PATIENT WILL NOT BE SEEN WITHOUT PHOTO ID Patient Information Kimberly Walpert, M.D. 1199 Prince Avenue Athens GA 30606 Ph 706-475-1870 Fax 706-475-1879 www.athensbrainandspine.com Patient Name First Middle Last Address Street City State Zip Home Phone Work Phone Cell Phone Date of Birth SS# Email (Circle all that apply) Male Female Employer Asian Black Hispanic White Other Preferred Drug Store Divorced Single Married Widow Drug Store Address PRIMARY CARE PHYSICIAN List persons that we can contact in case of emergency Release Information Name Phone Relationship (circle yes or no) Y/N Y/N Guarantor (Person Responsible for Payment) If person responsible for the bill is same as the patient, you do not need to complete this section. Thank You Name First Middle Last Address Home Phone Work Phone Cell Phone Date of Birth SS# Employer Insurance Information Copy of insurance cards is required. If card is not available you will be entered as self pay until insurance card returned. INSURANCE SELF-PAY Primary Member ID number Secondary Member ID number Policy Holder (if different from card) Date of Birth Assignment of Benefits: I hereby assign all medical and/or surgical benefits to which I am entitled including major medical, Medicare, private insurance and any other plans to the office of Athens Regional Specialty Services. This agreement will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release all information necessary to secure the payment. If you choose not to sign you are still responsible for all charges. Signed Date
PATIENT HEALTH HISTORY Patient Name first middle last Date of Birth Exam Date Medical Record # Full Name of Referring Physician Full Name of Primary Care Physician CHIEF COMPLAINT What are your current symptoms? How long have you had these symptoms? Please circle a number from 1 to 10 that most closely measures the amount of pain you feel. 0 1 2 3 4 5 6 7 8 9 10 No Hardly noticeable Noticeable & Wearing Worst Pain Athens Brain and Spine Patient Health History Page 1
In the last year have you tried any of the following treatments to relieve your symptoms? (check all that apply): physical therapy bed rest reduction of activity pain medication muscle relaxants anti-inflammatory medications cervical or lumbar traction exercise program chiropractic treatment back or neck brace ultrasound hydrotherapy heat/tens unit unit massage therapy pain control clinic oral steroids steroid / cortisone injection surgery others: What makes your symptoms worse? What makes your symptoms better? Please name the physicians you have seen about your current medical problem: Have you ever had the same or similar condition? yes no If your symptoms are related to any injury, please mark the type of injury: auto injury personal injury work-related injury other Athens Brain and Spine Patient Health History Page 2
If work related, did you report this to your current employer? yes no Date of injury: If no specific date, when did you first notice your problem? PAST MEDICAL HISTORY Patient Name first middle last Date of Birth Exam Date Medical Record # List any medication allergies and the reaction: Allergy: Reaction: Other allergies (please check all that apply): iodine/dyes latex tape shellfish Medications: (the clinical staff member will review with you): Pharmacy: (Name / Address / Phone Number) Athens Brain and Spine Patient Health History Page 3
Please list any surgeries or prior hospitalizations: Have you ever had an MRSA or Staph infection? If so please give dates and treatment received. For diagnostic purposes: Do you have a pacemaker or an aneurysm clip? Y N Do you have a spinal cord stimulator or an intracranial shunt? Y N Are you claustrophobic? Y N Please check any previous illnesses that apply: Anemia High blood pressure Diabetes Reflux Asthma Heart disease Ulcers Seizures Cancer Heart murmur CVA/stroke Enlarged prostate Hepatitis B High cholesterol Thyroid disease Osteoporosis Hepatitis C Kidney disease Sleep Apnea Osteoarthritis HIV/AIDS COPD Depression Rheumatoid arthritis Other: FAMILY HISTORY Patient Name first middle last Date of Birth Exam Date Medical Record # Athens Brain and Spine Patient Health History Page 4
Family Members (Alive or Deceased) health status or cause of death: Father: Mother: Sibling: Sibling: Sibling: Sibling: SOCIAL HISTORY Working Yes No Occupation: Disabled Yes No Reason for Disability: Medical Leave Yes No Who took you out of work?: Last day of work: Marital Status: Single Married Divorced Widowed Do you have any children? Yes No Do you use tobacco products? No, never No, but I used to. Quit Date: Yes. Form of tobacco? Packs/day? For how long? Do you drink alcohol? No, never No, but I used to Yes If yes, Daily Weekly Monthly Yearly Occasionally Rarely Socially Do you currently use illegal drugs? No Yes If yes, list: Athens Brain and Spine Patient Health History Page 5
Review of symptoms (please check all that apply): CONSTITUTIONAL Fatigue Fever Generalized Weakness Weight Gain HEAD, EYES, EARS, NOSE AND THROAT Hearing loss R / L Sinusitis Swallowing difficulty RESPIRATORY Short of breath Cough Wheezing Known TB Exposure HEART Chest pain Irregular heartbeat Leg swelling GASTROINTESTINAL Bowel Incontinence Constipation Nausea Vomiting GENITOURINARY Bladder Incontinence Frequent urination Urinary retention METABOLIC/ENDORCINE Hormone problems Irregular menses CONSTITUTIONAL Depression Dizziness Headache Memory Impairment Speech changes MUSCULOSKELETAL Joint pain Muscle pain / spasms Numbness / tingling Weakness HEMOTOLOGIC Easy bleeding Easy Bruising Athens Brain and Spine Patient Health History Page 6
