HEALTH INSURANCE INFORMATION (Please provide copies of all insurance cards) PRIMARY INSURANCE POLICY # GROUP # PHONE #

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PATIENT INFORMATION

(PLEASE PRINT)

LAST NAME FIRST NAME MI

ADDRESS CITY STATE ZIP CODE

HOME # CELL # WORK #

DATE OF BIRTH SEX SOCIAL SECURITY # MARTIAL STAUS

REFERING PHYSICIAN/ PRIMARY CARE PHYSICIAN PHONE #

_______________________________________________________________________________________________________________________________________

FOUND ON WEBSITE /INTERNET REFERED BY FRIEND /FAMILY

Name:____________________________________ REASON FOR VISIT

IS THIS RELATED TO AN ACCIDENT? TYPE OF ACCIDENT? DATE OF INJURY

YES NO AUTO EMPLOYMENT RELATED OTHER

IN CASE OF EMERGENCY, CONTACT (Name of friend or relative – not living with you)

LAST NAME FIRST NAME MI RELATIONSHIP

ADDRESS CITY STATE ZIP CODE

HOME # CELL # WORK #

HEALTH INSURANCE INFORMATION (Please provide copies of all insurance cards)

PRIMARY INSURANCE POLICY # GROUP # PHONE #

POLICY HOLDER NAME POLICY HOLDER DATE OF BIRTH RELATIONSHIP

SECONDARY INSURANCE POLICY # GROUP # PHONE # POLICY HOLDER NAME POLICY HOLDER DATE OF BIRTH RELATIONSHIP

The above information is true to the best of my knowledge. I authorize treatment for the above- mentioned individual or myself and I understand that I am ultimately responsible for charges associated with medical services and agree to pay all bills within 30 days from receipt of a statement, unless other arrangements are made.

INSURANCE AUTHORIZATION AND ASSIGNMENT (Please read and sign)

I hereby authorize Texas Spine & Neurosurgery Center, P.A. to furnish information to insurance carriers concerning my illness and treatment and I hereby assign all payments for all medical services rendered to the above-mentioned individual or myself. I understand that I am responsible for all charges regardless of insurance coverage.

SIGNATURE DATE

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We are committed to providing you with the best possible care. If you have medical insurance we are eager to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance, and your understanding of our payment policy.

1. PRIVATE INSURANCE: All contracted insurance companies are billed directly as a courtesy. Any

remaining balance for non-covered benefits and deductibles are your responsibility. Payment for this is expected within 30 days from receipt of your statement.

2. CO-PAYS: All co-pays are expected at the time the service is rendered.

3. REFFRALS: All referral for the each office visit are your responsibility and you need to provide a copy or

make sure your PCP sends us a copy before services are provided. In absence of the referral office visit is your responsibility and the charges need to be paid in full before services are rendered.

3. METHOD OF PAYMENT: We accept cash, checks, or cashier checks.

4. PAYMENT ARRANGEMENTS: We understand that there may be times when financial difficulties come

upon us without warning. Under special circumstances temporary payment arrangements may be made if approved in advance. Accounts on a temporary payment plan are required to make payment each and every month. Missed payments could result in collections. Accounts on a payment plan also must continue to pay at the time of the service. Our goal is to help you from attaining a greater debt and to assist you by keeping your

account at a manageable level.

5. NO SHOW/CANCELLATION POLICY: There may be a fee for no-show appointments or cancellation of

appointments without 24-hour notice.

If you have any questions about the above information or any uncertainty regarding insurance coverage, PLEASE don't hesitate to ask us. We are here to help you.

Print Name: ________________________

Signature: ________________________

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MEDICAL HISTORY

NAME:

AGE: MALE



FEMALE

HT: WT:



RIGHT-HANDED



LEFT -HANDED NAME OF FAMILY DOCTOR:

REASON FOR OFFICE VISIT Injury/Date of Injury

Illness/Date Illness began

Symptoms/Date symptoms began

Second Opinion/IME

How would you describe your symptoms since they began?

BETTER WORSE NO CHANGE

What symptoms do you have today?

How did this problem begin? (Give details)

Do you have urinary or fecal incontinence?

NO YES

Do you have foot drop or paralysis?

NO YES

Were you treated or seen at a hospital emergency room or urgent care center for this injury/illness?

