SPECTRUM NEUROSURGICAL SPECIALISTS, PC by mmcsx

VIEWS: 9 PAGES: 14

									                                                                        Date:_____________

           SPECTRUM NEUROSURGICAL SPECIALISTS, P.C.
Steven P. Disch, M. D., F.A.C.S                      Charles E. Weaver, Jr., M.D., PhD
Thomas W. Belknap, M.D.                             Janice D. Reed, MS, NP-C


                                 PATIENT INFORMATION

Name_________________________________________ Date of Birth ___________Age________
Address_________________________________________________________ Apt. #__________
City________________________ State_________ Zip Code_____________ Sex: M____ F____
Social Security # _________________________ Marital Status: M____ S____ D____ W____
Home Phone_________________ Work Phone _________________ Cell Phone______________
Email Address:_____________________________________________________________
Referring Doctor___________________________ Doctor’s Phone Number_______________
                   ALTERNATE CONTACT IF PATIENT CANNOT BE REACHED
Name:______________________ Address:______________________________________
Phone #____________________________ Relationship ____________________________

             Is this condition a result of a motor vehicle accident or workers comp?
                                  If yes, please refer to section C.
(A) PRIMARY INSURANCE INFORMATION:
Insurance Company Name: ____________________________________________________
Address: _______________________________ City/State/Zip:_______________________
Enter the name of person who is responsible for the primary insurance
Cardholder’s Name __________________ID #__________________ Group #____________
Employer’s Name________________________________ Work Phone__________________
Is this a Group or Individual Policy? _____________________________________________
Have you had this policy for longer than 12 months? Yes___ No___
Cardholder’s Date of Birth____________________
Relationship to Insured_____________________ Co-Pay _________ Referral: Yes___ No___
PCP: __________________________________ Telephone #_________________________


(B) SECONDARY INSURANCE INFORMATION:
Insurance Company Name: ____________________________________________________
Address: _______________________________ City/State/Zip:_______________________
Enter the name of person who is responsible for the primary insurance
Cardholder’s Name __________________ID #__________________ Group #____________
Employer’s Name________________________________ Work Phone__________________
Is this a Group or Individual Policy? _____________________________________________
Have you had this policy for longer than 12 months? Yes___ No___
Cardholder’s Date of Birth____________________
Relationship to Insured_____________________ Co-Pay _________ Referral: Yes___ No___
PCP: __________________________________ Telephone #_________________________
          SPECTRUM NEUROSURGICAL SPECIALISTS, P.C.
Steven P. Disch, M. D., F.A.C.S                     Charles E. Weaver, Jr., M.D., PhD
Thomas W. Belknap, M.D.                            Janice D. Reed, MS, NP-C



(C) WORKER’S COMPENSATION INFORMATION:
Employer___________________________________ Date of Injury___________________
City/ State/ Zip_____________________________________________________________
Date 1st Accident Filed_____________________________ Claim #_____________________
HR Phone #____________________ Worker’s Compensation Carrier___________________
Address__________________________________________________________________
Do you have an attorney? Yes     No
If yes, please give complete name, phone/fax numbers and address:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________


(D) MOTOR VEHICLE ACCIDENT INFORMATION:
Do you carry med coverage on your auto policy? _____________________________________
Auto Insurance _______________________________ Date of Injury___________________
Address____________________________________City/State/Zip____________________
Claim #________________ Adjustor___________________ Telephone #_______________
Do you have an Attorney?   Yes    No
If yes, please give complete name, phone/fax numbers and address:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Notes:___________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
                          Spectrum Neurosurgical Specialists’ Registration Form

PLEASE READ AND SIGN THE FOLLOWING:

                                             CONSENT FOR TREATMENT

I hereby consent to and authorize the performance of examinations and treatment for the below named
patient, that in the judgment of Spectrum Neurosurgical Specialists’ medical staff – Steven P. Disch, M.D.,
Charles E. Weaver, M.D., Thomas Belknap, M.D., Janice Reed, NP-C, Kathy Moore, R.N. or Karen Johnstone, R, N,.
 - may be considered necessary or advisable.

