MF South Florida Neurosurgery REGISTRATION FORM Today s Date: Primary Care Physician: PATIENT INFORMATION Patient s last name: First: Middle: Marital status: Birth date: Age: Sex: Social Security no.: M F [SS#] Address: Home phone no.: Cell phone no.: Occupation: Employer: Employer phone no.: Referring Doctor: Preferred Pharmacy: Is this visit for a second opinion? Do you have a legal case pending? INSURANCE INFORMATION (Please give your insurance card to the receptionist.) Person responsible for bill: Birth date: Address (if different): Home phone no.: Is this person a patient here? Is this patient covered by insurance? Occupation: Employer: Employer address: Employer phone no.: Please indicate primary insurance: Subscriber s name: Subscriber s S.S. no.: Birth date: Co-payment: Policy no.: Group no.: $ Patient s relationship to subscriber: Name of secondary insurance (if applicable): Subscriber s name: Policy no.: Group no.: Patient s relationship to subscriber:
IN CASE OF EMERGENCY Name of local friend or relative (not living at same address): Relationship to patient: Home phone no.: Work phone no.: The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize South Florida Neurosurgery or insurance company to release any information required to process my claims. Patient/Guardian signature Date
NEW PATIENT FORM DATE: FIRST NAME: M: LAST: ADDRESS: CITY/STATE ZIP TEL #: CELL#: LANGUAGE: DOB: SEX: M / F S.S. # : MARTIAL: S / M / D / W EMAIL ADDRESS: OCCUPATION: EMPLOYER: WORK #: Referring Doctor: Primary Care Physician: Describe briefly your present symptoms: When did this problem first start? Are you Right OR Left Handed? Medication Allergies: Food Allergies: Drug Allergies: Are you Allergic to contrast dye? CURRENT MEDICATIONS Are you on any blood thinners: No Yes Please list any medications that you are now taking. Include non-prescription medications & vitamins or supplements. How long have you been taking this? Name of drug: Dose (include strength & number of pills per day) 1. 2. 3. 4. 5. 6. 7.
PAST MEDICAL HISTORY Do you now or have you ever had: Coronary Artery Disease Diabetes Stroke (TIA) Hepatitis High blood pressure Epilepsy (seizures) Stomach or peptic ulcer High cholesterol Cataracts Rheumatic fever Cancer (type) Kidney disease Tuberculosis Heart murmur Kidney stones HIV/AIDS Pneumonia Crohn s disease Pulmonary embolism Colitis Asthma Anemia Emphysema Jaundice Other medical conditions (please list): List Surgeries/ Dates: MRI (location and date): CT Scan/X-rays (location and date): Your blood relatives have had the following: Cancer: Heart Disease: Stroke: Diabetes: PERSONAL HISTORY Past Surgeries and dates: Previous treatment Brain or Spine dates: Injections/epidurals/cortisone shots to the area/dates: Physical therapy dates: Do you have any Metal or Implants in your body? SOCIAL HISTORY: Do you smoke? How many packs a day? Do you drink? How much and how often? IV Drug user: Please Explain:
SYSTEMS REVIEW In the past month, have you had any of the following problems? GENERAL NERVOUS SYSTEM PSYCHIATRIC Recent weight gain; how Headaches Depression much Recent weight loss: how Dizziness Excessive worries much Fatigue Fainting or loss of consciousness Difficulty falling asleep Weakness Numbness or tingling Difficulty staying asleep Fever Memory loss Difficulties with sexual arousal Night sweats Poor appetite Food cravings MUSCLE/JOINTS/BONES STOMACH AND INTESTINES Frequent crying Numbness Nausea Sensitivity Joint pain Heartburn Thoughts of suicide / attempts Muscle weakness Stomach pain Stress Joint swelling Vomiting Irritability Where? Yellow jaundice Poor concentration Increasing constipation Racing thoughts EARS Persistent diarrhea Hallucinations Ringing in ears Blood in stools Rapid speech Loss of hearing Black stools Guilty thoughts Paranoia EYES SKIN Mood swings Pain Redness Anxiety Redness Rash Risky behavior Loss of vision Nodules/bumps Double or blurred vision Hair loss Dryness Color changes of hands or feet OTHER PROBLEMS: THROAT BLOOD Frequent sore throats Anemia Hoarseness Clots Difficulty in swallowing Pain in jaw KIDNEY/URINE/BLADDER Frequent or painful urination HEART AND LUNGS Blood in urine Chest pain Shortness of breath Women Only: Fainting Abnormal Pap smear Swollen legs or feet Irregular periods Bleeding between periods PMS
