Marc Irwin Sharfman, M.D., P.A. / Headache and Neurological

Marc Irwin Sharfman, M.D., P.A. / Headache and Neurological Treatment Institute
2137 W. State Road 434
Longwood, FL 32779
Phone (407) 644-3737 / Fax (407) 644-3009
AUTHORIZATION TO RELEASE, REQUEST, OR OBTAIN CONFIDENTIAL INFORMATION
By signing this authorization, I authorize Headache and Neurological Treatment Institute to use and/or disclose certain protected
health information, (PHI), about me to or for the party or parties listed below.
I, _____________________________________, Date of Birth: ________________________, SSN: _____________________,
hereby authorize Headache and Neurological Treatment Institute to   OBTAIN   RELEASE medical information via, mail,
facsimile, or other appropriate source   TO   FROM:
______________________________________________________________________________________________________
(Person(s) or Entity(s) to receive/release requested information)
______________________________________________________________________________________________________
(Address)
(City, State, Zip)
(Phone number)
(Fax Number)
I.
The individually identifiable health information to be obtained/released is: (Please place a  in appropriate space(s)).
____
____
____
____
____
____
____
____
Dr. Sharfman Office Notes
____ Entire Medical chart (Specify if cover to cover)
Massage / Physical Therapy notes
____ Medication List(s)
____ Financial Information
X-Ray, Laboratory or other Diagnostic Reports _______________________________________________
Emergency Room Records from___________________________________________________ (Dates)
Inpatient Records from___________________________________________________________ (Dates)
Only the Records from _____________________ to ___________________________________ (Dates)
Only information related to (Specify) ________________________________________________
Other (Specify) _________________________________________________________________
Additional information to obtain/release: (Please place a  in appropriate space(s)).
_____ Psychological Records / Information
_____ Drug / Substance Abuse

_____ HIV results, information
Alcohol, drug abuse information, etc, if present, has been disclosed from records whose confidentiality is protected by Federal Law. Federal
regulation (42CFR part II) prohibits making any further disclosure of it without the specific written authorization of the undersigned, or as
otherwise permitted by such regulations. Additionally further release of HIV related information is prohibited without specific authorization.
II.
The purpose or need for the disclosure of information:
III.
This authorization will expire on ___________________________ (Please indicate expiration date or specific event).
(If authorization is not revoked and no expiration/event is noted it will terminate1 year from the date of signature below.)
IV.
I understand that I have the right to revoke this authorization at any time and must do so in writing. I understand that the revocation
will not apply to protected health information (PHI) that has already been disclosed in response to this authorization. I understand
that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under
my policy. My written revocation must be submitted to Headache and Neurological Treatment Institute’s Privacy Officer at the
address noted on this authorization.
___ Continued Medical Care ___ Legal Case ___Personal Use
___ Other, please explain: ____________________________
I understand that Headache and Neurological Treatment Institute may not condition treatment, payment, enrollment or eligibility for
benefits on this signed authorization.
I understand that the release, use, or disclosure of my protected health information (PHI) carries with it the potential for re-disclosure
by the recipient and the PHI may not be protected by the federal HIPAA privacy rule.
I understand I have the right to refuse this authorization and that the facility named above is released from all legal liability that may
arise from the release or receipt of the information requested.
___________________________________________
(Signature of Patient or Legal Guardian)
________________________________
(Relationship to Patient)
____________________
(Date Signed)
For Office Use Only: Authorization fulfilled and information sent By: __________________________________ on Date:_________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
(Revised 9/13)
MARC IRWIN SHARFMAN, M.D., P.A.
