IMPORTANT PATIENT NOTICE

The enclosed “New Patient” forms must be completed PRIOR to your visit with

us. All information captured must be entered into your Electronic Medical Record prior to

starting your visit with our clinical team. If these forms are not complete upon registration you

may risk having your visit rescheduled. There are two bubble forms that state to use a number

2 pencil, however it is fine to use a pen to complete.

Established patients will also be required to fill out “New Patient” paperwork, if you haven’t

been seen in the office since we upgraded our Electronic Medical Record system.

ALL NEW PATIENTS MUST BRING A COMPLETE LIST CURRENT MEDICATIONS YOU ARE TAKING

AS WELL AS CD’S OR FILMS RELATED TO THE PROBLEM WE ARE SEEING YOU FOR.

ALSO, A PHOTO ID IS REQUIRED AT THE TIME OF YOUR APPOINTMENT.

Thank you in advance for your patience during this transition.

7 Vanderbilt Park Drive • Asheville, NC • (828)255-7776

CSNC Account# Provider# Appt. Date

PATIENT DEMOGRAPHICS

Patient Name Sex Male Female DOB SSN

Patient Address

Street Address City & State Zip Code

Mailing Address

Street Address City & State Zip Code

County Tertiary Phone

Primary Phone Secondary Phone

Email Address Preferred Language

Race Asian/Pacific Islander-1

African American-2

American Indian-5

Caucasian-3

Hispanic-4

Other-9

Refused to Report-9999

Ethnicity Hispanic or Latino Not Hispanic or Latino Unknown Refused to Report

Responsible Party Address

Relationship to the Patient

Referring Dr. Address Phone

Primary Dr. Address Phone

Are you CURRENTLY in a skilled nursing facility? Yes No Where?

Employment Status (Please Mark One) Employer (If Applicable) Employed Unemployed Name

Retired Disabled Address

Marital Status (Please Mark One) Phone

Single Married Divorced Widowed

IS THIS APPOINTMENT RELATED TO A WORKER’S COMPENSATION ACCIDENT/INJURY? Yes No

Date of Injury Job Motor Vehicle Other

(CSNC USE ONLY: AUTHORIZATION FOR W/C VERIFIED_______ (initials))

INSURANCE INFORMATION 1. PRIMARY Ins Co & Address

Subscriber’s Name Subscriber’s Sex Male Female

Subscriber’s DOB Subscriber’s SSN Employer

ID Number Group Number

Relationship to Patient Self Spouse Parent

2. SECONDARY Ins Co & Address

Subscriber’s Name Subscriber’s Sex Male Female

Subscriber’s DOB Subscriber’s SSN Employer

ID Number Group Number

Date

Account #

Provider #

PATIENT INFORMATION

PATIENT NAME:

Family Doctor: Family Doctor Phone:

Referring Physician DOB Sex M F Age: (check one)

What body part is involved? Please mark below:

Neck and R arm R R R R R R

radiates L arm Shoulder Elbow Hand Pelvis Knee Foot

to neither L L L L L L

Back and R leg R R R R R R

radiates L leg Arm Wrist Finger Hip Ankle Toe

to neither L L L L L L

How were you hurt? On a scale of 0-10 (10 being the worst), What makes your symptoms worse?

Bending how severe is your pain? Standing Twisting

Falling 0 1 2 3 4 5 6 7 8 9 10 Walking Lying in bed/sleeping

Lifting Lifting Bending Forward

Twisting What is the quality of your pain? Stairs Bending Backward

Gradual onset No pain Constant Exercise/activity Squatting

Other Aching Comes and goes Kneeling Sitting

Burning Stabbing Coughing Driving/riding in car

Where were you hurt? Throbbing Stinging Sneezing Other

No injury Sharp Dull

Auto accident Other What makes your symptoms better?

Sports Resting Lying in bed/sleeping

Work Sitting Exercise

Do not recall Do you have any of the following? Heat Elevation

Other None Numbness Ice Medication

Bruise Tingling Other

Swelling

Weakness in arm/dropping objects What tests/scans have you had for your problem?

Weakness in leg X-rays

How long have you been hurt? Loss of control of bowel or bladder MRI

Days Loss of balance or falls CAT scan

Weeks Other Bone Scan

Months Nerve Test (EMG/NCV)

Years

Please mark where your pain exists on the bodies. Have you received any of these treatments?