Patient Consent To Release Information Authorization to Release Information to Family Members Many of our patients allow family members such as their spouse, parents or others to call and request the results of tests and procedures. Under the requirements for H.I.P.P.A. we are not allowed to give this information to anyone without the patient s consent. If you wish to have your test results released to family members you must sign this form. Signing this form will only give consent to release laboratory/pathology results to the family members indicated below. This consent form will not allow South Florida Neurosurgery to release any other information to these family members. You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent. I authorize South Florida Neurosurgery to release my medical information/results and reports to the following individuals. 1. Relation to Patient: 2. Relation to Patient: 3. Relation to Patient: Signature of Patient/Guardian: Authorization to Leave Messages with Household Members/Answering Machine From time to time it is necessary for representatives of South Florida Neurosurgery to leave messages for patients. The purposes of these messages is to remind patients that they have an appointment, to notify the patient that the medical staff would like to discuss procedure results, or to ask a patient to call South Florida Neurosurgery regarding an issue or concern. At no time will a representative of South Florida Neurosurgery discuss your medical circumstances or condition without your consent. The purpose of this consent is to leave messages with members of your household or on your answering machine. You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent. Signature of Patient/Guardian: Date:
AUTHORIZATION FOR THE RELEASE OF MEDICAL RECORDS TO SFN I,, D/O/B, (Patient Name) hereby authorize (Organization) to release copies of medical records and other records concerning my treatment, including but not limited to, information concerning drug abuse or drug related conditions, alcoholism, psychological and psychiatric conditions, and including the release of information containing HIV testing, AIDS diagnosis, AIDS related conditions or sexual preference, or permit review of the same. ( ) Other Exclusions The above information is to be released to: South Florida Neurosurgery 5503 South Congress Avenue Suite 204 Atlantis, FL 33462 Phone: (561) 410-5110 Fax: (561) 328-3911 I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I do not need to sign this form to obtain treatment. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by law. I understand this authorization may be revoked ay any time except to the extent actions have been taken prior to revocation. This consent will expire in sixty (60) days after the date below. I acknowledge that I have read and fully understand this authorization as it applies to me. Date Signature of Patient Other person legally authorized to give consent Relationship to Patient
South Florida Neurosurgery Notice of Privacy Practices Effective Date: THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. If you have any questions about this notice, please contact the Facility Privacy Official by dialing the main medical office number. OUR OBLIGATIONS: We are required by law to: Maintain the privacy of protected health information Give you this notice of our legal duties and privacy practices regarding health information about you Follow the terms of our notice that is currently in effect HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION: The following describes the ways we may use and disclose health information that identifies you ( Health Information ). Except for the purposes described below, we will use and disclose Health Information only with your written permission. You may revoke such permission at any time by writing to our practice Privacy Officer. For Treatment. We may use and disclose Health Information for your treatment and to provide you with treatment-related health care services. For example, we may disclose Health Information to doctors, nurses, technicians, or other personnel, including people outside our office, who are involved in your medical care and need the information to provide you with medical care. For Payment. We may use and disclose Health Information so that we or others may bill and receive payment from you, an insurance company or a third party for the treatment and services you received. For example, we may give your health plan information about you so that they will pay for your treatment. For Health Care Operations. We may use and disclose Health Information for health care operations purposes. These uses and disclosures are necessary to make sure that all of our patients receive quality care and to operate and manage our office. For example, we may use and disclose information to make sure the obstetrical or
gynecological care you receive is of the highest quality. We also may share information with other entities that have a relationship with you (for example, your health plan) for their health care operation activities. Appointment Reminders, Treatment Alternatives and Health Related Benefits and Services. We may use and disclose Health Information to contact you to remind you that you have an appointment with us. We also may use and disclose Health Information to tell you about treatment alternatives or health-related benefits and services that may be of interest to you. Individuals Involved in Your Care or Payment for Your Care. When appropriate, we may share Health Information with a person who is involved in your medical care or payment for your care, such as your family or a close friend. We also may notify your family about your location or general condition or disclose such