Patient’s Name _______________________________________

____________________________________________________                              _____________________
Signature of Patient or Legal Guardian                                                  Date


         CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH CARE INFORMATION

I understand that, under the Health Insurance Portability & Accountability Act of 1996, I have certain rights to
privacy regarding my protected health information. I understand and consent that this information can and will
be used to conduct, plan, and direct my treatment and follow-up care among the multiple healthcare providers
who may be involved in that treatment directly or indirectly, obtain payment from third-party payers and
conduct normal healthcare operations such as quality assessments and physician certifications.

I understand that I have the right to review Spectrum Neurosurgical Specialists’ Notice of Privacy Practices
prior to signing this consent.

With this consent, Spectrum Neurosurgical Specialists’ and its employees may, but not limited to, call my
home or other alternate locations, leave a message on voice mail or in person, can send mail to my home or
alternate location, in reference to any items that assist the practice in carrying out any treatment, payment or
healthcare operations.

I may revoke my consent in writing except if the practice has already made disclosures in reliance upon my
prior consent. If I do not sign this consent, or later revoke it, Spectrum Neurosurgical Specialists may decline
to provide treatment to me.

____________________________________________
Patient’s Name

____________________________________________                                  ________________
Signature of Patient or Legal Guardian                                        Date
                         Spectrum Neurosurgical Specialists’ Registration Form

PLEASE READ AND SIGN THE FOLLOWING:

                           NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

I have received, read and understand Spectrum Neurosurgical Specialists’ Notice of Privacy Practices
containing a more complete description of the uses & disclosures of my healthcare information. I understand
that Spectrum Neurosurgical Specialists’ reserves the right to revise its Privacy Practices at anytime. A
revised Notice of Privacy Practices may be obtained by requesting one in person at Spectrum Neurosurgical
Specialists’ office, located at 2500 Hospital Blvd, Suite 310, Roswell, Georgia.



____________________________________
Patient’s Name


_____________________________________                                     __________________
Signature of Patient or Legal Guardian                                    Date



                                            ASSIGNMENT OF BENEFITS

I hereby authorize and assign that insurance payments for services provided to me, be made directly to
Spectrum Neurosurgical Specialists, P.C.



__________________________________________
Patient’s Name

__________________________________________                                ___________________
Signature of Patient or Legal Guardian                                    Date
                        Spectrum Neurosurgical Specialists’ Registration Forms


                           FINANCIAL AND PAYMENT POLICY SIGNATURE FORM

             SIGNATURE FORM SHALL BE HELD AS RECORD OF ACCEPTANCE OF FINANCIAL AND
                                       PAYMENT POLICIES


I have received and read a copy of Spectrum Neurosurgical Specialists, P.C. Financial and Payment Policy
(2 pages). I understand and agree to abide by the policies noted which may be relevant to my financial
obligations for services received from Spectrum Neurosurgical Specialists, P.C. and its employees. I am also
aware of my responsibility to provide Spectrum Neurosurgical Specialists, P.C. with accurate and current
information, with regards to my insurance coverage, address, and telephone number.


__________________________________________
Patient Name


__________________________________________                                _____________________
Signature of Patient or Legal Guardian                                    Date
                                   Spectrum Neurosurgical Specialist, P.C.

Steven P. Disch, M.D. F.A.C.S                                                         Charles, E. Weaver, Jr., M.D., PhD
Thomas W. Belknap, M.D.                                                               Janice D. Reed, MS, NP-C


                                      FINANCIAL AND PAYMENT POLICY

In order to provide efficient, cost effective, and personalized service, Spectrum Neurosurgical Specialist has
instituted the following policy. We are here to serve you and hope that your visit is a pleasant one. Please feel free
to voice any concerns, which may relate to this policy.

Spectrum Neurosurgical Specialist honors cash, checks, Visa and Master Card. Please be aware that there is a
$25.00 service charge for all returned checks.