HEADACHE and NEUROLOGICAL TREATMENT INSTITUTE
2137 WEST STATE ROAD 434
LONGWOOD, FL 32779
PHONE: 407-644-3737 / FAX: 407-644-3009
DATE: ________________
EMAIL:____________________________
Patient's Name: ______________________________________________________________________ Age:________________
Patient's Home Address ____________________________________________________________________________________
City ____________________________________________________State ____________Zip ____________________________
Home Phone _______________________ Cell Phone ______________________ Other Phone __________________________
Date of Birth_____________________ Social Security #__________________________ Sex _______ Marital Status __________
Current Employer ______________________________________________________________ Phone _____________________
Employers Address ____________________________________Patient Driver’s License _________________________________
PRIMARY INSURANCE
Insured's Name __________________________________________ Relationship to patient______________________________
SSN of Insured __________________________________________ Date of birth of Insured _____________________________
Primary Insurance Company ________________________________________________________________________________
Policy #_________________________________________________ Group #_________________________________________
Insurance Company Address ________________________________________________________________________________
Phone ________________________________________ Insured's Employer __________________________________________
SECONDARY INSURANCE
Insured's Name __________________________________________ Relationship to patient______________________________
SSN of Insured __________________________________________ Date of birth of Insured _____________________________
Primary Insurance Company ________________________________________________________________________________
Policy #_________________________________________________ Group #_________________________________________
Insurance Company Address ________________________________________________________________________________
Phone ________________________________________ Insured's Employer __________________________________________
ACCIDENT INFORMATION
Condition Related to Patient's Employment:
Yes ___ NO ____ Employer name: __________________________________
Condition Related to Auto Accident:
Yes ___ NO ____
Condition Related to Other Accident:
Yes ___ NO ____ Explain accident:___________________________
Date of Accident:____________________________________Claim #________________________________________________
Insurance Company _______________________________________________________________________________________
Phone _____________________________________Claim Representative/Adjuster ____________________________________
Who is your representing attorney/lawyer: _______________________________Phone:________________________________
In case of emergency please contact:_______________________________________Relationship to patient:_________________
Home Phone #_________________________________________ Cell Phone #________________________________________
Please indicate method of payment:
____ CASH
____ CHECK
____ VISA / MASTERCARD / AMEX / DISCOVER
Please note:
Returned checks will incur a $25.00 service fee. Past due accounts may be subject to collection and/or attorney
fees. Past due balances may be released to an outside collections agency and may also be reported to a credit bureau which may
affect your credit rating.
Registration form reviewed / no changes noted: Please date and have patient initial:
Date:
Date:
______________ Initials: ________________
______________ Initials: ________________
Date: ______________ Initials: ___________
Date: ______________ Initials: ___________
PLEASE TURN OVER AND COMPLETE BACK OF FORM
SIGNATURES REQUIRED
(Please read the below carefully and sign ONLY those sections that pertain to you.)
I.
ALL PATIENTS:
I understand that I am financially responsible for ALL charges, whether or not paid by my current insurance carrier. (To include any amount not covered
or reduced due to USUAL AND CUSTOMARY - unless Dr. Sharfman is a participating provider with my plan). It is my responsibility to pay any deductible
amount, co-payments, coinsurance, selfpay, etc at the time services are rendered and any other remaining balance(s) not paid for by my insurance
within 45 days. I understand that this office will only submit claims to my insurance carrier if (1) they are considered a participating provider with my
plan and authorization has been provided, when necessary, (2) if claims are related to a Florida motor vehicle accident or (3) if claims are related to a
Work Comp claim and our office has been pre-authorized for a visit, treatment, etc.
I am aware that my secondary insurance, as noted on the front of this form, will be billed when applicable/necessary information has been provided to
Dr. Sharfman’s office. I further understand that it is my responsibility to notify this office of any changes in my address, phone number(s), insurance
plan(s) or coverage. It is also my responsibility to know and understand my own insurance benefits.
My signature below authorizes Dr. Marc Sharfman to obtain copies of old medical records when applicable to my treatment/care. My signature further
authorizes Dr. Marc Sharfman to release all appropriately related medical information to those physicians that he finds necessary to refer or consult
with, when applicable to my treatment/care. When necessary and applicable I also provide authorization for the use of fax transmittal and/or email of
my medical records/information. Furthermore, I authorize Dr. Sharfman and his staff to communicate with my pharmacist and physician(s) as
necessary by letter, phone, email, or fax.
My signature below certifies that the information provided on the front of this registration form is true and correct to the best of my knowledge.
Additionally I have read and understand all of the above and have no questions or concerns.
PATIENT (OR AUTHORIZED) SIGNATURE:
__________________________________________________________________DATE:__________________
II.
NON-MEDICARE PATIENTS (IE: Self pay, Private Insurance etc):
I authorize the release of my medical information, to those carriers noted on the front of this registration form, when necessary to process all claims and
request payment of medical benefits to be made to Dr. Marc Sharfman for services provided when claims are submitted to my insurance carrier.
PATIENT (OR AUTHORIZED) SIGNATURE:
__________________________________________________________________DATE:__________________
III.
