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Piedmont Spine _ Neurosurgical Group_ PA

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					                      Piedmont Spine & Neurosurgical Group, PA
            109 Montgomery Drive                                      3 St. Francis Drive, Suite 490
             Anderson, SC 29621                                           Greenville, SC 29601
                864-224-5700                                                  864-220-4263

________________________________________________________________________
                           Patient Demographics

Please Complete ALL Questions:
PATIENT LEGAL NAME: (Last)__________________________(First)_____________________(Middle)________________
SOCIAL SECURTITY #: _________________________ DATE-OF-BIRTH: __________________

ADDRESS: ____________________________________________________________________

CITY: __________________________________ STATE:__________ ZIP:__________________

Marital Status: □ S □ M □ D □ W       Sex: □ M □ F     Employed: □ Full □ Part □ Retired □ Student □ Other

Home Phone #: (               )___________________ Cell Phone #: (                   )__________________

Employer/School: _______________________________ Employer Phone #: ________________

Referring Doctor: _________________________ Primary Care Doctor: _____________________

Emergency Contact (outside of home):_________________________Relationship:__________
 Address:
_______________________________________________________________________
 Phone #: ___________________________ Date of Birth: ____________________


                                         Insurance Information

As a courtesy to you, we will file your insurance. If your claim is denied, you are ultimately responsible for
the entire bill. We do not file for any automobile injuries. We will file the claim either with your health
insurance or we will accept your personal payment. It will be your responsibility to work out reimbursement
from auto insurance companies.

Primary Insurance/Workers Comp: ___________________________ Effective Date: ___________
Employer: ________________________________ Employer Phone #: _____________________
Insured: Name: __________________________________ Sex: □ M □ F DOB: ______________________
SS#: _________________________ Relationship to patient: □ self □ spouse □ child □ other ______ ______
Policy # / Claim #: ______________________________ Group #:__________________________________

Secondary Insurance: ______________________________ Effective Date: __________________
Employer: ________________________________ Employer Phone #: _____________________
Insured: Name: __________________________________ Sex: □ M □ F DOB: ______________________
SS#: _________________________ Relationship to patient: □ self □ spouse □ child □ other ______ ______
Policy # / Claim #: ______________________________ Group #:__________________________________
                   Please Provide Copies of All Current Insurance Cards at your visit.
                                                     -1-
                         Piedmont Spine and Neurosurgical Group, PA
   Michael N Bucci, MD FACS   Aaron C MacDonald, MD FACS Christie B Mina, MD     D Mark Melton, MD   H Earle Russell, MD
                                                B Christopher Johnson, PA

                DISCLOSURE OF PROTECTED HEALTH INFORMATION
Date:__________________

By law, medical information is considered confidential unless written authorization to disclose information is
given. This does not include any request we may receive concerning your treatment by another physician or
facility. This also doesn’t pertain to any information requested from an insurance company in payment of a
claim. Therefore, upon signing this form, I, __________________________ am authorizing Piedmont Spine
and Neurosurgical Group, PA to release medical information as described below to:

Name: ________________________ Phone#: ___________________ Relationship: __________
Name: ________________________ Phone#: ___________________ Relationship: __________

I give permission for Piedmont Spine and Neurosurgical Group, PA to release the following information:
         Scheduled appointment times:         □ Yes □ No
         Bill and account information:        □ Yes □ No

May we call you at home?
         □ Yes
         □ No – If no, please provide alternate phone contact information:______________________________

May we leave you a voice mail?
         □ Yes
         □ No

May we mail any correspondence pertaining to your medical care to your home address?
         □ Yes
         □ No – If no, please provide alternate mailing address:   _____________________________________

This authorization remains in effect until I give written notification to discontinue. By signing, I acknowledge I
received a copy of the HIPPA policy.
_____________________________________                        ________________________
Signature of Patient                                             Date
_________________________________________________________________________
                        FAX AND E-MAIL PRIVACY WAIVER
I understand that my medical records may be transmitted electronically by fax and may be received in error by a third
party. In the event that this should occur, I absolve this practice of all liability.

I give my consent to fax my records for the purpose of treatment, payment or healthcare operations and understand that I
may withdraw this consent at any time in writing.