By accepting treatment at this facility a patient or his/her guardian is considered to have entered into an agreement to
accept financial responsibility to compensate Spectrum Neurosurgical Specialist for any services rendered to
him/her. Please understand that this agreement is solely between the patient and Spectrum Neurosurgical Specialist
and as such the patient, not his/her insurance carrier, is ultimately responsible for payment of such services. As a
courtesy to our patients, Spectrum Neurosurgical Specialist will file all appropriate charges to the patient’s primary
insurance carrier. In the event that an insurance carrier denies payment because it has determined the service to be a
“non-covered benefit” or “not medically necessary’, payment for these services will become the patient’s
responsibility. In addition, if any payment is denied or pended by an insurance carrier due to “member
noncompliance”, the patient will be responsible for compensation of services rendered.

By requesting services be performed at this facility, the patient acknowledges and accepts full responsibility for
verifying with his/her plan that our doctors are contracted providers for his/her healthcare insurance. He/she also
accepts responsibility for obtaining; prior to treatment, any necessary referrals or authorizations which may be
required by his/her plan. By accepting this responsibility, the patient agrees to accept any financial consequence
resulting from an insurance carrier determination which may reduce or deny payment due to no referral, no
authorization or other noncompliance with a patient’s plan document. Spectrum Neurosurgical Specialist will
accept “contracted” or “negotiated” fees as payment from insurances for which we have an existing, contracted,
agreement to provide services.

For services, provided to a patient, which are construed to be related to a work injury, Spectrum Neurosurgical
Specialist will submit charges to the appropriate workers compensation carrier, provided a claim by the injured party
has been filed and appropriate billing information is provided to the office staff prior to services being rendered.
Please be aware that these services require preauthorization from the carrier and failure to provide this information
may result in charges billable to the patient.

Spectrum Neurosurgical Specialist requires that a patient provide his/her automobile insurance information, in
addition to his/her healthcare, prior to receiving treatment for any condition resulting from a motor vehicle accident.
The auto carrier is the primary insurer in a MVA, and as such these charges must be submitted to the Auto Insurance
for payment prior to filing with the healthcare insurance. It is also advisable to provide the office staff with the
patient’s personal injury attorney’s name and contact information.

All copays, noncovered service charges, coinsurances, deductibles, and any fees considered by an insurance carrier
to be over an arbitrary Usual and Customary Rate, will be considered payable by the patient as follows:

         1.) Payments for services not covered by an insurance plan, copays and yearly deductibles are due at the
         time of service, unless prior arrangements are made.

         2.) After receipt of payment by a patient’s healthcare carrier, any patient balance will be billed either by a
         monthly statement or by issuance of a monthly installment coupon book.
                                                     ... CONTINUED ON BACK....
         3.) Balances less than $100.00: Payment in full is due 30 days following the receipt of initial billing statement. If
         payment is not received, a $10.00 penalty fee will be charged to the patient’s account. Any account with a balance
         less than $100.00 that has not been satisfied within 90 days of receipt of the original billing statement will be
                                                                                                       Financial and Payment Policy
                                                                                                                         Page Two




                                     Spectrum Neurosurgical Specialist, P.C.


Steven P. Disch, M.D. F.A.C.S                                                             Charles, E. Weaver, Jr., M.D., PhD
Thomas W. Belknap, M.D.                                                                   Janice D. Reed, MS, NP-C

                                        FINANCIAL AND PAYMENT POLICY




           deemed “delinquent” and will be forwarded to a collection agency, unless an alternate arrangement is approved by
          the office manager.

