not honor a previously signed advance directive/living will. Disclosure of ownership Notice to patients Your surgeon or anesthesia provider may be an owner in Laser Spine Institute, LLC. This information is available for your review at each of our surgery centers. 20

22 Registration Forms Registration Forms Before you get started Gather the following information to complete your forms: Insurance card Medical records Medication names and doses Doctor information Your accurate and complete medical history must be received before your visit to Laser Spine Institute to avoid appointment cancellations or delays. Please complete all the forms in this packet. Questions? Call your dedicated Patient Empowerment Consultant Laser Spine Institute, LLC BW

23 Registration Forms COMPLETE SIGN RETURN COPY BRING ORIGINALS Personal information Prefix: First name: MI: Last name: Suffix: Date of birth: Age: Social Security #: Driver s license #: Current mailing address: City: State: ZIP code: Home phone #: Cellphone #: Secondary address City: State: ZIP code: Sex: Male Female Undifferentiated Unknown Marital status: Single Married Partnered Divorced Widowed If you are married or otherwise partnered, what is the person s name? Race: Black/African-American American Indian Asian White Hispanic or Latino Alaska Native Native Hawaiian/Pacific Islander Decline to answer Other Ethnicity: Not Hispanic or Latino Hispanic or Latino None Date: Preferred language: English Spanish Decline to answer Other Emergency contact information I authorize Laser Spine Institute to VERBALLY discuss my selected information with the following people, including translation from/to another language: Contact name 1: Relationship: Home phone #: Cellphone #: Street address: City: State: ZIP code: Contact name 2: Relationship: Home phone #: Cellphone #: Street address: City: State: ZIP code: By selecting from the following options and signing, I authorize Laser Spine Institute to discuss the following information with my emergency contact(s): My appointment information My billing and payment information My lab/test results My location within the facility My medical information (including symptoms, diagnosis, medication and treatment) Cancellation of this authorization must be submitted in writing. Signature needed Patient/guardian signature: Printed name: Date: Page 1 of BW

24 Registration Forms COMPLETE SIGN RETURN COPY BRING ORIGINALS Insurance information We MUST obtain this information to coordinate with your insurance company and provide the best care. Primary insurance: Insurance company s phone #: Policyholder s name (as on card): Policyholder s relationship: Insurance claims address: Policyholder s DOB: Policyholder s SSN: Member ID/policy #: Group #: Secondary insurance: Insurance company s phone #: Policyholder s name (as on card): Policyholder s relationship: Insurance claims address: Policyholder s DOB: Policyholder s SSN: Member ID/policy #: Group #: Tertiary insurance: Insurance company s phone #: Policyholder s name (as on card): Policyholder s relationship: Insurance claims address: Policyholder s DOB: Policyholder s SSN: Member ID/policy #: Group #: Attorney information If your condition is the result of an accident or other injury for which you are represented by an attorney, please provide the following information about your attorney: Name: Phone #: Street address: City: State: ZIP code: Auto insurance If your condition or injury is the result of an automobile accident, please provide the following information about the automobile insurance involved: Company name: Claim #: Phone #: Date of accident: Name of policyholder: Relationship: State accident occurred in: Adjuster name: Have auto benefits been exhausted? Yes No If yes, enter date benefits exhausted: Workers compensation If applicable, please take a moment to provide the following information: Company name: Claim #: Phone #: Date of accident: Name of insurance adjuster: Page 2 of BW

25 Registration Forms COMPLETE SIGN RETURN COPY BRING ORIGINALS Patient history - Chief Complaint/Physician Information Chief complaint What is your primary concern? How long have you had neck/back pain? How did you hurt your neck/back? (For auto accident or workers compensation, please complete the necessary section on page 2.) Does your pain interfere with your activities of daily living (self-care, meal prep, home maintenance)? Yes No If yes, please explain: Are you able to stand for long periods of time? Yes No Are you able to sit for long periods of time? Yes No Does your pain interfere with your daily job functions? Yes No If yes, please explain: Have you been diagnosed previously with a spine condition such as spinal stenosis, arthritis, scoliosis, herniated disc or fracture? Yes No If yes, please explain: Physician information Primary care physician name: Phone #: Fax #: Street address: City: State: ZIP code: Specialist name 1: Type: Phone #: Fax #: Specialist name 2: Type: Phone #: Fax #: Specialist name 3: Type: Phone #: Fax #: Specialist name 4: Type: Phone #: Fax #: Specialist name 5: Type: Phone #: Fax #: By providing this information, you authorize Laser Spine Institute to send a summary of your care and/or medical records to the providers listed above. Page 3 of BW