If I choose to e-mail my healthcare provider(s), I understand that e-mail is considered a convenience and is not
appropriate for emergencies, or time-sensitive issues. I also understand that highly sensitive or personal information
should not be communicated via e-mail.

I understand that although safeguards will be made to protect the confidentiality of any information contained within e-
mail, no one can guarantee the absolute privacy of e-mail messages and that depending on their job function, staff my
have the right to access any e-mail sent or received by my healthcare provider(s).

I therefore give my consent to include any e-mails pertinent to the treatment, payment, or healthcare operations in my
medical record. Finally, I understand that I may withdraw this consent at any time in writing.

____________________________________                         ____________________________________
Signature of Patient/Personal Representative                  Printed Name of Patient/Personal Representative


                                                           -2-
                    Piedmont Spine & Neurosurgical Group, PA
                                FINANCIAL RESPONSIBILITIES

Our goal here at Piedmont Spine and Neurosurgical Group, PA is to provide you with high-quality,
efficient care. There are many details involved in the process of payment for the services you
receive. In order for this process to flow smoothly it is important to get the proper information from
you prior to billing. The doctor’s service is provided directly to you. Therefore, you as the patient
have the ultimate responsibility for payment of his or her account. We participate with numerous
insurance companies and as a courtesy; we will submit your claim to the insurance company with
which you have provided us information as well as current billing addresses and phone numbers.
    Due at the Time of Service: co-pay amounts, deductibles, co-insurance amounts, and any
     services not covered by insurance.
    Surgery deposits: required on all non-emergent procedures. Our deposits are based on
     estimates and patient responsibility may vary depending on the actual surgery/procedure
     and what your insurance reimburses.
    Services denied by your insurance company: you are responsible for payment.
     Responsibility for payment begins on the date that services are provided.
    Vehicular accident claims: We do NOT file for automobile accidents. We will file for you
     on your regular health insurance or you can pay for the service in full.
    Workers’ Compensation: If your claim has been accepted and services are approved,
     your claim will be handled directly with your Workers’ Compensation carrier and no charges
     will be incurred by you, the patient. Your recovery and return to work takes a partnership
     with you, your case manager and us. If your claim is denied, charges will be your
     responsibility.
    Balances: If you have a balance remaining after your insurance carrier has paid or if you
     are self pay, we offer several options. If you are self pay, you will receive a discount at the
     time of service. Based on income and family size, additional discounts may be available to
     self pay patients. A completed application form is required to verify qualification for any
     other discounts. If you think you may qualify for this, please ask the office for an
     application.
    Payments: we accept cash, check, and Visa/Master Card credit/debit card. For extended
     payment plans, you will be asked to fill out an application for CareCredit. This may be
     available to you based on your acceptance by CareCredit.
    Outstanding Accounts: accounts with a remaining balance where no resolution has been
     made in a timely manner may be turned over to a collection agency.
    Short Term Disability / FMLA Forms: If your employer required that you have a Short
     Term Disability or FMLA completed, our office will complete it. You will need to bring the
     form to our office as soon as you can. We require up to fifteen business days to complete
     the form. There will be a $20 cash only fee due before the form can be completed. Faxed
     forms will not be completed until this fee is paid.
I understand that I am financially responsible for payment of medical charges incurred on
my behalf as stated above.

_______________________________________                       ______________________________
Signature                                                     Date



                                                 -3-
                   Piedmont Spine and Neurosurgical Group, PA

                                 INJURY DETAIL REPORT


PATIENT: ____________________________ INITIAL DATE OF SERVICE: ________________

IS YOUR TREATMENT RELATED TO AN ACCIDENT OR INJURY?
       □ NO - STOP - Please sign and date this form.    (NO FURTHER QUESTIONS TO BE ANSWERED.)
       □ YES – CONTINUE FILLING OUT FORM.

