NASHVILLE NEUROSURGERY GROUP

Robert A. Mericle, MD Arthur J. Ulm, MD Doug萱as C. Mathews. MD Robbi L. FrankIin, MD

DearPatient,

Welcome to Nashvi11e Neurosurgery Group. We ask that you take some time to complete this questionnaire to the best of

your knowledge・ This questionnaire wi= a1書ow the doctorto know more about you, yOur medical condition, yOur family and

your habits. We askthat vou範I萱out this form in ink I)rior to vourvisit and bring itwith vou on the date ofvour

a叩Ointment. This questionnaire is confidential and wi1萱be kept as part ofyour medica音record. Ifyou have any questions

about issues ofconfidentiality, Please feel free to contact our o冊ce at (61 5) 320-0007.

Date ofvisit:

Patient Name:

Email Address:

Date of Birth:

PhOne Numbers: (H)

Checka11 thatapply‥ Messagecanbelefton □ Home □ Work □ Ce11　Messagemaybe口Brief口Extended

Are you right-handed or left-handed? (Circle One) Height:

RACE: Please check one (optional)

American Indian or Alaska Native

Asian

Native Hawaiian or other Pacific

Caucasian

INSURANCE INFORMATION:

Primary Insurance:

Address:

PhO重1e:

Black or African American

Hispanic or Latino

Other

Name of Insured:

EmpIoyer of Policyholder:

Secondary Insurance:

Address:

Ph0ne:

Weight:

PRIMARY LANGUAGE :

Arabic French

Chinese　　_Spanish

English Other:

DOB: SSN:

Name of Insured:

EmpIoyer of Policyholder:

Worker’s Compensation

I11SuranCe Carrier:

Address:

Ph0萱1e:

DOB: SSN:

〇〇〇〇〇〇OR〇〇〇一〇〇

C萱aim #:

A句ustor’s Name:

Date of I巾ury:

Pho萱le:

WHO REFERRED YOU TO OUR OFFICE?

PhysICian Name:

Address:

WHO IS YOUR PRIMARY CARE PHYSICIAN?

PhySICian Name:

PLEASE LIST ALL OTHER PHYSICIANS WHO

O SAME AS REFERRING DOCTOR

Address: Ph:

SHOULD RECEIVE A COPY OF OUR REPORT:

1. PhySICian Name:

2. PhySIClan Name:

Address:

Address:

PLEASE LIST BELOW THE NAMES OF ANYONE ELSE THAT YOU WOULD LIKE TO HAVE ACCESS TOYOUR MEDICAL INFORMATION WITH OUR OFFICE:

I authorize the re萱ease ofany medical information necessary to process insurance cIaims. I authorize payment of

medica看benefits to Nashville Neurosurgery Group・

Patjent’s or Authorized Signature

HISTORY OF PRESENT ILLNESS:

1. What is the reason foryour visit today?

2. How Iong have you had the problem?

3. How severe is the problem?

Date

4. What type of symptoms are you experiencing?

5. How ofte11 do your symptoms occur?

6. How Iong do your symptoms last?

7. Is there anything that makes the problem worse?

8. Does anything make the problem better?

9. Have you ever had treatment or surgery for this prob音em?

10. Please rate your paln On a SCale from O to 10.

PREVIOUS TREATMENT: Please check a旧reatments you have tried.

O previous surgery O physICal therapy O exercise program O narcotic pain medication (Lortab, Percocet, VicodiIl)

O brace O Chiropractor O Anti-inflammatory medications (MotriIl, Naproxen, Aspirin)

O wrist sp!ints O Other:

O epidural steroid i巾ection(s)_times ⇒ Theseprovided relieffor: O no relief Ol-4weeks O 5-8 weeks O 8+weeks

Patient Nameこ DOB:

MEDICA丁IONS: Please list a= medications and dosage you are currently taking, lnCluding ove「 the counte「 medications,

Please aIso include the iength oftime you have been taking any narcotic medications.

1,

Do you take aspirin or any medicines that contain aspirin such as Ibuprofch or Motrin? Ifyes, Please specify:

PHARMACY :

needed.