          4.) Balances that exceed $100.00: Payment for balances which exceed $100.00, may be paid in full at
          any time or in monthly installments that are an equivalent of 10% of the original balance. For example, if
          the patient’s original balance were $200.00, his/her monthly installment would be 10% of $200.00 or
          $20.00 per month until the balance is paid in full. An initial statement of charges, insurance payments
          and any patient payments will be mailed to the patient. If the balance is not paid in full following the
          initial billing, installment payments will be calculated and coupons will be issued to the patient on the
          next billing cycle. No further billing statements will be sent unless additional balances are incurred after
          a patient receives a coupon booklet. If a patient incurs additional balances, a statement will be mailed to
          the patient, indicative of the new balance and additional monthly coupons will be included as may be
          necessary to satisfy the additional balance. In the event that Spectrum Neurosurgical Specialist feels that
          a patient’s balances have increased to such an amount that an increase of monthly payment is deemed
          necessary, a replacement coupon booklet will be issued. Please be aware that the installment amount is
          the minimum amount acceptable to Spectrum Neurosurgical Specialist to keep your account in “Good
          Standing”. If a patient wishes to payoff their balances more quickly, he/she is encouraged to do so, and
          may submit any amount over the required monthly installment. However, making a payment, which
          exceeds the monthly installment amount, will not be considered to reduce a subsequent installment
          payment and the next payment amount will be required as noted on the coupon until all balances are
          satisfied. A $10.00 penalty fee will be charged to the patient’s account for any payment that is 30 days
          past due. These penalties must be satisfied for the account to be considered paid in full. If necessary,
          a final statement will be mailed to the patient for any penalties that may have accrued on his/her account.
          A patient’s account will be deemed “delinquent” if no payments have been received within a 90-day time
          period. In addition, it is expected that a patient account be brought current for any missed monthly
          installment payments prior to the following month’s due date. Balances that are not brought current within
          the 90-day time period will be considered “delinquent” and will be forwarded to a collection agency unless
          the office manager approves an alternate arrangement.

Patients who are uninsured or who are insured through a “cafeteria type” plan, as well as those whose service is relevant to a
designated “pre-existing” condition, as determined by their insurance plan document, will be expected to pay in full at the time of
service.

Spectrum Neurosurgical Specialist reserves the right to request prepayment for services at any time.




                                                       REVISED 3/3/2004
                                                                  Financial and Payment Policy
                                                                                   Page Three




                     SPECTRUM NEUROSURGICAL SPECIALIST, P.C.
Steven P. Disch, M.D. F.A.C.S                             Charles, E. Weaver, Jr., M.D., PhD
Thomas W. Belknap, M.D.                                   Janice D. Reed, MS, NP-C


               FINANCIAL AND PAYMENT POLICY SIGNATURE PAGE

            SIGNATURE PAGE TO BE HELD AS RECORD OF ACCEPTANCE




I have received and read a copy of Spectrum Neurosurgical Specialist, P.C. Financial
and Payment Policy (2 pages). I understand and agreed to abide by the policies noted
which may be relevant to my financial obligations for service received from Spectrum
Neurosurgical Specialist, P.C... I am also aware of my responsibility to provide
accurate and updated information, in regards to my insurance coverage, address and
telephone number, to Spectrum Neurosurgical Specialist, P.C.




___________________________________________               ___________________
Signature of Patient or Authorized Individual              Date
                      Spectrum Neurosurgical Specialists’ Registration Form

    Steven P. Disch, M.D., F.A.C.S.            Charles E. Weaver, Jr., M.D. PhD.          Thomas Belknap, M.D.
                                               Janice D. Reed, MS, NP-C


Date of Visit: ____________________

Patient Name ______________________________________ Date of Birth: ______________                   Age __________

Marital status:       □ Married           □ Divorced           □ Single

Current work status: □ Employed - Occupation _________________ □ Unemployed □ Disabled □ Full-time student

Referred for Opinion & Consultation by: (Physician’s name) _____________________________________________

Reason for today’s visit:
_____________________________________________________________________________________________

_____________________________________________________________________________________________

Approximate date of onset: _________________

Is the reason for your visit today related to an automobile accident? □ Yes      □ No   Date of accident ___________

Is the reason for your visit today related to a work injury?   □ Yes      □ No   Date of injury ____________________

Have you ever been treated for this problem before? □ Yes         □ No
If yes, please state when and name of treating physician, _______________________________________________

ALLERGIES
Please list any allergies (include drug Allergies):_______________________________________________________