PLEASE COMPLETE THE FOLLOWING:

Date of accident or injury: ____________________________
Where did the accident/injury occur?
      At Work:      □ Yes □ No
      At Home:      □ Yes □ No
      Automobile: □ Yes □ No
      Other:        Please specify where _______________________________
Please describe the accident/injury ________________________________________________
______________________________________________________________________________
Did anyone other than you cause this injury?
      □ No
      □ Yes – please explain: _____________________________________________________
       ________________________________________________________________________

If the injury is work related, please answer the following:
Have you filed or will you file a claim under Worker’s Compensation or a similar law?
      □ Yes
      □ No – please state your reason(s) for not filing: __________________________________
       ________________________________________________________________________
If a claim has been filed, did your worker’s compensation carrier accept liability?
         □ Yes
         □ No
Worker’s Compensation Carrier’s Name, Address, and Telephone Number:
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________

After you have answered the above questions, please sign and date this form. Accurate
completion of this form will assist in the filing and/or processing of your Insurance claims.

______________________________________ ____________________________
Signature                                Date



                                              -4-
                    Piedmont Spine and Neurosurgical Group, PA
  Michael N Bucci, MD FACS   Aaron C MacDonald, MD FACS Christie B Mina, MD   D Mark Melton, MD   H Earle Russell, MD
                                               B Christopher Johnson, PA



                                      PRESCRIPTION POLICY
In an effort to provide our patients with the highest quality care, our practice abides by the following
prescription policy:

Controlled substance medications are very useful in pain management, but have a small potential
for misuse, and therefore are closely controlled by local state and federal authorities. It is essential
that you take controlled substances as prescribed. After your physician at Piedmont Spine and
Neurosurgical Group, PA has released you from care following your surgery, prescriptions will no
longer be provided.

   1. NO PRESCRIPTIONS WILL BE FILLED EARLY. YOU, the patient, are responsible for
      keeping track of medication, and taking it as the dose and frequency are prescribed.

   2. Prescriptions Will Not Be Refilled if Lost or Stolen – even if a police report is provided

   3. While a patient at Piedmont Spine and Neurosurgical Group, PA, I agree to obtain all
      pain medications (narcotics) from the physician treating me at this facility. I agree
      that I Will Not call a family physician or any other physician to prescribe pain medications.

   4. Our office needs 2 days notice for refills. Request for medications must be called in by
      12:00pm. These will be called in by the end of the day. Request after 12:00pm will be
      called in the next working day.

   5. If you miss your scheduled appointment, medications Will Not be called in for you.

Please list the pharmacy where you prefer your prescriptions called:
                Pharmacy: ___________________________________
                Phone Number: _______________________________


***We will need a new signed Prescription Policy if you wish to switch pharmacies***


Patients who do not comply with the guidelines of the Prescription Policy of Piedmont
Spine and Neurosurgical Group, PA will have their treatment of pain medications
discontinued, and may be dismissed from our care.

I acknowledge by my signature that I have read and agree to the Prescription Policy of
Piedmont Spine and Neurosurgical Group, PA. I understand if I do not follow the rules of
the Prescription Policy, my treating physician may stop my medications or discharge me
from the practice.

_______________________________________ _____________________________________
Patient Signature                                            Date

_______________________________________ _____________________________________
Witness                                                      Date

                                                       -5-
                          Piedmont Spine & Neurosurgical Group, PA
Date: ___________________

PATIENT: ______________________________________________ DOB: __________________________
AGE: __________ HEIGHT: _____________ WEIGHT:_________________
PRIMARY CARE PHYSICIAN: _________________ REFERRING PHYSICIAN:_______________

CHIEF COMPLAINT/ ILLNESS:_______________________________________________________
Location_________________ Onset______________ Duration___________ Severity Scale 0-10 ________
Associated symptoms: □ Numbness □ Weakness □ Tingling □ Pain □ Dizziness □ Headaches □ Other _____________
Have you had any conservative treatments for this complaint/illness? □ Yes □ No If yes, please describe: __
______________________________________________________________________________________

ALLERGIES: ___________________________________________________________________________
CURRENT MEDICATIONS: _______________________________________________________________
______________________________________________________________________________________

Do you use aspirin products or blood thinners? □ Yes □ No If yes, name of medication _________________

PAST MEDICAL HISTORY (Check all that apply):
□ Heart Attack □ Stroke □ High Blood Pressure □ Angina □ High Cholesterol □ Thyroid Disease
□ Diabetes □ Seizures □ Migraines □ Cancer □ Lung Disease □ Urinary Infection □ Kidney Stones
□ Osteoporosis □ Arthritis □ Claustrophobia □ Pacemaker/Artificial Valve □ Metal Additions to Body
□ Other ________________________________________________________________________________