ACCIDENT PATIENTS, IE: WORKER’S COMP, AUTO ACCIDENT, LIABILITY, ETC:
I authorize the release of my medical information, to those carriers noted on the front of this registration form, when necessary to process all claims and
request payment of medical benefits to be made to Dr. Marc Sharfman for services provided when claims are submitted to my insurance carrier. The
undersigned also provides authorization for Dr. Marc Sharfman and/or his staff to discuss my medical and financial information with my current
representing attorney also noted on the front of this registration form.
PATIENT (OR AUTHORIZED) SIGNATURE:
__________________________________________________________________DATE:__________________
IV.
FOR MEDICARE PATIENTS: (Lifetime authorization for Medicare).
I hereby request payment of authorized Medicare benefits and/or any other insurance benefits to be made either to me or on my behalf to Dr. Marc
Sharfman for any services furnished me by Headache and Neurological Treatment Institute/Dr. Marc Sharfman. I authorize any holder of medical
information about me to release to the Health Care Financing Administration and it agents any information needed to determine these benefits or the
benefits payable to related services. I understand my signature requests that payment be made and authorizes releases of medical information
necessary to pay the claim. If item 9 of the HCFA-1500 claim form is completed, my signature authorizes releasing of the information to the insurer or
agency shown. In Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full
charge, and I am responsible only for the deductible, coinsurance, non-covered services, and those services I have signed an Advanced Beneficiary Notice
form on. Coinsurance and the deductible are based upon the charge determination of the Medicare carrier. I further request that payment of
authorized MEDIGAP benefits be made on my behalf to Dr. Marc Sharfman, M.D., P.A. for any services furnished me by Headache and Neurological
Treatment Institute/Dr. Marc Sharfman. I authorize any holder of medical information about me to release to the mentioned MEDIGAP Insurance
Company on the front of this registration form any information needed to determine these benefits or the benefits payable for related services.
PATIENT (OR AUTHORIZED) SIGNATURE:
__________________________________________________________________DATE:__________________
V.
CONFIDENTIALITY STATEMENT: (All Patients)
This office adheres to rules regarding the confidentiality of patient information and/or patient medical records. This office will communicate with
the patient’s pharmacy and other physician(s) by letter, phone or fax upon written consent/permission from the patient and/or for purposes of
TPO, Treatment, Payment, and other Health care Operations, as per HIPAA guidelines. Only information necessary to process claims is released to
the insurance companies, unless otherwise requested and upon written permission/authorization from the patient.
PATIENT (OR AUTHORIZED) SIGNATURE: __________________________________________________________________DATE:__________________
0814006
7/14/11
2:42 PM
Page 1
HISTORY FORM
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
NAME:
IDENTIFYING DATA: RIGHT HANDED អ
AGE:
MARITAL STATUS:
DIVORCED
WIDOWED
CHIEF COMPLAINTS:
Page 1
LEFT HANDED អ
SINGLE
MARRIED
WHO REQUESTED THAT YOU SEE DR. SHARFMAN?
MEDICINES ALLERGIC TO:
I am not allergic to any medication
I am allergic to
CURRENT MEDICATIONS (PRESCRIPTION AND/OR NON-PRESCRIPTION):
Name of Medicine:
Strength:
How many times per day:
1.
2.
3.
4.
5.
Please list additional Medicines:
Do you take over the counter medicines? Name
Quantity
PLEASE FILL OUT THE FORM REGARDING PAST MEDICATION USE (SEE LAST PAGE)
SOCIAL HISTORY:
Do you use:
Tobacco
No
Yes
Alcohol
No
Yes
Caffeine
No
Yes
Illegal Drugs
No
Yes
HIV (The virus that causes AIDS) Do you wish to discuss risk factors? No
Yes
Occupation:
FAMILY HISTORY:
Adopted
Twin
List any illness or medical condition that runs in your family & that is NOT listed below:
YES
YES
HEADACHE
HEART DISEASE
HYPERTENSION
KIDNEY DISEASE
MENTAL ILLNESS
STROKE
THYROID DISEASE
ARTHRITIS
ASTHMA
BLEEDING DISORDER
BRAIN TUMOR
CANCER
DEMENTIA
DIABETES
EPILEPSY (SEIZURES)
K.
SEPARATED
REVIEW OF SYSTEMS: If you feel the complaint below is related to an accident or injury place a (ឡ) mark in the អ (box).
If you feel the complaint below is medically related, place an (x) in the box.