information to an entity assisting in a disaster relief effort. Research. Under certain circumstances, we may use and disclose Health Information for research. For example, a research project may involve comparing the health of patients who received one treatment to those who received another, for the same condition. Before we use or disclose Health Information for research, the project will go through a special approval process. Even without special approval, we may permit researchers to look at records to help them identify patients who may be included in their research project or for other similar purposes, as long as they do not remove or take a copy of any Health Information. SPECIAL SITUATIONS: As Required by Law. We will disclose Health Information when required to do so by international, federal, state or local law. To Avert a Serious Threat to Health or Safety. We may use and disclose Health Information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Disclosures, however, will be made only to someone who may be able to help prevent the threat. Business Associates. We may disclose Health Information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract. Organ and Tissue Donation. If you are an organ donor, we may use or release Health Information to organizations that handle organ procurement or other entities engaged in procurement, banking or transportation of organs, eyes or tissues to facilitate organ, eye or tissue donation and transplantation.
Military and Veterans. If you are a member of the armed forces, we may release Health Information as required by military command authorities. We also may release Health Information to the appropriate foreign military authority if you are a member of a foreign military. Workers Compensation. We may release Health Information for workers compensation or similar programs. These programs provide benefits for work-related injuries or illness. Public Health Risks. We may disclose Health Information for public health activities. These activities generally include disclosures to prevent or control disease, injury or disability; report births and deaths; report child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using; a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law. Health Oversight Activities. We may disclose Health Information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws. Data Breach Notification Purposes. We may use or disclose your Protected Health Information to provide legally required notices of unauthorized access to or disclosure of your health information. Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose Health Information in response to a court or administrative order. We also may disclose Health Information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested. Law Enforcement. We may release Health Information if asked by a law enforcement official if the information is: (1) in response to a court order, subpoena, warrant, summons or similar process; (2) limited information to identify or locate a suspect, fugitive, material witness, or missing person; (3) about the victim of a crime even if, under certain very limited circumstances, we are unable to obtain the person s agreement; (4) about a death we believe may be the result of criminal conduct; (5) about criminal conduct on our premises; and (6) in an emergency to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime. Coroners, Medical Examiners and Funeral Directors. We may release Health Information to a coroner or medical examiner. This may be necessary, for example, to
identify a deceased person or determine the cause of death. We also may release Health Information to funeral directors as necessary for their duties. National Security and Intelligence Activities. We may release Health Information to authorized federal officials for intelligence, counter-intelligence, and other national security activities authorized by law. Protective Services for the President and Others. We may disclose Health Information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or to conduct special investigations. Inmates or Individuals in Custody. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release Health Information to the correctional institution or law enforcement official. This release would be if necessary: (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) the safety and security of the correctional institution. USES AND DISCLOSURES THAT REQUIRE US TO GIVE YOU AN OPPORTUNITY TO OBJECT AND OPT Individuals Involved in Your Care or Payment for Your Care. Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your Protected Health Information that directly relates to that person s involvement in your health care., If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. Disaster Relief. We may disclose your Protected Health Information to disaster relief organizations that seek your Protected Health Information to coordinate your care, or notify family and friends of your location or condition in a disaster. We will provide you with an opportunity to agree or object to such a disclosure whenever we practically can do so. YOUR WRITTEN AUTHORIZATION IS REQUIRED FOR OTHER USES AND DISCLOSURES The following uses and disclosures of your Protected Health Information will be made only with your written authorization: 1. Uses and disclosures of Protected Health Information for marketing purposes; and 2. Disclosures that constitute a sale of your Protected Health Information Other uses and disclosures of Protected Health Information not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you do give us an authorization, you may revoke it at any time by submitting a written