PAST SURGICAL HISTORY:
Surgery                                         Date                                    Surgeon
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

FAMILY HISTORY (Check all that apply):
□ High Blood Pressure □ Lung Disease □ Stroke □ Heart Disease/Heart Attack □ Cancer □ Diabetes

SOCIAL HISTORY:
Tobacco Use □ Yes □ No If yes, Type _____________ # of years _______ # packs per day _________
Alcohol     □ Yes □ No If yes, Amount _______________

REVIEW OF SYSTEMS (Check all that apply):
CONSTITUTION:    □ Weight Loss □ Fever □ Night Sweats □ Other ___________________________
EYES:            □ Double Vision □ Headaches □ Other ___________________________________
ENT:             □ Sore Throat □ Difficulty Swallowing □ Other _____________________________
CARDIOVASCULAR: □ Chest Pain □ Palpitations □ Other _____________________________________
RESPIRATORY:     □ Shortness of Breath □ Cough □ Other __________________________________
GI:              □ Nausea □ Vomiting □ Dark/Bloody Stools □ Other ________________________
GU:              □ Incontinence □ Kidney Stones □ UTI □ Other ____________________________
MUSC:            □ Weakness □ Muscle Pain □ Other _____________________________________
HEM/LYMPHATIC:   □ Free Bleeding □ Blood Disorders □ Other _______________________________
ALLER/IM:        □ Allergies □ Other ___________________________________________________

WORK HISTORY:
Employed: □ Yes □ No If yes, Employer ____________________________ Occupation _______________

________________________________
Patient Signature
                                                   -6-
                                          Medicare Patients Only
                                               MSP Questionnaire

Last Name                                                             First Name
Street Address
City                                                                  State                    Zip
Telephone Number                                                      Date of Birth
Social Security Number                                                Today’s Date
IN ORDER TO PROPERLY BILL YOUR INSURANCE CARRIER OR MEDICARE PLEASE
                                                                                                 YES   NO
ANSWER THE FOLLOWING QUESTIONS:
1. Are you covered by the Federal Black Lung Program?
2. Has the department of Veteran Affairs authorized and agreed to pay for your care due to a
service related injury?
3. Is this a work related injury or illness? If YES, complete Section A below
OR if No complete Section B below.
Section A
If you answered YES to question 3, what was the date of the injury/illness?
Date of Injury/Illness__________________________________________________________
Name & Address of Worker’s Compensation Plan
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Patient’s Policy or ID Number___________________________________________________

Name & Address of Employer __________________________________________________
__________________________________________________________________________
__________________________________________________________________________

Section B
If you answered NO to question 3, what was the date of the injury/illness?
Date of Injury/Illness__________________________________________________________
What event caused the injury/illness?_____________________________________________
Automobile Accident?__________ Other (Describe)_________________________________
__________________________________________________________________________
Name of No fault or liability insurer______________________________________________
__________________________________________________________________________
Insurance Claim Number
4. Do you have End Stage Renal (Kidney) Disease?
5. Have you received maintenance dialysis treatments?
   If YES, what was the date of the first treatment? _________________________________
6. Have you received a kidney transplant?
   If YES, what was the date of transplant? _______________________________________
7. Are you currently disabled?
   If YES, what was the date of your disability? ____________________________________
8. Are these services paid for by a government program such as a research grant?
9. Are you currently employed? (If YES, go to question 10.)
   If NO, what was the date of your retirement? ____________________________________
10. If you answered YES to question 9:
     Are you full-time or part -time? ______Full-Time ______Part-time
11. If you are married, is your souse working (If YES, go to question 12.)
    If NO, what was the date of your spouse’s retirement? ___________________________
12. If you answered YES to question 11:
    Is your spouse Full-time or Part-time? ______Full-Time ______Part-time
    Name and Address of Employer_____________________________________________
    ______________________________________________________________________
13. Are you (the patient) covered by your spouse’s Employer’s Group Health Plan?
    If YES, is your spouse’s health plan Primary or Secondary?
                                                    _____Primary _____Secondary


                                                           -7-
Subrogation/Workers’ Compensation
I-20 at Alpine Road
Columbia, SC 29219-0001
1800-228-2227, extension 43060
Fax: 1-803-865-0654


                                                 ACCIDENT QUESTIONNAIRE


Subscriber:         __________________________                         Patient:                __________________________
Address:            __________________________                         Identification No.:     __________________________
Address:            __________________________                         Provider:               __________________________
                                                                       Date of Service:        __________________________
                                                                       Group Number:           __________________________
                                                                       Claim Number:           __________________________
                                                                       Claim Amount:            __________________________

Dear Member:

Our review process indicates this patient may have received healthcare services related to an accident. So we may evaluate our
responsibility, please complete, sign and return this form within five days of receipt. If we do not receive this information, we may
have to deny your claims. If you previously completed a form for this accident, please check here _____ and update.