GENERAL:
អ Fever
(current temp greater than 100)
អ Rash
អ Cough
អ Shortness of breath
PATIENT NAME:
អ Chest pain
អ Palpitations
អ Change in bowel habits
អ Blood in stool
អ Indigestion
អ Change in urination
អ Pain on chewing
អ Joint pains
អ Depression
អ Suicidal thoughts
អ Have you had a prior
suicide attempt
អ Pregnancy, or trying to become
អ Weight loss / gain (please circle)
អ Muscle aches
អ Sleep difficulty
អ Fear / Anxiety while driving
DATE:
POS® Reorder # 0814006
0814007
7/14/11
2:43 PM
Page 1
Page 2
K. (cont.) NEUROLOGIC: (Current complaints only, please.) If you feel the complaint below is related to an accident or injury, put a
check (ឡ) mark in the box. If you feel the complaint below is medically related, put an (x) mark in the box.
អ Stiffness
អ Headache
អ Nausea
អ Ringing of the ears
អ Clumsiness
អ Dizziness/Vertigo
អ Vomiting
អ Decreased hearing R / L
អ Poor balance
អ Passing out
អ Trouble with smell
អ Swallowing difficulty
អ Poor coordination
អ Confusion
អ Blurred vision
អ Hoarseness
អ Trouble walking
អ Concentration difficulty
អ Personality change
អ Choking
អ Incontinence bladder
អ Memory difficulty
អ Double vision
អ Weakness - Arms R / L
អ Incontinence bowel
អ Lethargy
អ Blindness
អ Weakness - Legs R / L
អ Sexual dysfunction
អ Hallucinations
អ Facial numbness
អ Numbness - Arms R / L
អ Speech difficulty
អ Difficulty tasting
អ Numbness - Legs R / L
FEMALE PATIENTS:
Menstrual history
Last menstrual cycle
Birth control method
Menopause
Yes
No
PAST MEDICAL HISTORY:
L.
Do you now have or have you ever had any of the following disorders?
If you feel your complaint is related to an accident or injury, put a check (ឡ) mark in the blank. If you feel your complaint is
medically related, put an (x) mark in the blank. (Ex. NOT accident related)
Yes
Age of onset
Yes
Age of onset
Encephalitis / Meningitis
Aids (HIV+)
Epilepsy / Seizures
Addiction
Glaucoma
Anemia
Heart trouble
Angina (chest pain)
Mitral Valve Prolapse
Arthritis
High blood pressure
Asthma
Hypoglycemia
Bleeding disorder
Kidney disease
Blood clots
Liver disease / hepatitis
Cancer
Menstrual irregularities
Car sickness
Pneumonia / lung disease
Chronic back pain
Stroke
Chronic neck pain
Thyroid disease
Head injury
TMJ
Diabetes
IBD (Inflam. Bowel Dis.)
Ulcers
Fibromyalgia
Sleep Apnea
Other
PAST SURGICAL HISTORY (List operations and date performed)
M.
1.
4.
2.
5.
3.
6.
PSYCHIATRIC HISTORY (Name of therapist and date)
N.
1.
3.
2.
4.
PREVIOUS CARE: List doctors who have treated you for your problem.
O.
Neurosurgeon
Internist
Allergist
Anesthesiologist
Ophthalmologist
Dentist
Psychiatrist
Chiropractic
Ear, Nose, Throat
Orthopaedic
Neurologist
Family Physician
Rheumatology
Physiatry
EEG
List any tests you have had and when done:
P.
Blood work
MRI (what part of body)
EKG
CT scan (what part of body)
EMG/NCV
Spine Xrays (what part of body)
Carotid Ultrasound
Spinal tap
MMPI (personality profile)
Temporal Artery Biopsy
List any other treatments you have had and quantity:
Q.
Botox
TMJ
Biofeedback
Trigger point injections
Acupuncture
Nerve Block
Physical Therapy
TENS
Massage Therapy
Other
Traction
Chiropractic
What is your goal for today's visit?:
R.
PATIENT NAME:
DATE:
POS® Reorder # 0814007
9819583
07 14 2011
14:56
Page 1
HEADACHE INSTITUTE
Marc I. Sharfman, M.D., P.A.