Name:

Please provide the name and phone number ofyour phamacy so that we may keep this infomation on珊e if

Phone:

PAIN MANAGEMENT:

Are you currently in Pain Management orreceiving pain medications from another physician?　O Yes ONo

Ifyes, Please list below the name and address this physIClan:●　　　　●

Name:　　　　　　　　　　　　　　　　　　　　　Address:

Phone:

ALLERGIES: PIease list any known drug and/or food a11ergleS.●

二二二二

1.

5.

7.

2.

4.

6.

8.

Patient Nameこ

REl〃EW OF SYSTEMS:

DOB:

PIease check al′ conditions that currently app-y to you・

GENERAL:臆臆臆二〇二二二‾　‾　　‾　‾

O Weightlossorgaln

O Chestpaln

O Change in appetite

O Altered taste o「smell

O Heartmurmur

O Chest pressure

O Anglna

O Fainting

O Excessive sleepineSS

O Low blood pressure

O UnabletosIeep

O Fatigue

O Legswe冊ng

EARS, NOSE & THROAT:

O Mouth sores

O Ve面g0

O Sinusdisease

O So「ethroat

O RinglnginearS

O HearIngioss

O Cataracts

O Biurred vision

O Doubievision

RESPIRATORY:

O Shortness ofbreath

O Trouble breathing

O Emphysema

O Tuberculosis

O Chroniccough

GENiTOUR書NARY:臆　　　　臆臆臆臆　臆臆臆臆臆臆臆臆臆　　　　　　臆　　　　　　　　　　　　　　　　　　　　‾‾‾‾　‾‾‾‾‾　‾

O Sexual dysfunction

O lmpotence

O Kidneystones

O Urinary InCOntinence

O U「inary urgency

O VagInai bleeding

O Frequentu「ination

O Painful urination

O BIoodin urjne

PSYCHIA丁RIC:

O Anxiety

O Depression

O Troub看e concentrating

GASTROINTEST漢NAL:

O UIce「

O Vomiting

O Constipation

O Diar「hea

O Bowe=ncontinence

O HiataIhemia

O RefIux

O Rectal bleeding

NEUROLOGiCAL:

O Headache

O Seizure

O Memoryioss

O Loss ofconsciousness

O Weakness

O Fa=ingdown

O Ve面g0

O Concussion

MUSCULOSKELETAL:

O Lowbackpain

O NeckpaIn

O JointpaIn

O Troub看ewalking

O Jointswe帖ng

O Numbness

HEMATOLOGICAL:

O B看ood disorder

O HIV

O Enlarged lymph nodes

O Hepatitis

O Tingling leukemia

O Sickle ce= disease

Patient Name:

PAST MED看CAしH書STORY:

O GERD/Hearfbum

O UIcers

O CoIonPolyps

O Hemia

O Pancreatitis

O UIcerative Colitis

O Hype巾ension

O Corona「y Arte「y Disease

O Congestive Heart Fai看ure

PAST SURGICAL HIS丁ORY:

O CoIonoscopy

O EGD(Upperendoscopy)

O UIcerSurge「y

O Coion Surgery

O Cholecystectomy

O Appendectomy

O Peripheral Nerve Stimulator

O Other二

O Atrial Fibr川ation

O Pacemake「

O A看CD(Defib刷ator)

O COPD

O Diabetes

O Thyroid ProbIems

O Elevated CholesteroI

O Stroke

O Fibromyaigla

O Hemorrhoidectomy

O Bypass Surge「y

O HeartValve RepIacement

O Hyste「ectomy

O Ova「ies Removed

O Breast CancerSurgery

O Spinal Cord StimuIator

Have you everhad a problem with anesthesia? O Yes

lf yes, Please expiain.

O No

DOB:

O Arthrjtis

O ChronicBackpaIn

O Cancer

O KidneyFa血re

O HeartAttack

O Seizures

O Glaucoma

O Pneumonia

O Aneurysm

O P「ostate Surge「y

O Back

O NeckSurgery

O HipSu「gery

O KneeSurge「y

O Weight Loss Surge「y

O Brain Surgery

O lntrathecal Pain

Pump

Haveyou eve「had a bloodtransfusion?　　　O Yes O No

1fyes, Why?

SOCIAL H書STORY:

Doyou drinkalcohoI? O Yes O No lfyes, aPP「OXimately howmanydrinks perweek?

