New Patient Office Information Last Name: First Name: Initial Date of Birth: SSN # Marital Status: Single Married Divorced Widowed Address: City: State: Zip: Gender: M Parent/ Legal Guardian if Patient is a Minor: Home Phone: ( ) Preferred Calls: Morning / Afternoon/ Evening Cell Phone: ( ) Email Address: Race: Asian White Indian Hispanic African American Other: Language: English Spanish Other: Employers Name: Occupation: Employers Number: ( ) Spouses Name: Are you a Veteran of the US Armed Forces? YES NO Emergency Contact Name: Relationship: Home #: ( ) Cell #: ( ) Alternate #: ( ) Pharmacy Information Pharmacy Name: Phone #: ( ) Location: Insurance Information Primary Insurance Company: Policy # Group # Second Insurance Company: Policy # Group # Policy Holder: SSN # D.O.B How were you referred? Referring Doctor Phone Number/City Primary Doctor Phone Number/ City F Axis Brain & Back Institute, PLLC Office Copy Page 1 of 1
Patient Medical history Please circle all previous or current medical problems: Diabetes Depression Arthritis High Blood Pressure Heart Disease Stroke Kidney Migraines Seizures Asthma Blood Clot Liver Lung Thyroid Problem: Cancer: Other: List Previous Surgeries: Month/ Year Surgery Month/ Year Surgery Medication Allergies (Food, Latex): List all current Medications: (Name, Amount Dose) 1) 7) 2) 8) 3) 9) 4) 10) 5) 11) 6) 12) Please list any herbal supplements or vitamins you take: Do you smoke? Y N If YES, how many packs/day? Date Quit: Nonsmoker Do you chew or dip tobacco? Do you drink alcohol? Y N If yes, how much a day Family History Has anyone in your immediate family had or have any of the following diseases? If deceased, what diseases? (Place X in the box) Family Member Diabetes High BP Heart Disease Stroke Cancer Deceased Mother Father Axis Brain & Back Institute, PLLC Office Copy Page 1 of 2
Chief Complaint (reason for visit): Date of occurrence: Back/ Neck 1. Do you have Back pain? Y N How long? Do you have Arm pain? Y N How long? 2. Do you have Hip pain? Y N How long? Do you have Neck pain? Y N How long? 3. Do you have Leg pain? Y N How long? 4. Are you improving? or Worsening? or same: 1. On a PAIN SCALE of 1 10 (1 being slight pain and 10 being server pain) what number would you consider yourself? (circle one) 1 2 3 4 5 6 7 8 9 10 2. Do you have numbness tingling burning If so where (arms, legs)? 3. What seems to aggravate your symptoms? Sitting Standing Lying Down Walking 4. How far are you able to walk? Head 1. Where is your pain: Front Back Left side Right side Eyes 2. How long does this pain last? How often does it occur? 3. Do you have Headaches Migraines Seizures Lyme Disease Epilepsy 4. Do you have problems with vision, hearing, fainting, dizziness, nausea, vomiting, loss of balance, Black outs, Concussions, LOC, stroke, TIAs. Please place the appropriate letter as noted above the areas of the body where you experience pain, burning, tingling, and/ or numbness on the drawing. X = Pain B = Burning T = Tingling W = Weakness Axis Brain & Back Institute, PLLC Office Copy Page 2 of 2
Pain Medication Policy At Axis Brain & Back Institute, PLLC, our goal is to address your condition with the most innovative, minimally invasive, and cost conscious treatments available. When appropriate, providers at Axis Brain & Back Institute, PLLC will prescribe ONE 30 day supply of pain medication for post operative pain. This prescription iss order after surgery, upon discharge from the hospital. Patients experiencing pain beyond the 30 day post operative follow up appointment will be referred to a pain management provider for continued care. Axis Brain & Back Institute, PLLC does not offer pain management. By signingg below, I agree to the Pain Medication Policy and understand the following: Axis Brain & Back Institute, PLLC does NOT provide pain management. Pain medication is NOT prescribed before surgery. Pain medication prescribed to me will be after surgery for post operativee pain. I will only be prescribed ONE 30 day supply of pain medication. If pain management is needed, Axis Brain & Back Institute, PLLC will referr me to an appropriate pain management provider. Patient or Legal Guardian Signature Date Printed Name Axis Brain & Back Institute, PLLC Office Copy Page 1 of 1
DO NOT FILE TO INSURANCE Out-of-Pocket-Payments Notifier(s): Patient Name: Date: Date: If you paid out-of-pocket (or in other words, you have requested that we not bill your health plan) in full for a specific item or service, you have the right to ask that your Protected Health Information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we will honor that request. I request that the below service(s) not be disclosed to a health plan for purposes of payment or health care operations. I understand that the below service will NOT be submitted to my insurance company for reimbursement by Axis Brain and Back Institute. I understand that the below service is considered self-pay and will be paid in full at the time of service to Axis Brain and Back Institute. Date of Service Service(s) Amount of service(s) paid in full $ Signature: Date:
DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI) TO FAMILY MEMBERS & CONSENT OF DISCLOSURE OF INFORMATION I acknowledge thatt Axis Brain and Back Institute, PLLC will disclose my protected Health Information (PHI) to a family member, other relative, close friend or any other person I identify that directlyy relates to that person s involvement in my care. People we can disclose your PHI to: Relationship to you: OR I OBJECT to the disclosure of my Protected Health Information to a family member, other relative, close friend Or any other person. SHARING OF INFORMATION FOR PURPOSE OF PAYMENT I acknowledge that Axis Brain and Back Institute, PLLC will share all necessary information with my insurer(s), payer(s), governmental entities (such as Medicare, Medicaid, etc.) and their representativess (including, but not limited too benefit determinationn and utilization review) as well as your representatives involved in the billing processs (including, but not limited to) claims representatives, data warehouses, billing companies. Sharing of information for purposes of operations: You will share all information necessary for ongoing operations of this office (including, but not limited to) the credentialing for ongoing operations of this office and any relevant processes, the credentialing processes, peer review, accreditation and compliance with all federal and state laws. COMMUNICATION AUTHORIZATION I acknowledge that Axis Brain and Back Institute, PLLC may communicate with me via US mail, home phone, throughh the patient portal, on a cell phone and through text messaging. ALTERNATIVE COMMUNICATION AUTHORIZATION I request for an alternative method of communication such as alternative address or work phone number. Alternative Method: DATE: Patient Signature: Personal Representative Signature (if applicable): Relationship to Patient: Axis Brain & Back Institute, PLLC Office Copy Page 1 of 1