PLEASE CIRCLE ANY MEDICINES YOU HAVE USED
E. MUSCLE RELAXANTS
I. SYMPTOMATICS
Soma
A. TRIPTANS
Soma compound
Amerge
Amrix
Axert
Baclofen
Treximet
Dantrium
Imitrex:
Equanil
Oral
Flexeril
Injectable/Sumavel
Norflex
Nasal spray
Norgesic Forte
Frova
Parafon Forte
Maxalt/MLT
Robaxin
Relpax
Zanaflex
Zomig/ZMT/NS
Valium
B. ERGOTAMINES:
Xanax
Cafergot
Ativan
DHE-45
Skelaxin
Nasal spray (Migranal)
Klonopin
Injectable
C. COMB. ANALGESICS: F. ANTINAUSEA:
Phenergan
Fioricet/with codeine
Compazine
Fiorinal/with codeine
Tigan
Esgic Plus
Reglan
Midrin
Zofran
Phrenilin
Vistaril
Dolgic
Thorazine
D. PAIN MEDICINES:
G. STEROIDS:
Ultracet
Medrol
Ultram
Prednisone
Darvocet
Decadron
Darvon
H. OXYGEN
Duragesic
Kadian
II. PREVENTIVES:
OxyContin
A. BETA BLOCKERS:
Morphine
Inderal
Methadone
Corgard
Avinza
Lopressor
Lorcet
Tenormin
Lortab
Blocadren
Norco
Zebeta
Vicodin
B. ANTICONVULSANTS:
Vicoprofen
Depakote
Percocet
Tegretol
Demerol
Dilantin
Dilaudid
Gabitril
Nubain
Neurontin
Stadol
Lamictal
Actiq
Topamax
Tylenol # 3
Keppra
Panlor
Opana
PATIENT NAME:
ANTICONVULSANTS (Con’t.)
Lyrica
Sabril
Vimpat
Banzel
Zonegran
Trileptal
C. ERGOTAMINES:
Bellergal-S
Sansert
Methyl/ergonovine
D. CALC. CHAN. BLOCK:
Calan
Cardene
Sular
DynaCirc
Cardizem
Nimotop
Norvasc
Plendil
E. SEROTONIN BLOCK:
Pristiq
Cymbalta
Elavil
Savella
Triavil
Pamelor
Tofranil
Sinequan
Vivactil
Surmontil
Desyrel
Serzone
Prozac
Viibryd
Zoloft
Paxil
Celexa
Luvox
Effexor
Wellbutrin
Remeron
Meridia
Lexapro
F. ANTIINFLAM.:
Naprosyn
Ansaid
Daypro
Motrin
ANTIINFLAM. (Con’t.)
Orudis
Toradol
Indocin
Lodine
Trilisate
Dolobid
Feldene
Flector
Mobic
Relafen
Voltaren/Cambia
Celebrex
G. MAO INHIBITORS
H. MISCELLANEOUS:
Periactin
Lithium
Clonidine
BuSpar
ACE inhibitor
B2=Riboflavin
Lidoderm
Zostrix
Antivert
Magnesium
Histamine
Melatonin
Provigil/Nuvigil
Diamox
Botox
Acyclovir
Accolate
Petadolex/Feverfew
Seroquel
Zyprexa
Geodon
Biofreeze
Neudextra
ARB
Stretch & Spray
I. HORMONES:
Birth control
Estrogen replacement
J. MEMORY DIFFICULT:
Aricept
Reminyl
Exelon
Namenda
DATE:
POS® Reorder # 9819583
Headache and Neurological
Treatment Institute
PATIENT:
_________________________________________
DATE
_________________________________________
I HEREBY GIVE CONSENT TO DR. MARC SHARFMAN, HEADACHE AND NEUROLOGICAL
TREATMENT INSTITUTE TO PROVIDE WHATEVER TREATMENT THE ASSIGNED PHYSICIAN
MAY DEEM NECESSARY.
I UNDERSTAND THAT MY SIGNATURE OF THIS CONSENT AUTHORIZES DR. SHARFMAN HEADACHE AND NEUROLOGICAL TREATMENT INSTITUTE, TO EXAMINE, EVALUATE AND
RENDER TREATMENT.
I ALSO UNDERSTAND THAT AFTER EACH EVALUATION ANY TREATMENT DEEMED
"NECESSARY" WILL BE DISCUSSED WITH ME PRIOR TO BEING RENDERED UNLESS DEEMED
AN EMERGENCY.