Doyousmoke? OYes O No lfyes,howoften? Oeveryday Osomedays lfyes,howmanyaday?

How soon after you wake do you smoke?

What is your occupation?

Are you interested in quitting? O Yes O Thinking about it O No

O Fu=Time O Part丁ime O Reti「ed O Homemaker O Student O UnempIoyed O Disabled

Was the ln」u「y due to a work-related accident?　　　　　　　　O Yes

Was the川ness/in」ury CauSed by an automobile accident?　　　O Yes

Was anothe「 party responsible fo「 the accident?　　　　　　　O Yes

!sthereanylitigation invoived? O Yes O No lfyes, PIeaseexpIain,

FAM看LY HISTORY:

O Arthritis

O HeartAttack

O Heart Disease

O PerjpheraI VascuIar Disease

O N○

○　No

O No

O Hype巾ension

O High CholesteroI

O DiabetesMe冊us

O St「oke

O Cancer

Nashv雪8漢e Neu「osu「ge「y G「oupPA丁IENT FINANCIAL PO」ICY

Patient Name: DOB:

丁hank you for chooslng Nashvil看e Neurosurge「y Group for you「 medical care! We are committed to the

SuCCeSS Of your medicai treatment and care" P看ease understand that a mutuai financial unde「standing lS Pa巾

Of ou「 reIationship.

We sincereIy hope that by sharlng Our financia看expectations we wi= strengthen the p「actice-Patient

relationship and keep the Iines of communication open. This financial poiicy helps the practice p「ovide quaIity

Care tO Our Va!ued patients. If you have any questions or need clarification of any of the above poIicies,

Please feei f「ee to contact our b冊ng depa巾ment at

Pavment is Due At the Time of Service

・　We accept cash, Checks, debit, and credit cards.

●　All co-PaymentS’deductibIes and non-COVered services are due at the time of service unless you have

made payment a「rangements in advance of your appointment.

●看nsurance requ-red co-PaymentS a「e due when you check in for your appointment〃　We charge an

administ「ation fee of塗昼型for co-PaymentS nOt Paid at the time of check in.

If your co-Payment is based on a percentage (example‥ 20% of the a看lowed payment) and you do not

have a seconda「y policy, PIease be prepared to pay a minimum of $50.(坦On the date of service.

Patient-「eSPOnSible balances are due when you check in for your appointment〃 Our b冊ng staff wi=

assist you in making payment a「rangements。

● In the event you need surgery we wiil provide you an estimate of you「 insurance requI「ed deductib案e

and co-insurance amounts.

●　We reques=hat at least 24 hour advance notice be glVen tO the o怖ce ifyou wi= be unabIe to keep

your scheduled appointment"　丁his a=ows us to 「elease your appointment time to another patient。

Patients who repeatediy “no show” for appointments may be discha「ged f「om the p「actice.

Proof of lnsu「ance二臆臆二臆臆臆臆臆臆臆臆臆臆臆臆二臆臆臆臆臆二臆二臆臆臆臆臆臆臆臆臆二臆臆臆臆二臆二臆臆臆臆臆臆二_臆臆臆臆臆臆臆臆臆臆二臆臆臆二二二臆臆臆臆臆臆臆臆臆臆臆臆臆臆二臆臆臆臆臆二臆臆臆臆二二臆臆二臆臆臆臆臆二二臆臆臆臆二臆二二二

・ PIease bring your insu「ance ca「d(S) and a vaiid photo ID with you to each appointment.

・ lt is your 「esponsib掴ty to notify the p「actice ofchanges in your heaIth insurance.

Self-Pav Accounts

We designate accounts, Self-Pay, unde「 the fo=owing circumstances: (1) patient does not have heaIth

insurance coverage, (2) patient does not have a cu「rent, VaIid insu「ance card on甜e, Or (3) patient does

not have a va看id insurance referral on冊e。

Refem貧ls

● ifyou have an HMO pIan we are contracted with, yOu need a referral authorization from your prlmary

Care Physician・ lfwe have not received an authorization p「IOr tO yOur arrival at the o冊ce, CaIl your

Prlmary Care Phys-Cian to obtain it" Without an insurance requ看red refer「al, the insurance company wi=

deny paymentfo「 services. As such, lfvou are unabIe to obtain the referral at tha=jme, VOu W帥be

rescheduled or asked to pay for the visit in advance.