Steroid injections None

Brace/cast Chiropractor

Physical/home therapy Pain Medication

Cane/crutch Epidural

Nerve root block Surgery

Anti-inflammatory

Seen another Physician for this problem?

Who?

XXX - PAIN

OOO - PINS, NEEDLES, NUMBNESS

Medication Treatment AgreementThe purpose of this agreement is to prevent misunderstandings about certain medicines you could be taking for pain management. This is to help both you and your doctor to comply with the state and federal law regarding controlled pharmaceuticals. I understand that this agreement is essential to the trust and confidence necessary in a doctor/patient relationship and that my doctor undertakes to treat me based on this agreement. Females Only: If you plan to become pregnant or believe that you have become pregnant while taking this pain medication, your obstetrician must be notified immediately and this office must be informed. I understand that if I violate this Agreement, my doctor may stop prescribing these pain-control medicines, discharge me from the practice, and may also inform my referring doctor, medical facilities, and other authorities. In this case, my doctor will taper off the medicine over a period of several days, as necessary to avoid withdrawal symptoms. Also, a drug-dependence treatment program may be recommended. I will communicate fully with my doctor about the character and intensity of my pain, the effect of the pain on my daily life, and how well the medicine is helping to relieve the pain. I will not use any illegal controlled substances, including marijuana, cocaine, etc. A history of alcohol or drug abuse increases the risk of addiction. I will not share, sell or trade my medication with anyone. I will not attempt to obtain any controlled medicines, including opioid pain medicines, controlled stimulants, or anti-anxiety medicines from any other health care provider. I will safeguard my pain medicine from loss or theft. Lost or stolen medicines will not be replaced. I agree that refills of my prescriptions for pain medicine will be made only at the time of an office visit or during regular office hours. No refills will be available during evenings, weekends, or holidays. Prescription requests or renewals require a 24-hour notice. I agree to use only one pharmacy. If for some reason I need to change pharmacies or use more than one, I will contact the physician and pharmacy about the change. I agree that I will submit to a blood or urine test if requested by my doctor to determine my compliance with my program of pain control medicine. I agree that I will use my medicine at a rate no greater than the prescribed rate and that use of my medicine at a greater rate will result in my being without medication for a period of time. I understand that I will not be able to obtain an early refill on my medication. I will not consume alcoholic beverages while on this medication. Consumption of alcoholic beverages may result in rapid release and absorption of a potentially fatal dose of medication. I will bring all unused pain medicine to every office visit. I understand that if I require chronic pain medication, I will be referred to a pain specialist for medical management of my pain. I understand that Carolina Spine & Neurosurgery Center does not provide pain medication for chronic pain management. I understand that my doctor has an obligation to report any condition that can impair the ability to drive (such as taking the medication) to the N.C. Department of Transportation. I understand that a photo ID and signature are required to pick up medications. I authorize the doctor and my pharmacy to cooperate fully with any city, state or federal law enforcement agency, including this state's Board of Pharmacy, in the investigation of any possible misuse, sale or other diversion of my pain medicine. I authorize my doctor to provide a copy of this Contract to my pharmacy. I agree to waive any applicable privilege or right of privacy or confidentiality with respect to these authorizations. I agree to follow these guidelines. A copy of this document will be provided to me at my request. Patient Signature: _______________________________________________________________________ Date: ___________________ Witnessed by: __________________________________________________________________________

9.11

7 Vanderbilt Park Dr. � Asheville, N.C. 28803 � (828) 255-7776

Name________________________________

Account_________________

Provider_________________

     

   

Name      Account    Provider    

Authorization for the Use and Disclosure of Individually Identifiable Health Information 

I hereby authorize the use or disclosure of my individually identifiable health information as described below. I understand that the information I authorize, to a person(s) or entity to receive may be re-disclosed and no longer protected by federal privacy regulations.

1. Please list the family member(s) or other persons with names and phone numbers, if any, whom we may inform about your appointments, lab and x-ray results or other healthcare information. Please use the first line for your emergency contact person. I authorize this information to be released verbally or in writing.