X________________________________________
PATIENT OR AUTHORIZED SIGNATURE
________________
DATE
_________________________________________
WITNESS
________________
DATE
Marc Irwin Sharfman, MD PA
Board Certified Neurologist
2137 W State Road 434, Longwood, FL 32779-4983
Phone: 407-644-3737 / Fax: 407-644-3009
www.headache-institute.com
9816075
07 14 2011
15:00
Page 1
HEADACHE FORM
HEADACHE
MARC I. SHARFMAN, M.D., P.A.
and Neurological Treatment
INSTITUTE
2137 W. State Road 434
Longwood, FL 32779
(407) 644-3737
IF MORE THAN ONE TYPE OF HEADACHE, REQUEST ANOTHER FORM
IF NOT HAVING HEADACHES, TURN TO NEXT PAGE
What do you think caused your headache?
How old when started?
Number of headache days per month?
What time of day do the headaches start?
How many hours do they last?
How severe is the pain?
none 0 1 2 3 4 5 6 7
Where in your head does the pain start? (include side and location)
Does the pain radiate to other locations? If so, where?
Does it hurt inside like a stomach ache or is it a superficial pain?
What is the pain quality? (please circle all that apply)
A) Throbbing
B) Pressure
C) Knifelike
E) Exploding
F)
What triggers the pain? (please circle one)
A) Dietary
B) Environmental
1. Alcohol
1. Lights
2. Chocolate
2. Odors
3. Cheeses
3. Sounds
4. Oriental Foods
4. Smoke
5. Ice Cream
5.
6.
6.
C)
1.
2.
3.
4.
5.
6.
Don’t know
8
Biorhythms
Sleep
Exercise
Menstrual Cycle
9
10
Severe
D) Jab and Jolts
D) Stress
1.
2.
3.
What other symptoms are associated with your pain? (please circle)
Nausea
Vomiting
Nasal Congestion
Eye tearing (left, right, both)
Bothered by light
Bothered by sound
Bothered by odors
Bothered by change in position
Other
Vision Symptoms (circle type)
Left eye
Right eye
Both eyes
Positive phenomena (flashes, sparkles, spots)
Negative phenomena (blurred, partial vision loss, total blindness)
Hearing Symptoms (circle type)
Left ear
Right ear
Both ears
Ringing in ears
Clicking
Hissing
Buzzing
Other
Dizziness (circle type)
Lightheadedness
Vertigo (spinning sensation)
Loss of Equilibrium
Other
Any facial numbness / weakness (Please describe when, where and how long)
Speech Changes? Describe
Loss of Consciousness
What makes the pain worse?
What makes the pain better?
Are there any new or different symptoms?
Any questions you have for the Doctor?
PATIENT NAME:
DATE:
POS® Reorder # 9816075
9900114
07 14 2011
14:55
Page 1
HEADACHE INSTITUTE
MARC I. SHARFMAN, M.D., P.A.
BACK PAIN HISTORY
Back pain: Which areas apply?
អ Neck
អ Mid back
អ Low back
When did symptoms begin?
How often per month do they occur?
What time of day do they start?
How many hours do they last?
How severe is the pain?
Neck
Mid-back
Low-back
none
none
none
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
Does the pain radiate to other locations?
to Arms
right អ
left អ
to Legs
right អ
left អ
Do you experience numbness: Yes អ No អ
If Yes, where?
When do you experience this numbness?
Do you have any weakness?
Yes អ
No អ
If Yes, where?
When do you experience this weakness?
How would you describe this pain? Steady អ
Aching អ
severe
severe
severe
Burning អ
Knife-like អ
What makes the pain worse?
What makes the pain better?
PATIENT NAME:
Revised 07/14/11
DATE:
POS® Reorder # 9900114
9900118
8/4/11
1:40 PM
Page 1
HEADACHE
and Neurological Treatment
INSTITUTE
INJURY FORM
Date of accident / injury:
Type of Claim:
Motor Vehicle Accident អ
Worker’s Compensation
អ
Liability
អ
Worker’s Comp and Auto អ
Other
If motor vehicle accident, were you:
Driver អ
Pedestrian អ
Passenger
អ
Vehicle was hit from?
Front អ
Rear អ
Left side
អ
Right side
អ
Was vehicle moving at time of impact?
Yes
អ
No
អ
What was the speed?
Were you wearing seat belt?
Yes
អ
No
អ
Describe accident / injury (include speed at which you were travelling or were hit by):
Were your hands on the wheel?
Yes អ
What was the estimated amount of damage(s)?