revocation to our Privacy Officer and we will no longer disclose Protected Health Information under the authorization. But disclosure that we made in reliance on your authorization before you revoked it will not be affected by the revocation. YOUR RIGHTS: You have the following rights regarding Health Information we have about you: Right to Inspect and Copy. You have a right to inspect and copy Health Information that may be used to make decisions about your care or payment for your care. This includes medical and billing records, other than psychotherapy notes. To inspect and copy this Health Information, you must make your request, in writing, to South Florida Neurosurgery. We have up to 30 days to make your Protected Health Information available to you and we may charge you a reasonable fee for the costs of copying, mailing or other supplies associated with your request. We may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state of federal needs-based benefit program. We may deny your request in certain limited circumstances. If we do deny your request, you have the right to have the denial reviewed by a licensed healthcare professional who was not directly involved in the denial of your request, and we will comply with the outcome of the review. Right to an Electronic Copy of Electronic Medical Records. If your Protected Health Information is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your Protected Health Information in the form or format you request, if it is readily producible in such form or format. If the Protected Health Information is not readily producible in the form or format you request your record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form. We may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record. Right to Get Notice of a Breach. You have the right to be notified upon a breach of any of your unsecured Protected Health Information. Right to Amend. If you feel that Health Information we have is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for our office. To request an amendment, you must make your request, in writing, to South Florida Neurosurgery. Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures we made of Health Information for purposes other than treatment, payment and health care operations or for which you provided written authorization. To request an accounting of disclosures, you must make your request, in writing, to South Florida Neurosurgery. Right to Request Restrictions. You have the right to request a restriction or limitation on the Health Information we use or disclose for treatment, payment, or health care
operations. You also have the right to request a limit on the Health Information we disclose to someone involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not share information about a particular diagnosis or treatment with your spouse. To request a restriction, you must make your request, in writing, to South Florida Neurosurgery. We are not required to agree to your request unless you are asking us to restrict the use and disclosure of your Protected Health Information to a health plan for payment or health care operation purposes and such information you wish to restrict pertains solely to a health care item or service for which you have paid us out-of-pocket in full. If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment. Out-of-Pocket-Payments. 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. Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you by mail or at work. To request confidential communications, you must make your request, in writing, to South Florida Neurosurgery. Your request must specify how or where you wish to be contacted. We will accommodate reasonable requests. Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice at our office. CHANGES TO THIS NOTICE: We reserve the right to change this notice and make the new notice apply to Health Information we already have as well as any information we receive in the future. We will post a copy of our current notice at our office. The notice will contain the effective date on the first page, in the top right-hand corner. COMPLAINTS: If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. To file a complaint with our office, contact the Manager at South Florida Neurosurgery. All complaints must be made in writing. You will not be penalized for filing a complaint.