_____________________________________________________________________________________________

Do you have or have you had any of the following conditions? (Please circle Yes or NO)
                            Condition                                            Explain
Yes No         Cancer
Yes No         Heart Disease (Include Heart Murmur, Bypass
               Surgery, Pacemaker, Mitral Valve Prolapse)
Yes No         High Blood Pressure
Yes No         Asthma
Yes No         Liver Disease/Hepatitis
Yes No         Jaundice
Yes No         Diabetes
Yes No         Epilepsy/Seizures/ Neurological Problems
Yes No         Thyroid or Goiter Problems
Yes No         Bowel/Colon Disease or Problems
Yes No         Bleeding or Clotting Abnormalities
Yes No         An Abnormal Chest X-Ray
Yes No         An Abnormal EKG
Yes No         Stroke
                                   Spectrum Neurosurgical Specialists’ Registration Form

Patient Name ____________________________________                                       Date of Birth ________________

If you answered yes to any of the previous conditions, please list the physician who treated you for that condition and
when:
        CONDITION                      TREATING PHYSICIAN                     APPROXIMATE DATES




Medications

Name and Phone number of your pharmacy:
__________________________________________________________

Please list all medications you are currently taking, including dosages and the physician who prescribes them for you.

    Name of Medication                             Dosage and how many times a day          Prescribing Physician




Please ask for additional page from receptionist if there are additional medications.




Past Medical History

List any injuries or any other medical problems for which you have sought treatment in the past and when:
_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________
                            Spectrum Neurosurgical Specialists’ Registration Form


Patient Name __________________________________                        Date of Birth ________________

Please list any surgeries you have had in the past: (Please include approximate dates)
_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Have you ever had complications from surgery or anesthesia? □ Yes       □ No

If yes, please explain:
___________________________________________________________________________________________

_____________________________________________________________________________________________

Have you ever received a blood transfusion? □ Yes        □ No


Social History

Do you use tobacco products? □ Yes □ No If yes, how much and for how many years? _____________________

Do you drink alcohol? □ Yes □ No       If yes, how much and how often? __________________________________

Do you use any non-prescribed drugs? □ Yes □ No          If yes, please list _________________________________


Family History

Check any of the following that anyone in your immediate family or a direct relative has been treated for. Please
indicate their relationship to you.
                   Relationship                        Relationship                                Relationship
□ Arthritis      ______________        □ Stroke      _______________               □ Cancer       ________________
□ Rheumatoid                           □ Sickle Cell _______________               □ Diabetes ________________
   Arthritis     ______________        □ Obesity _______________                   □ Kidney Disease _____________
□ High Blood                            □ Psychiatric                              □ Liver Disease _______________
   Pressure ______________                 Problems ______________                 □ Heart Failure _______________
                                       Spectrum Neurosurgical Specialists’ Registration Form


            Patient Name_________________________________________                             Date of Birth __________________