NO YES Where?/When?

Have you received further treatment for this injury/illness?

NO YES

Check any of the following tests or treatments you have had for this illness or injury? (Specify when and where tests or treatments were done.) Blood tests or lab tests

X-Rays

CT or MRI scan

Physical therapy

Chiropractic care

Epidural Steroid Injections GENERAL INFORMATION

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PATIENT NAME:

REASON FOR OFFICE VISIT (continued)

Are you able to do everything you did before the injury/illness? (Explain NO answers)

YES NO

Drive

Housework

Yard work

Sports

Hobbies

Second job

Sex

Have you ever seen a doctor for neck or back problems?

YES If yes, specify problem, doctor, date, and any surgery.

NO

Are you taking any medications for this injury/illness, including medications from a doctor or over-the-counter medications such as aspirin, Tylenol, or Advil?

YES If yes, specify medications.

NO

Are you taking medications now for any other reason (including vitamins, birth control pills)?

YES If yes, specify medications.

NO

Do you drink or eat any beverages or food that contain caffeine?

YES If yes, specify. Coffee Tea Cola Chocolate

NO How much per day?

FAMILY HISTORY

Has anyone in your family had any of the following conditions (please explain who and what they had)? NO YES

Cancer

Heart problems

Diabetes

Kidney disease

Depression/mental problems

Alzheimer’s/Memory loss

High blood pressure

Stroke/brain tumor/aneurysm

Lung problems

Parkinson’s

Multiple Sclerosis



NO YES

Do you take hormones? NO YES

PERSONAL MEDICAL HISTORY

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PATIENT NAME:

Do you use any tobacco products?

YES Specify: Cigarettes Snuff Tobacco Cigars Pipe

NO How much per day? How many years?

Did you use any tobacco products in the past?

YES Specify: Cigarettes Snuff Tobacco Cigars Pipe

NO How much per day? When did you quit? Do you drink alcohol?

YES Specify: Beer Wine Liquor

NO How much per day? How many years?

Did you drink alcohol in the past?

YES Specify: Beer Wine Liquor

NO How much per day? When did you quit? Have you ever received treatment for drug and/or alcohol problems?

YES Specify when and where? NO

Indicate your marital status: Single Married Widowed Other

Do you live alone? YES NO

Do have any children? If yes, indicate age(s) and whether they live at home.

NO YES Age(s)?

Do you have a relative with a physical or mental health problem living at home? If yes, indicate whether you take care of this relative.

NO YES Explain.

Do you exercise regularly? If yes, indicate the activity and how often you do it. NO YES Explain.

EMPLOYER Length of employment? JOB TITLE How long have you done this job?

Does your job require you to perform the following activities:

Lift pounds Sit Use a computer

Lift over head Bend Drive a truck or forklift Reach over head Stand

Are you working now?

YES NO If no, how long have you been off work? If you are married, does your spouse work?

YES NO If no, how long has he/she been off work?

Patient’s signature Date

Physician’s signature Date

LIFESTYLE/SOCIAL

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PATIENT AUTHORIZATION FOR USE AND DISCLOSURE

OF PROTECTED HEALTH INFORMATION

By signing this authorization, I authorize all of my previous healthcare providers and testing facilities disclose certain protected health information (PHI) about me to Texas Spine & Neurosurgery Center, P.A.. This

authorization permits the use and/or disclosure of following individually identifiable health information about me: Hospital and office notes, and test results. The information will be used or disclosed in order to assist in my medical treatment. This authorization will not expire. The Practice will not receive payment or other remuneration from a third party in exchange for using or disclosing the PHI.

I do not have to sign this authorization in order to receive treatment from Texas Spine & Neurosurgery Center, P.A. In fact, I have the right to refuse to sign this authorization. When my information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization. My written revocation must be submitted to the Privacy Officer at:

16605 South West Frwy., Ste 285 Sugar Land, TX 77479

Dr. Bindal and Dr. Park are active in the Sugar Land medical community. They have helped to develop some of the health care institutions in the area, offering increased choice to our residents. As such, they have an

ownership interest in institutions such as St. Luke’s Sugar Land Hospital. This involvement ensures that the highest level of care is given to our patients.

Signed by: ______________________ __________________________ Signature of Patient Date ________________________

Patient’s Name