MEDICATION AGREEMENT The purpose of this agreement is to let you know the requirements for receiving prescription medications from Athens Brain & Spine. This agreement is between the patient and providers of the office. If you do not understand this fully, please speak to your provider. By signing this form you are indicating that you understand and will comply with these guidelines. All medications are to be taken as per the schedule indicated on the bottle. Prescribed medications can be deadly if taken incorrectly. Contact our office should you have any questions about the directions/schedule. Do not alter your medications without speaking to us. Early refills will not be granted unless there is documentation that our staff instructed you to increase the dosage. You will need to choose only one pharmacy for your medications. Please alert our staff if you are changing pharmacies so that we can make the corrections. Provide us with the name, number, and location of your pharmacy. If one of our providers prescribes narcotic medication for you, it is understood that you will not receive narcotic medication from any other provider outside of this practice. If we receive information that you have been getting medications from other providers Athens Brain & Spine will no longer provide these. We will not replace lost or stolen medications. Requests for refills of medications are taken during normal business hours 8 am- 4pm. We will not refill medications after office hours or on weekends. When you call for a refill, please have the medication name and strength available. We will send this by email (except for certain narcotic medications) to the pharmacy on file unless you indicate otherwise to us. We will only call you back if the medication request is denied or if there has been a change in the prescription recommended by your provider. Otherwise check with your pharmacy to see when it can be picked up. Narcotic medications now require written prescriptions that will need to picked up or mailed. With this in mind, please call the office a few days before you run out. Our providers will not refill medications if you have not been seen in the last 6 months. Narcotics are usually reserved for postoperative treatment and not prescribed routinely by Athens Brain & Spine for non-surgical issues. This agreement is to ensure patient safety as well as to comply with the regulations of the Georgia Drug Enforcement Agency. / / Patient or Legal Guardian's Signature Witnessed By Today s Date
Dear Valued Patient, Insurance companies have many types of plans. These plans often have copay, coinsurance, and deductibles associated with them. Many plans require advance notification and authorization prior to rendering non-emergency health care services. Please be advised that if you have insurance, it is your responsibility to know your health plans policy and of all the requirements. If prior approval, pre-certification, or authorization is needed we will be happy to assist you. If your insurance company allows claims appeals, by signing this form, you give us the right to submit claim appeals on your behalf. In the event that appeal is denied, the balance is your responsibility. All balances for services are due at time of service. We will also work with you to make payment arrangements, if this is necessary. We value you and all of our other patients and wish to provide the highest level of service and patient care. Appointment times are valuable to those desiring patient care, and we make every effort to ensure we provide reminder of scheduled appointments. In the event a patient does not show for their scheduled appointment, this will be considered a no show. It is our policy to make recommendation for discharge from the practice, any patient that no shows three (3) times within a calendar year. Each no show event will be subject to a $25 service fee. We value all of our patients care and feel such policy helps maintain compliance with your scheduled healthcare needs. In the event you need to cancel your appointment, please provide 24 hour advance notification. We will be happy to reschedule your appointment for the next available time. Patient/Legal Guardian: Date of Birth: (Please Print Name) Patient/ Legal Guardian: Date: (Signature) FOR PRACTICE USE ONLY Witness: (Please print name) Date: Witness: (Signature) Revised 12/2015
Privacy Consent Patient name date of birth Our Notice of Privacy Practice (NPP) states we may disclose your protected health information (PHI) to others who are involved in your care, such as spouse, children, parents, caregivers or others. Please complete either Section A or B: A) List anyone you would authorize us to share or discuss your PHI. This could include medical treatment, diagnosis or releasing of records. Name: Name: Name: Name: Name: Relationship: Relationship: Relationship: Relationship: Relationship: B) If you do not wish for us to disclose your PHI to anyone, please initial here. Your right to limit uses of PHI for treatment, payment or operations (TPO): Under the terms of the NPP, you can ask ARPG to limit how your personal health information is used or disclosed to carry out treatment, payment or operations. Only the Athens Regional Health Services Privacy Officer is authorized to agree to limitations on the use of your PHI for TPO. The Privacy Officer does not have to agree to your request. If you wish to RESTRICT the use/disclosure for TPO, please request the Restriction Request Form or make your request in writing to Athens Brain & Spine, 1199 Prince Avenue, Athens, GA 30606. In your written request, you must tell us 1) what information you want to limit; 2) whether you want to limit our use, disclosure or both; and 3) to whom you want the limits to apply, for example: disclosures to your adult children. We may be reached at (706)475-1870. You may change or revoke this consent at any time by completing a new form or sending us a letter. Patient signature Date Relationship if other than patient