Authorization for Use or Disclosure of Protected Health Information Pt. Name: SS# DOB: Daytime Phone#: Evening Phone #: Address: City: State: Zip Code: I hereby authorize to use or disclose my protected healthh information as indicated below to: Name: Phone# #: Fax #: Address: City: State: Zip Code: Information to be released: From & To Dates: Copy of complete records Information related to HIV testing results History and Physical/Consultation reports Laboratory, Xrays,, PFT, Echo, Angio,, OP reports Other Purpose of Disclosure: Changing physician Second Opinion Continuing Care Legal At my (patient) request Insurance Workers Compensation School Other: I understand that this health information may include HIV related information and/ /or information relating to diagnosis or treatment of psychiatric disabilities and/or substance abuse and that by signing this form, I am specifically authorizing the release of information relating to: Substance Abuse (including alcohol/drug abuse Mental Health Psychotherapy Notess HIVV related information (including AIDS related testing) Signature of Patient or Legal Guardian Date 1. I understand that this authorization will expire two years from my last date of service visit. A photocopy of this form will be considered as valid as the original. 2. I understand that I may revoke this authorization at any time by notifying Frayba Aryan, Privacy Officer at the address indicated below in writing, and this authorization will cease to be effective on the date notified except to the extent action has already been taken in reliance upon it. 3124 N Tarrant Parkway, Suite 200, Fort Worth, Texas 76177, Phone: 817 502 7411, Fax: 817 502 7412 3. I understand that information used or disclosed pursuant to this authorization may be subject to re disclosure by the recipient and no longer be protected by Federal privacy regulations. However, other state or federal law may prohibit thee recipient from disclosing specialty protected information, such as substance abuse treatment information, HIV/AIDS related information, and psychiatric/mental healthh information. 4. My health care and payment for my health care will not be affected if I do not sign this form. 5. I understand that I will get a copy of this form after I sign it. By signing below, I acknowledge that I have read and understand this Authorization. Signature: Patient or representative Relationship Date Witness Date
Patient Name: DOB: SSN#: CONSENT FOR TREATMENT FORM I understand that I have presented myself to Axis Brain and Back Institute, PLLC for evaluation and/or treatment for my condition. I authorize and direct Axis Brain and Back Institute, PLLC to perform quality care upon me, andd all options will be discussed prior to the administration of such treatment. I acknowledge that the practice of medicinee is not an exactt science and that no guarantees have been made to me as to the outcome of any procedures and/or treatments. I grant this consent without duress, confusion, or pressure from my physician and/ /or his or her staff, associates, or FACSIMILE AUTHORIZATION FORM I, the undersigned, authorize Axis Brain and Back Institute, PLLC to send/receive confidential healthcare information as is defined by HIPAAA (Health Insurance Portability and Accountability Act of 1996, 45 C.F.R., Parts 160 164) by facsimile to healthcare providers, hospitals, laboratories, and other medical caregivers in the necessary coordination of care for the patient listed. I may revoke this authorization by giving Axis Brain and Back Institute, PLLC five (5) days written notice. This revocation may bee facsimile transmission; however a written copy of the revocation must be mailed to Axis Brain and Back Institute, PLLCC as well. ASSIGNMENT OF BENFITS / FINANCIAL AGREEMENT I hereby give authorization of insurance benefits to be made directly to Axis Brain and Backk Institute, PLLC services rendered. I understandd that I am financially responsible for all charges whether or not they are covered by insurance. In the event of default, I agreee to pay all costs of collection. I hereby authorize this healthcare provider to release all information necessary to secure the payment of benefits. I further agree that a photocopy of this agreement shall be as valid as the original. ACKNOWLEDGEMENT OF PATIENTT RIGHTS I have read the NOTICE OF PATIENT RIGHTS and have had any questions answered by this office. I understand that by signing this form I acknowledge that I have read the Patient Rights Notice. My consent is freely given. I understand that I may revoke this consent at any time if that revocation is in writing. But any disclosures given in reliance on this priorr consent will bee permissible. ACKNOWLEDGMENT OF PATIENT RESPONSIBILITIES I have read the NOTICE OF PATIENT RESPONSIBILITIES and have had any questions answered by this office. I understand that by signing this form I acknowledge that I have read the Patient Responsibilities Notice posted in all Axis Brain and Back Institute, PLLC locations. My consent is freely given. I understand that I may revoke this consent at any time if that revocation is in writing, but any disclosures given in reliance on this prior consent will be permissible. NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT I acknowledge that Axis Brain and Back Institute, PLLC has provided me with the opportunity to view and read a written copy of NOTICE OF PRIVACY PRACTICE Axis Brain & Back Institute, PLLC Office Copy Page 1 of 1