            Please indicate YES or NO if you are currently experiencing any of the following symptoms:
                                     YES      NO                                 YES     NO                                      YES   NO
CHEST/HEART/LUNG                                    GASTROINTESTINAL                             EARS
Shortness of Breath                                 Indigestion or Heartburn                     Ear Pain
Poor Exercise Tolerance                             Vomiting                                     Drainage from Ear
Fluttering of Heart                                 Abdominal Swelling                           Sinus Problems
Unusual Heartbeat                                   Abdominal Pain/Cramps
Chest Pain                                          Abdominal Swelling                           SKIN
New cough of any kind                               Diarrhea                                     Changing Mole
Coughing up Blood                                   Change in Bowel Habits                       Rash
High Blood Pressure                                 Passing Blood in Bowel                       Psoriasis
                                                    Movement
Angina                                              Black, Tarry Bowel                           Other Skin Problems
                                                    Movement
Rheumatic Fever                                     Difficulty controlling
                                                    bowels
Varicose Veins                                      Nausea                                       ENDOCRINE
Wheezing                                            Cirrhosis of the Liver                       Always Feel Cold
Prior Heart Attack                                  Stomach/Duodenal                             Always Tired/ Sluggish
                                                    Ulcer
Heart Murmur                                        Hemorrhoids                                  Always Hot/Warm
Enlarged Heart                                      Gallstones                                   Diabetes
History of DVT                                                                                   Gout
History of PE                                                                                    Night Sweats
Emphysema                                           Neurological                                 Overactive Thyroid
                                                    Blurred Vision                               Underactive Thyroid
                                                    Double Vision                                Nervousness
                                                    Dizziness/Fainting                           Milky Discharge from
                                                    Spells                                       Breasts
BONES/JOINTS                                        Difficulty with Balance                      Marked Weight Loss
Arthritis                                           Poor Muscle Strength                         Marked Weight Gain
Painful Joints                                      Arm Weakness                                 Absent Periods
Polio                                               Leg Weakness                                 Irregular Periods
Swollen Joints                                      Light Flashes
Back Pain                                           Difficulty Hearing                           PSYCHIATRIC
Neck Pain                                           Difficulty Swallowing                        Sever depression
                                                    Buzzing/Ringing in Ears                      Hospitalization for
                                                                                                 Psychiatric Problems
GENITOURINARY                                       Speech Difficulty
Blood in urine                                      Severe Headaches
Pain/Burning with urination
Difficulty Passing Urine                            HEMATOLOGIC
Trouble Controlling Urine                           Nosebleeds (not due to
                                                    an injury)
Kidney Stones                                       Easy Bruising
Prostate Trouble                                    Poor Blood Clotting
                                                    Swollen Glands
                                                    Unexplained Fevers
                                                    Chills
SPECTRUM NEUROSURGICAL SPECIALISTS, P.C.
                            Steven P. Disch, M. D., F.A.C.S
                           Charles E. Weaver, Jr., M.D., PhD
                              Thomas W. Belknap, M.D.
                              Janice D. Reed, MS, NP-C


      PAIN MEDICATION AND PRESCRIPTION REFILL POLICY

***IT IS A VIOLATION OF GEORGIA STATE LAW TO OBTAIN NARCOTIC
       MEDICATIONS FROM MORE THAN ONE (1) PROVIDER***

 1.   Are you currently being treated with narcotic pain medications? Yes or No If yes, please
      provide the name of the medication and the provider who prescribes this medication:______
      _________________________________________________________________
      _________________________________________________________________

 2. Only 1 {one} pharmacy may be used for filling narcotic prescriptions. Please provide your
      pharmacy’s name, phone number and location is:_______________________________
      _________________________________________________________________
      Please notify us if you change pharmacies.

 3. Medications will NOT be phoned in after hours or on the weekends.

 4. I agree to allow 48 hours for prescription refills.

 5. I understand that prescription refills requested after 3:00 p.m. will not be received until the
      next business day.

 6 I understand that follow-up visits are required while receiving narcotic medications.

 7. I agree to take all medication exactly as instructed. I am NOT allowed to change the dosage
    amounts or alter the time schedule of taking the medication without first speaking to my
    physician.

 8. Pain persisting beyond the usual time frame despite therapeutic interventions may require a
    referral to a Chronic Pain Management Clinic.

 9. Patients are responsible for their own medications. Spectrum Neurosurgical Specialists will
    not refill prescriptions that have been lost, misplaced, or stolen.

 10. Medications must not be given, traded or sold.
                                                       Pain Medication & Prescription Refill Policy
                                                                                        Page Two




  PAIN MEDICATION AND PRESCRIPTION REFILL POLICY

11. I am aware that most of the manufactures of drugs used to treat chronic pain recommend
    against the operation of heavy equipment, which includes driving a motor vehicle. Please be
    aware that if you  choose to drive a vehicle, you could be charged with a DUI.

12. Patients must not combine any narcotic medications with the consumption of alcohol.

13. Patients may be terminated from the practice with 30 days notice for noncompliance in the
    taking of their medication. The following are conditions for immediate termination from the
    practice:

   Obtaining narcotics from any other physician while under Spectrum Neurosurgical
   Specialist’s care.

   Altering or forging of a prescription. {This is a felony and will be reported.}




I have read, understand and agree to the policies above. I understand that if I do not sign
this document, my physician may refuse to prescribe me pain medications.


Patient Name:_________________________________________________________
                                 {Please Print}

Patient Signature:___________________________________Date:_______________

								
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