26 Registration Forms COMPLETE SIGN RETURN COPY BRING ORIGINALS Patient history - Medical/Surgical Medical history Please indicate if you have any of the following and explain below: Angina Fibromyalgia Kidney/bladder disease Seizures Arthritis Gastrointestinal disease Liver disease Skin disorders Asthma GERD MRSA Sleep apnea Bleeding disorders Headaches/migraines Multiple sclerosis Strokes/TIA Cancer Heart attack Nervous system disease Tremors Cholesterol disease Heart murmur Osteoporosis Thyroid disease Congestive heart failure Heart rhythm abnormalities Pacemaker/defibrillator Tuberculosis Coronary heart disease Hepatitis Prior infections Vascular disease Depression/anxiety High blood pressure Pulmonary (lung) disease Other Diabetes HIV/AIDS Rheumatic fever If any of the above was checked, please explain: Surgical history Please indicate if you have had any of the following procedures, conditions or surgery on any of these areas: Abdominal Chest/lung Leg Spine (neck/back) Anesthesia complications Coronary artery bypass Low back/lumbar spine Thyroid Angioplasty/stents Foot Mid back/thoracic spine Tonsil/wisdom teeth/adenoids Ankle/knee/hip Gallbladder Neck/cervical spine Uterus/ovary Appendix Hand Nerve stimulator or pump Varicose veins Arm Hernia Pacemaker/defibrillator Wrist/shoulder/elbow Breast History of dura leak Prostate If any surgery in the past year, or any spine surgery at any time, please explain: Spinal surgical procedure #1 Surgeon name: Phone #: Street address: City: State: ZIP code: Surgery performed: Date (MM/YY): Level: Outcome: Spinal surgical procedure #2 Surgeon name: Phone #: Street address: City: State: ZIP code: Surgery performed: Date (MM/YY): Level: Outcome: Page 4 of BW

27 Registration Forms COMPLETE SIGN RETURN COPY BRING ORIGINALS Patient history - Medications/Allergies Current Medications: Please clearly list below any prescription medications, over-the-counters and pain medications. Name and dose Daily dosage Last date taken Reason for taking Ex: Med name 20mg Twice a day Cholesterol Supplements: Please clearly list below any herbs, vitamins or supplements. Name and dose Daily dosage Last date taken Reason for taking Ex: Supplement name 20mg Twice a day Immune support Allergies: Please clearly list any allergies, medical or nonmedical. Type of allergy Reaction Severity (please check one) Mild Moderate Severe Life threatening Example: Penicillin Hives, itching and rash X Pain management care Are you currently taking prescription pain medications? Yes No Who prescribes your pain medication? Primary care physician Pain management physician Other Physician name: Phone #: Street address: City: State: ZIP code: Fax#: Start date (MM/YY): End date (MM/YY): Do you have a pain management contract with your prescribing physician? Yes No Is your prescribing physician aware that you are having surgery at Laser Spine Institute? Yes No Have you scheduled a follow-up appointment with your prescribing physician after your surgery? Yes No Do you need assistance transitioning off of pain medication after your surgery? Yes No Page 5 of BW

28 Registration Forms COMPLETE SIGN RETURN COPY BRING ORIGINALS Patient history - Conservative Care Please bring all medical records for the treatment of your neck and back pain within the last 12 months. Physical therapy Provider name: Phone #: Street address: City: State: ZIP code: Percentage of relief: Start date (MM/YY): End date (MM/YY): If unable to do or discontinued therapy before six to 12 weeks please explain why: Pain management care Provider name: Phone #: Street address: City: State: ZIP code: Percentage of relief: Start date (MM/YY): End date (MM/YY): Injection/Procedure (steroid injection/esi, radio frequency ablation/rfa) Provider name: Phone #: Street address: City: State: ZIP code: Date of first injection (MM/YY): Percentage of relief: Date of second injection (MM/YY): Percentage of relief: Date of third injection (MM/YY): Percentage of relief: Chiropractic care (traction, inversion, manipulation, decompression) Percentage of relief: Start date (MM/YY): End date (MM/YY): Massage Percentage of relief: Start date (MM/YY): End date (MM/YY): Home therapy - Heat/Ice Percentage of relief: Start date (MM/YY): End date (MM/YY): Acupuncture Percentage of relief: Start date (MM/YY): End date (MM/YY): Home exercise program Percentage of relief: Start date (MM/YY): End date (MM/YY): Over-the-counter pain medication (NSAIDs, Tylenol, topicals) Percentage of relief: Start date (MM/YY): End date (MM/YY): Prescription pain medication Percentage of relief: Start date (MM/YY): End date (MM/YY): Page 6 of BW