Financia獲Assistance

・　Our practice treats patients regardless of financial status. We offer assistance in the form of a

SIiding scaie discount of charges based on ve輔able household income。

Divorce and ChiId Custodv Cases

● ln cases of divo「ce, the individuai who 「eceives care is responsjbIe for payment of co-Payments,

COjnsurance, deductjbles, and nonpa面cipating InSu「anCe ba看ances at the time of service. We w=l

not bilI a divo「ced spouse fo「 the patient’s services。

The parent who brings the child to the o冊ce fo「 care is 「esponsibIe for payment at the time of

Service no matter if the account is self-Pay, Pa面cipating lnSuranCe, Or nOnPa巾cipating InSu「anCe.

丁he p「actice does not honor divo「ce specifics (e〃g・, perCenfage of#nancial reaponsib〃i助.

If the child has coverage with a pa面cipating lnSuranCe Pian型坦the proper insurance identification

is present at the time of service’the practice wi!l bi= that insurance company・ AppIicabie co-

PaymentS, COinsurance and/o「 deductibles are due at the time of service, uniess a「rangements

have been made with the o冊ce p「IO「tO ar「ival.

Billinq, Payments and Refunds

・　AIl balances a「e due in fu= within 14 days ofthe statementdate.

● lfyou cannot pay the balance in full with 14 days, Please contact our b冊ng department to see if

you qualify for specia書payment options.

●

●

lt is your responsibility to notify the o冊ce of any change in add「ess, Phone, emPIoyment, Or

insurance coverage,

!f you make an overpayment on your account, We Wil=ssue a refund f there a「e no other

OutStanding balances on othe「 accounts with the same gua「anto「 or financial 「esponsible party

We reserve the right to 「epo巾delinquent accounts to credit bureaus, aSSeSS a COllection fee, take

Other collection action, Or te「minate you as a patient ofthis p「actice.

l have read’understand’and ag「ee to the above FinanciaI Policy. I understand that cha「ges not

COVered by my lnSu「anCe COmPany’aS WeiI as applicable copayments and deductibIes, are my

「esponsib冊y.

I authorize my InSu「anCe bene冊s be paid direct!y to Nashvi11e Neurosu「qerv G「oup.

l authorize Nashville Neu「osuraerv Group, th「ough its approp「iate personneI, tO Perform o「 have

Performed upon me, Or the above named patient, aPP「OPriate assessment and t「eatment procedures。

I authorize Nashville Neurosurqerv Group to reIease to appropriate agencies, any information

acqul「ed in the course of my o「 the above named patient,s examination and t「eatment。

I autho「ize Nashv冊e Neu「osurqerv Group to contact, discuss my personal health information with二

Name:

Name二

X Patient/

Relationship

Relationship

Date

Guarantor Signature

Acknowiedqement of Nashvi=e Neurosur鋼erv Group Notice of Privacy Practices

看hereby acknowiedge that l have reviewed or received o「 have been given the oppo巾nity to receive a copy

Of Nashv川e Neu「osuraerv Group Notice of Privacy Practices。

X Patient Signature Date

Nashv岨e

NeurosurgeryGROUP

AUTHORI乙Ar「lON TO RELEASE HEAI|“HCARE INFORMATiON

★Patient’s Name:　　　　　　　　　　　　　　　★Date of Birth:

P「evious Name:

I request and authorize

★SociaI Security #:

to

release heaIthcare information of the patient named above to:

Name: NashviIle Neurosurgery Group

Address: 330 22nd Avenue No鷹h

City: NashviIIe

Phone: (615) 320-0007

State: TN

This request and authorization applies to:

Zip Code:

Fax: (615) 320-0009

37203

□ HeaIthcare information 「elating to the fo=owlng treatment, COndition, Or dates:●

ロA= heaIthcare information

□ Other:

★Patient Signature: Date Signed:

Nashv雪看漢e Neu「osurgery G「oupF寒NANCiAL ASSISTANCE POLICY

Nashv冊e Neurosurgery Group IS COmmitted to p「oviding quality healthca「e to a= of ou「

Patients in the most cost-e什ective manne「"　We are sensitive to the needs of our

uninsured patients as weII as our patients who are experiencing financiaI hardships" As

SuCh’We a「e Pleased to amounce the foIIowlng OPtions二

CareCredit

Patients who wilI be undergoing surgery, Or Who have balances over $300, are

encouraged to app!y for financ-ng through CareCredit。 CareCredit o什ers no interest

Payment termS (up to 18 months) or competitive interest rates for extended payment

te「ms (up to 60 months) to he案p finance your surgery or Iarge ba看ance. Ou「 sta什a「e

happy to assist you in the application process.