Patient Financial Responsibility Form Thank you for choosing South Florida Neurosurgery as your healthcare provider. We are honored by your choice and are committed to providing you with the highest quality healthcare. We ask that you read and sign this form to acknowledge your understanding of our patient financial policies. Patient Financial Responsibilities The patient (or patient s guardian, if a minor) is ultimately responsible for the payment for her treatment and care. We are pleased to assist you by billing for our contracted insurers. However, the patient is required to provide us with the most correct and updated information about their insurance, and will be responsible for any charges incurred if the information provided is not correct or updated. Patients are responsible for the payment of copays, coinsurance, deductibles, and all other procedures or treatment not covered by their insurance plan. Payment is due at the time of service, and for your convenience, we accept cash, check, and most major credit cards at our office. Patients may incur, and are responsible for the payment of additional charges at the discretion of South Florida Neurosurgery. These charges may include (but are not limited to): Charge for returned checks, Charge for missed appointments without 24 hours advance notice, Charge for extensive phone consultations and/or after-hours phone calls requiring diagnosis, treatment, or prescriptions.,charge for the copying and distribution of patient medical records, Charge for extensive forms completion, Any costs associated with collection of patient balances. Patient Authorizations By my signature below, I hereby authorize South Florida Neurosurgery and the physicians, staff, and hospitals associated with South Florida Neurosurgery to release medical and other information acquired in the course of my examination and/or treatment (with the exceptions stipulated below) to the necessary insurance companies, third party payors, and/or other physicians or healthcare entities required to participate in my care. I understand that I must check one or more of the following types of health information in order to indicate that I authorize that information type to be released to the necessary insurance companies, third party payors, and/or other physicians and/or healthcare entities required to participate in my care. By checking one or more of the following boxes, the health information I authorize to be released may include any of the following: Diagnosis, evaluation, and/or treatment for alcohol and/or drug abuse. Records of HTLV-III or HIV testing (AIDS test) result, diagnosis, and/or treatment. Psychiatric and/or psychological records, or evaluation and/or treatment for mental, physical, and/or emotional illness, including narrative summary, tests, social work assessment, medication, psychiatric examination, progress notes, consultations, treatment plans, and/or evaluations. By my signature below, I hereby authorize assignment of financial benefits directly to South Florida Neurosurgery and any associated healthcare entities for services rendered as allowable under standard third party contracts. I understand that I am financially responsible for charges not covered by this assignment. By my signature below, I authorize South Florida Neurosurgery personnel to communication by mail, answering machine message, and/or email according to the information I have provided in my patient registration information. I have read, understand, and agree to the provisions of this Patient Financial Responsibility Form: Signature of Patient or Guardian Date Waiver of Patient Authorizations I do not wish to have information released and prefer to pay at the time of service and/or to be fully responsible for payment of charges and to submit claims to insurance at my discretion. Signature of Patient or Guardian Date
Pharmacy Update Form Attention Patients We are updating our records and need to have your pharmacy information so all of the prescription we write for you will be sent directly to your pharmacy Patient's Name : Pharmacy Name: Pharmacy Address: Pharmacy Phone Number: South Florida Neurosurgery 5503 South Congress Avenue, Suite 204 Atlantis, FL 33462 Phone #: 561-410-5110 Fax #: 561-328-3911
Patient Consent Form (Please Read and Sign) I, (the undersigned), hereby consent to the following Treatment: Administration and performance of all treatments Administration of any needed anesthetics Performance of such procedures as may deemed necessary or advisable in the treatment of this patient Use of prescribed medication Performance of diagnostic procedures/tests and cultures Performance of other medically accepted laboratory tests that may be considered medically necessary or advisable based on the judgment of the attending physician or their assigned designees I, fully understand that this is given in advance of any specific diagnosis or treatment. I intend this consent to be continuing in nature even after a specific diagnosis has been made and treatment recommended. The consent will remain in full force until revoked in writing. I understand that South Florida Neurosurgery may include consent at satellite offices under common ownership. I, the undersigned, acknowledge that Dr. Kouri will use and disclose my information for the purpose of treatment, payment, and healthcare operations as described in the Notice of Privacy Practices. A photocopy of this consent shall be considered as valid as the original MEDICARE PATIENTS: I authorize to release medical information about me to the Social Security Administration or its intermediaries for Medicare claims. I assign the benefits payable for services to South Florida Neurosurgery. I acknowledge that I have been given the South Florida Neurosurgery Notice of Privacy Practices. I understand that if I have questions or complaints that I should contact the Privacy Official. Patient initial: I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents. Patient (or responsible party) Signature Date