29 Registration Forms COMPLETE SIGN RETURN COPY BRING ORIGINALS Patient history - Family/Social Family history Place a check by any family conditions and fill in the rest of the row. Mother = M, Father = F, Sibling = S, Child = C, Maternal Grandparent = MG, Paternal Grandparent = PG Condition (Please check) Arthritis Which family member? M F S C MG PG Onset Current family member condition Bleeding disorders Cancer Heart disease Diabetes Kidney/bladder disease Liver disease Neuromuscular disease Osteoporosis Pulmonary disease Stroke Thyroid disease Malignant hyperthermia Social history Have you ever used any form of nicotine or tobacco? Yes No If so, have you received counseling to stop tobacco use? Yes No Type of tobacco Daily amount Years used Age started Date ended Cigarettes Cigar Pipe E-cigarette Chewing/smokeless/snuff Nicotine patch Do you drink coffee, tea or soda? If you answered yes: Yes No How many cups per day? Per week? Do you drink alcohol? If you answered yes: Yes No How many drinks per day? Per week? Please sign and date upon completion of registration forms below: Signature needed Patient/guardian signature: Printed name: Date: Page 7 of BW

30 Registration Forms COMPLETE SIGN RETURN COPY BRING ORIGINALS Medication hold list (Please keep a copy for your reference.) Please review and sign to acknowledge that you understand the following Medication Hold List. If you are taking an over-thecounter medication not listed here and you are unsure of its actions, please consult your pharmacist or physician, or call Laser Spine Institute at , from Monday through Friday, 8 a.m. to 7 p.m. Eastern Standard Time. The following medications MUST BE STOPPED FIVE DAYS prior to your surgery. Advil Aggrenox Aleve Alka-Seltzer Amigesic Anacin products Anaflex Anaprox Ansaid Apo-ASEN Arco Pain Tablet Argeric Arthropan Arthrotec Ascriptin Aspergum Aspirin (all products containing aspirin) Aspir-Low Aspirtab Bayer Bayer time release Buffex Bufferin Bufferin Arthritis Buffinol Butalbital Compound Butazolidin Cama Arthritis Carisoprodol Compound Cataflam Clinoril Combunox Cope Daypro Diclofenac Diflunisal Disalcid Doan s Dolobid Easprin Ecotrin 81 Empirin Endodan Entrophen Equagesic Es Anacin Etodolac Excedrin Migraine Feldene Fenoprofen Fiorinal Flector Patch Floctafenine Flurbiprofen Glucosamine Goody s Halfprin Helidac Ibuprofen Indocin Indomethacin Instantine Kaopectate Kava Ketoprofen Ketorolac Lodine Lovaza Magan Magnaprin Marthritic Meclofenamate Meclomen Medipren Mefenamic acid Midol Mobic Mobiflex Momentum Mono-Gesic Motrin Nabumetone Nalfon Naprelan Naprosyn Naproxen Norgesic Forte Nuprin Ocuvite Oruvail Orudis Oxaprozin Pamperin-IB Pepto-Bismol Percodan Phenylbutazone Piroxicam PMS-ASA Ponstel Prevacid NapraPAC Relafen Robaxisal Roxiprin Salflex Salsalate Sine-Aid IB Sodium salicylate Soma Compound St. Joseph Aspirin Sulindac Suprofen Suprol Surgam Synalgos-DC Tandearil Talwin Compound Tenoxicam Tiaprofenic acid Tolectin Tolmetin Toradol Tricosal Trilisate Vanquish Vicoprofen Voltaren Zorprin We recommend you stop taking the following supplements at least five days prior to your scheduled surgery: St. John s wort, garlic, ginger, ginkgo biloba, ephedra (ma huang) and vitamin E. By signing, I agree that I must not take any of these over-the-counter medications for the time frame specified. I understand that failure to follow these instructions might result in the postponement of my surgery. Signature needed Patient/guardian signature: Printed name: Date: Page 8 of BW

31 Registration Forms COMPLETE SIGN RETURN COPY BRING ORIGINALS Medication alert list (Please keep a copy for your reference.) Continue these prescribed blood-thinning medications unless Laser Spine Institute has been provided with written approval/ permission from your doctor that you can stop the medication. If you are on any of these prescribed medications, speak to your Care Team nurse. If you are diabetic: Consult with the doctor who treats your diabetes about your insulin dosage or other diabetic medication. You may experience an elevation in your blood sugar before, during and/or after surgery due to the stress of surgery and the steroid medications used during the surgery. Please have a plan to address this with your local doctor who treats your diabetes so you are ready to handle elevations in your blood sugar while you are at Laser Spine Institute. This could include additional checking of your blood sugar and additional insulin as needed. Our providers will check and treat your blood sugar before, during and after surgery. For your safety, we ask that you follow your regular doctor s instructions after you are released from Laser Spine Institute. Please closely monitor your dietary intake to prevent blood sugar fluctuations. Laser Spine Institute will inform you of the exact date of your surgery. Medication instructions will be given after we are able to obtain written permission from your prescribing physician. Please take time to review and sign to acknowledge that you understand the following Medication Alert List. WARNING: THESE MEDICATIONS CAN ONLY BE STOPPED WITH APPROVAL OF YOUR PRESCRIBING PHYSICIAN. Aggrenox (aspirin/dipyridamole) Arixtra (fondaparinux) Aspirin (when prescribed by your physician) Brilinta (ticagrelor) Coumadin (warfarin) Eliquis (apixaban) Fragmin (dalteparin) Innohep (tinzaparin) Lovenox (enoxaparin) Plavix (clopidogrel) Pletal (cilostazol) Pradaxa (dabigatran etexilate) Xarelto (rivaroxaban) By signing, I understand that approval must be obtained from my prescribing physician before stopping any of these medications prior to my surgery date. I understand that failure to follow the exact instructions regarding what day to take the last dose of these medications might result in postponement of my surgery. Signature needed Patient/guardian signature: Printed name: Date: Page 9 of BW