SeIf-Pay discounts

Fo「 our uninsured patients, We are Pieased to orfer a 25%the time of service〃　Howeve「言f you are unabIe to pay you「 baIance in fu=, We

encourage you to apply for CareCredit。

ment

discount fo「 ful書payment at

Payment plans are o冊ered to those patients who do not qua甲y for CareCredit or who

have a baiance under $300〃　Payment plans are intended for our patients who may

need to pay their baIance ove「 several months’Whether you are uninsured, have a high

deductible or high co-insurance"　Please note that co-PaymentS are due at the time of

ServlCe・ We ask for a minimum EL坦good falth payment a=he time of the visit and

then we wi= work with each patient individually to develop a payment plan that meets

you「 needs and keep’s your baIance current。 We offe「 「ecu「「-ng b冊ng - Whe「eby your

Credit card is charged or your checking account is debited on an agreed date and

amount・ This saves you the hassIe of writing a monthly check and allows us to keep

COStS down.

Charitv care

We are pieased to o冊er our patients experienc-ng financia案ha「dship to app漢y for charity

Care○　○n order to qua!ify for cha「ity care, Patients must first apply fo「 TennCare.

Patients who do not quaIfty fo「 TemCare and who ea「n 200% and unde「 the federaI

POVerfy Ievel (FPL) shouId app案y for charity care. Patients who ea「n between 201%-

400% of FPL may receive discounted services〃　The f「ont desk receptionist wi= be

happy to provide you an application.

NashviIIe Neurosu「gery Group

Notice of Privacy Practices

丁HIS NOTICE DESCRIBES HOW MEDICAL iNFORMA丁ION ABOUT YOU MAY BE USED AND

D!SCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION, PLEASE REViEW IT

CAREFULLY.

The Heaith lnsu「ance Portab冊y and Accountab冊y Act (HIPAA; ’’Act’’) of 1996, reVised in 2013, requires

us as your heaith ca「e provider to maintain the prlVaCy Of your protected health info「mation, tO.PrOVide

you with notice of our legal duties and prlVaCy PraCtices with respect to protected heaIth information, and

to notify a什ected individuaIs fo=owIng a b「each of unsecu「ed protected health info「mation. We are

requ-red to maintain these records ofyour health ca「e and to maintain confidentiaiity ofthese records.

The Act also aliows us to use your information fo「 treatment, Payment, and cehain health operations

unless otherwise prohibited by law and without your authorization。

●　Treatment二We maydiscIose your p「otected heaith information to you and to our sta什orto other

health care providers in order to get you the care you need・ This includes information that may go

to the pharmacy to get your p「escription制ed, tO a diagnostic cente「 to assist with you「 diagnosis,

O「tO the hospitai shouid you need to be admitted“ lf necessary to ensure that you get this care,

We may also discussthe minimum necessarywith f「iends o「 famiIy membe「s involved in yourca「e

unIess you request othervise,

●　Payment‥ We maysend info「mation to you orto your health plan in o「de「to receive payment for

the service or item we deiivered. We may discuss the minimum necessa「y with friends or fam=y

members involved in your payment unless you request otherwise.

●　Health operations‥ We are a=owed to use or discIose your p「otected heaIth information to train

new health care wo「kers, tO eVaIuate the heaIth care deiivered, tO improve our business

development, Orfor other inte「naI needs.

」】 We are requ-red to discIose information as requ!red by law’SuCh as pubiic hea-th regulations,

health care oversight activities, Certain Iaw suits and law enforcement.