NAME PHONE NUMBER RELATIONSHIP TO PATIENT

___________________________________ ______________________ ________________________

___________________________________ ______________________ ________________________

___________________________________ ______________________ ________________________

2. Can confidential messages including appointment reminders, lab and x-ray results or other health care information be left on your primary answering machine or voicemail? (Circle one) YES NO

If no, please print the telephone number, if any, where you want to receive this information:_______________________

3. If you do not have voicemail, can a confidential message be left at your secondary number? (Circle one) YES NO

4. I understand that I may revoke or change this authorization at any time by notifying Carolina Spine & Neurosurgery Center in writing. I understand that CSNC has thirty (30) days from the date of receipt of the written revocation to update this information in the system. The revocation will not be valid if CSNC has taken action in reliance on the above authorizations or if this authorization is obtained as a condition for obtaining insurance coverage. Other law provides the insurer with the right to contest a claim under the policy or the policy itself.

I consent to medical treatment and diagnostic procedures by Carolina Spine & Neurosurgery Center healthcare providers. I have read the above Consent to Use or Disclose Information for Treatment, Payment, or Healthcare Operations and do hereby authorize the release/transmission of pertinent medical information necessary for treatment, payment or healthcare operations. I have also read and completed the above Authorization for Use and Disclosure of Individually Identifiable Health Information and understand that if I refuse to sign this authorization, the law may allow CSNC to refuse treatment. I am responsible for all charges incurred at Carolina Spine & Neurosurgery Center and authorize payment of insurance benefits (Medicare, Medicaid, liability or commercial insurance) directly to CSNC. I am responsible for payment of all charges not covered/denied by insurance contracts, including co-payments, deductibles, non-covered services, worker's compensation; and those determined by the insurance company, where there is no contract with CSNC, to be above the insurance company's usual and customary fee. 

___________________________________________ _________________

Signature of Patient or Authorized Representative Date

CSNC USE ONLY: ACCT#____________________ INITIALS/DATE ENTERED _______________PROVIDER#_________

Identity of Authorized Representative was verified by Drivers License # __________________________

Representative is MPOA/LEGAL GUARDIAN/HOME CARE PROVIDER

    9/11 

Receipt of Notice of Privacy Practices     

  7 Vanderbilt Park Drive   Asheville, NC  28803  Patient Name: _______________________________ 

DOB ______________  ACCT # _______________   Provider # _________ 

In the course of providing service to you, our office receives and stores health information that indentifies you.  It 

is often necessary to use and disclose this health information in order to treat you, to obtain payment for our 

services and to conduct health care operations involving our office.   

The Notice of Privacy Practices you have been given describes these uses and disclosures in detail.  You, the 

patient, have the right to review such Notice prior to signing this consent form. Carolina Spine & Neurosurgery 

Center reserves for itself the right to change the terms of its Notice of Privacy Practices for Protected Health 

Information at any time. If Carolina Spine & Neurosurgery Center does change the terms of its Notice of Privacy 

Practices, the Patient may obtain a copy of the revised Notice. Patient retains the right to request that Carolina 

Spine & Neurosurgery Center further restrict how his/her protected health information is used or disclosed to 

carry out treatment, payment, or health care operations. Carolina Spine & Neurosurgery Center is not required to 

agree to such requested restrictions; however, if Carolina Spine & Neurosurgery Center does agree to Patient's 

requested restriction(s), such restrictions are then binding on Carolina Spine Neurosurgery Center. 

I have received/read this document and understand it.  I consent to the use and disclosure of my health 

information for purposes of treatment, payment, and healthcare operations.  I acknowledge that I have received 

the Notice of Privacy Practices from Carolina Spine and Neurosurgery Center. 

 

_____________________________________________      _________________________ Signature of Patient or Authorized Representative      Date  If signing as a personal representative of the patient, describe the relationship to the patient and the source of authority to sign this form:  

 ____________________________________      _________________________ Print Name              Relationship to the Patient   ____________________________________ Source of Authority                              

Account #

Carolina Spine & Neurosurgery Center

An Affiliate of Mission Health

Our office is now using ePrescribe, a system which allows us to electronically submit your prescription information to you pharmacy. Although you may have different pharmacies that you use, please list below the one pharmacy that you wish our office to send your prescriptions to. (NOTE: You may update or change this information at any time)

**PLEASE PRINT ALL REQUESTED INFORMATION**

Patient Name:

Date of Birth: / /

Pharmacy Name:

Street Name:

City: State:

Phone Number (if known):