32 Registration Forms COMPLETE SIGN RETURN COPY BRING ORIGINALS Care Partner, nursing services and distance agreement Patient ID (office use only) Care Partner services I understand and acknowledge that Laser Spine Institute ( LSI ) requires that for any surgical procedure(s) I undergo at LSI s facility, I have a Care Partner. A Care Partner shall be defined as an adult 18 years or older and of able mind and body who aids and accompanies an LSI patient through the entire surgical process at LSI. My Care Partner must be fully capable of: Providing me physical support as I walk and get in and out of bed, a car and/or a chair Providing me with medications and meals Driving and transporting me to and from any and all of my surgery-related appointments My Care Partner must be deemed suitable by LSI; he or she must agree to assume all necessary duties and responsibilities for my care until after my postoperative appointment. I understand and acknowledge that my selected Care Partner understands instructions communicated in English. I understand and agree I am responsible to advise LSI of my Care Partner s language barriers in advance of my scheduled date of any surgery and agree to reasonable alternatives communicated by LSI. I understand and acknowledge that I will have a Care Partner accompany me on the day of my surgery and that my Care Partner will remain with me for a minimum of 24 to 48 hours after discharge from my surgical procedure(s). If requested, LSI will provide me with a list of several companies in the area that can offer care services. In the event that my Care Partner fails to arrive after my surgical procedure(s) has been completed, or if I do not schedule a Care Partner, I understand and acknowledge that LSI will contact a care partner service for me. I understand and acknowledge that any fee for these licensed care partner services is separate and apart from my surgical payment(s) to LSI, and that I am expressly responsible for payment of these services. Licensed nursing services I understand and acknowledge that my surgeon may order licensed nursing services for a minimum of 24 hours following discharge from the minimally invasive stabilization ( MIS ) surgical procedure(s) I undergo at LSI s facility. I understand and acknowledge that any fee for these licensed nursing services is separate and apart from my surgical payment(s) to LSI, and that I may be responsible for payment of these services. Distance agreement For my safety, I must stay within 15 miles of LSI s facility for a minimum of 24 to 48 hours after any surgical procedure(s) I ve undergone at its facility. If I request, LSI will provide me with a list of local hotel partners that can accommodate me after my surgery. Any payment for these accommodations is separate and apart from my surgical payment(s) to LSI. I will be responsible for payment of these accommodations and also for making hotel reservations prior to surgery day. I have been given an opportunity to ask an LSI employee any questions I might have regarding this Care Partner, Nursing Services and Distance Agreement, and all of my questions have been answered fully and satisfactorily. I confirm that I have read, understand and agree to the above. Signature needed Patient/guardian signature: Printed name: Date: Printed guardian name: Relationship to patient: Page 10 of BW

33 Registration Forms COMPLETE SIGN RETURN COPY BRING ORIGINALS Guidelines for patient deposits This statement serves as a written notice to all patients that you will be responsible for a non-refundable deposit to begin your pre-arrival screening when committed at Laser Spine Institute. Please note that this is not an additional fee and it will be credited toward the cost of your medical care or treatment. In the event that your procedure is canceled after diagnostic or evaluation services have been rendered, your deposit will be retained and applied first toward your patient responsibility. If your patient responsibility is more than your deposit, you will be responsible for this balance. If your plan is in network and your patient responsibility is less than your deposit, you will be refunded by cashier s check after all claims have been processed through your insurance carrier. If your appointments are canceled without rescheduling and prior to any diagnostic or evaluation services being rendered, your deposit will be retained but applied to any future appointments should you choose to reschedule within 12 months. If your visit is canceled by Laser Spine Institute for medical or surgical reasons prior to your arrival, your deposit will be refunded. By signing below, I agree that I fully understand the above statement. Signature needed Patient/guardian signature: Printed name: Date: Page 11 of BW