Was the injury or illness: Auto/Motorcycle Accident_____Work Related_____Other Accident_____No Accident____
Date of the injury or illness: ______________________         City/County and State of Injury: _____________________________
Describe the injury or illness and how it happened:__________________________________________________________________
__________________________________________________________________________________________________________
Names of other family members injured:__________________________________________________________________________


If you checked “Auto/Motorcycle Accident” or “Other Accident,” please answer the following:
Did another person cause this accident? YES / NO
If yes, name and address of person causing injury: __________________________________________________________________
Insurance Company of person causing injury:________________________________Policy/Claim # :_________________________
Address and Phone # :__________________________________________________Adjuster’s Name:_________________________


If you checked “Work Related,” please answer the following:
Name and address of patient’s employer at the time of injury: _________________________________________________________
Have you filed a Worker’ Compensation claim?       YES / NO
If yes, name of Workers’ Compensation carrier:____________________________________________________________________
Policy/Claim # :________________________________________Adjuster’s Name:_______________________________________
Address and Phone #_________________________________________________________________________________________
Has the employer or the worker’s compensation carrier accepted or denied liability? ACCEPTED / DENIED


Name, address and telephone number of your attorney (if applicable): __________________________________________________
__________________________________________________________________________________________________________


I agree that the above information is correct, and I will not settle a claim before contacting the Subrogation / Worker’s
Compensation Department of BlueCross BlueShield of South Carolina.

__________________________________________________________________________________________________________
Signature                                       Date                                    Telephone Number




                                                                 -8-
                    Piedmont Spine & Neurosurgical Group, P.A.
                                   Greenville Office - 864-220-4263
                                   Anderson Office – 864-224-5700

To help keep your healthcare costs as low as possible, our patient
payment policy is changing.
Dear Patient,

We are writing to let you know that effective June 1, 2011, we will require patients
to arrange for payment for any costs not covered by their insurance at the time of service.
This change helps us reduce our administrative costs, so we can keep the cost of our
services affordable.
Our current policy of billing after the insurance Explanation of Benefits is received is
being replaced with a requirement to arrange for the payment of the anticipated amount
of non-covered costs incurred at the point of service, while visiting our offices.
This amount will be based on actual insurance company estimates, expediting claims
settlement and allowing us to serve you better. Payment of this estimated amount can be
made by debit/credit card, cash or check.

As an alternative, in order to make this transition easier for
you, we have partnered with Visa to offer you a convenient
payment option.

It’s called a Visa Preauthorized Healthcare Transaction (VPHT). Here’s how it works:
• You will receive an estimate of charges not covered by your insurance when you
check-in
• You can then preauthorize us to charge your Visa debit or credit for no more than the
amount of that estimate
• Your card will only be charged once the Explanation of Benefits – which identifies
your responsibility for the charges – is issued by your insurance company

So you pay nothing until the actual amount you owe is finalized.

Keep in mind, your card will never be charged more than the quoted and authorized
amount. If your final financial responsibility ends up being higher than the authorized
amount, we’ll bill you for the difference.
If you have any questions, please don’t hesitate to stop by or call us. We will be more than happy to
help.

Providing affordable, quality healthcare
is our first priority.

P.S. Preauthorizing charges is secure. With Visa’s Zero Liability Policy1, you won’t ever
be responsible for unauthorized transactions.
       Zero Liability Policy covers U.S.-issued cards only and does not apply to commercial credit cards,
1 Visa’s
ATM transactions, or PIN transactions not processed by Visa. Cardholder must notify card issuer
promptly of any unauthorized use. Consult issuer for additional details or visit visa.com/security


                                                        -9-

				
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