Certain ways that your protected health information couid be used/ discIosed requIre an authorization

f「om you‥ disciosu「e of psychotherapy notes, uSe Or discIosu「e of your info「mation for ma「keting,

disciosures or uses that constitute a saie of protected heaIth information, and any uses or discIosures

not described in this NPP" We cannot disc!ose your p「otected heaIth information to your empIoyer

Or tO yOur SChooi without your authorization uniess requ一「ed by law・ You will 「eceive a copy of you「

authorization and may 「evoke the autho「ization in w「iting" We w川hono「 that revocation begInn-ng the

date we receive the written signed revocation.

You have several 「ights conce「n-ng yOur PrOteCted health information" When you wish to use one ofthese

rights, PIease inform ouro冊ce so thatwe mayglVe yOu the co「rect form fordocumenting your request.

●　You have the 「ight to access your records and/or to receive a copy of your records, With the

exception of psychotherapy notes. Your request must be in w「iting, and we must verify your

identity before a=owlng the requested access" We a「e requlred to a=ow the access or provide the

COPy Within 30 days ofyour request. We may provide the copy to you orto your deslgnee in an

eIect「onic format acceptabIe to you o「 as a hard copy. We may charge you our cost for making

and providing the copy" ifyou「 「equest is denied’yOu may 「equeSt a reView ofthis denial by a

Iicensed heaith care provider.

●　You have the right to 「equest restrictions on how you「 protected health information is used for

treatment’Payment, and health operations・ Fo「example, yOu may requeSt that a certain friend or

family member not have access to this information・ We are not requ一「ed to ag「ee to this request,

but ifwe agree to your request, We a「e Obiigated to fuIf冊he request, eXCePt in an emergency

Where this restriction might interfere with your care" We may terminate these restrictions if

necessary to fulf冊reatment and payment.

DoctorsManagement HIPAA MASTER FORMS

●

"I

■I

●We are requ-red to grant your request for restriction if the requested 「est「iction a師es only to

information that wouId be submitted to a hea-th pIan for payment fo「 a health care service or item

for which you have paid in full out-O白oocket, and ifthe 「estriction is not otherwise fo「bidden by

Iaw. For example, We are requ-red to submit information to federaI hea-th plans and managed

Care O「ganizations even if you request a restriction・ We must have your restriction documented

PrIO「 tO initiating the service・ Some exceptions may appIy, SO aSk for a form to request the

「estriction and to get additiona=nformation. We are not requl「ed to inform other covered entities

Ofthis request, butwe are not aIIowed to use or discIose information that has been restricted to

business associates that may discIose the info「mation to the hea-th plan.

You have the 「ight to request confidentiai communications・ For example, yOu may Prefer that we

CalI your cell phone number rather than your home phone・ These requests must be in w「iting,

may be 「evoked in writing, and must glVe uS an e鴨ctive means of communication for us to

COmPIy・ ifthe aIternate means of communications incurs additiona- cost】 that cost will be passed

OntOyOu.

Your medicaI 「ecords a「e iegaI documents that provide crucia。nformation regarding your care.

You have the right to request an amendmen=o your medical reco「ds, but you must make this

request in writing and understand that we are not required to grantthis request"

You have the right to an accounting of discIosu「es. This w岨ell you how we have used or

discIosed your protected heaIth information〃 We are requ-red to infdrm you of a breach that may

have a什ected your protected hea!th information.

. You havethe 「ightto receive a copy ofthis notice, eithereIectronic or paperor both.

. You havethe rightto opt outoffund raisIng COmmunications.

1fyou have any questions about our prIVaCy PraCtices- P獲ease contact our P「ivacy O冊ce「 at the number

below.

You have the rightto fiIe a compiaint with us orwith the O冊ce for Civil Rights. WewiIl notdiscriminate or

retaliate in anyway fo「this action. To file a complaint, Please contact the applicabIe party

Privacy O冊ce「

Phone Number 615-320鵜0007

Fax Number 615-320-0009

O冊ce ofCiv= Rights

US Depa「tment of HeaIth and Human Services

Atlanta Federal Center

Suite3B70

61 Forsyth St. NWAtIanta, GA. 30303-8909

http:〃www.hhs.gov.ocr/privacy/hipaa/complaints/index.htm看

We are requi「edto abide bythe poIiciesstated inthis Notice ofPrivacy Practices, Which became

e什ective on October 13, 2013。

DoctorsManagement HIPAA MASTER FORMS