Was airbag equipped?
អ Yes
អ No
Area of Injury:
Head
Other
Any lacerations (cuts), bruises, bumps? Describe
No
អ
Was airbag deployed?
Neck
អ Yes
អ No
Back
Did you lose consciousness?
Yes អ
No អ
Unknown អ
How long?
Did you go to the hospital / ER? Yes អ No អ What date?
Name of Hospital
Did you go by Ambulance?
Were you kept overnight at hospital / ER?
Yes អ No អ
For
days
Were XRays or Catscans taken at the hospital / ER?
Yes អ No អ
If Yes, what part of body was XRayed or Catscan performed of?
What treatment did you receive at the hospital / ER? Medication
Stitches
Other:
List all doctors that have treated you for the injury(s) sustained since this accident or injury:
Name
Specialty
Did you have similar symptoms before this accident / injury?
Have you had other accidents / injuries?
If Yes, please describe and include dates:
Yes អ
Yes អ
No អ
No អ
Employment History:
When accident / injury occurred, were you employed?
Yes អ
What type of work?
With what company?
Did you miss work due to the accident / injury?
Yes អ
If Yes, how many days, weeks or months have you missed?
Are you employed now?
Yes អ
No អ
Since the accident / injury, have your symptoms become:
Unchanged អ
Worse អ
Completely recovered អ
PATIENT NAME:
Marc Irwin Sharfman • M.D., P.A.
Board Certified Neurologist
POS® Reorder # 9900118 (Revised 8/11)
No អ
No អ
A little better អ
Much better អ
Date:
2137 W. State Rd. 434 • Longwood, Florida 32779
407 644-3737 • Fax 407 644-3009
[email protected]
Marc Irwin Sharfman, M.D., P.A.
Headache and Neurological Treatment Institute
CONSENT TO RELEASE OR USE INFORMATION FOR TREATMENT, PAYMENT, OR
HEALTH CARE OPERATIONS (TPO)
I hereby give my consent for Headache and Neurological Treatment Institute to use and
disclose protected health information (PHI) about me to carry out treatment, payment, and
health care operations (TPO). Please review the practice’s “Notice of Privacy Practices” for a
more complete description of the potential release and use of such information. You have the
right to review such Notice prior to signing this Consent Form.
We reserve the right to change the terms of its Notice of Privacy Practices at any time. If we
do make changes to the terms of its Notice of Privacy Practices, you may obtain a copy of the
revised Notice by asking a member of our front office staff for a copy or sending a written
request to our office address.
You retain the right to request that we further restrict how your protected health information is
released or used to carry out treatment, payment, or health care operations. Our practice is
not required to agree to such requested restrictions; however, if we do agree to your
requested restriction(s), such restrictions are then binding on the Practice.
I acknowledge and agree that the Practice may disclose my protected health information and
medical record information to the following individuals:
1.
Spouse:
_______________________________________________
2.
Children:
_______________________________________________
3.
Parent(s):
_______________________________________________
4.
Attorney:
_______________________________________________
5.
Other(s):
_______________________________________________
I agree that the Practice may also disclose the following types of information contained in my
medical record (please initial the appropriate categories listed below):
HIV/AIDS Information
Substance Abuse Information
Mental Health Information
Sexually Transmitted Disease Information
If Patient is under the age of eighteen (18), Pregnancy Information
With this consent, Headache and Neurological Treatment Institute may call my home or other
alternative location listed on my registration form, and leave a message on voice mail or in
person in reference to any items that assist the practice in carrying out TPO, such as
appointment reminders, insurance information, and any calls pertaining to my clinical care,
including laboratory and diagnostic results, among others.
With this consent, Headache and Neurological Treatment Institute may mail to my home or
other alternative location any items that assist the practice in carrying out TPO, such as
appointment reminder letters and patient statements as long as they are marked “Personal
and Confidential” and/or “confidential”, etc.
With this consent, Headache and Neurological Treatment Institute, when applicable, may
email to my home or other alternative location any items that assist the practice in carrying out
TPO, such as appointment reminders and patient statements.
© CHN Practice Consulting
06/09/14
With this consent, Headache and Neurological Treatment Institute may fax any items that
assist the practice in carrying out TPO, such as referrals for diagnostic testing, prescription
refills, referrals for consultations, etc. Additionally, outside of TPO areas, I consent to any
items being faxed to legal representatives when necessary and with appropriate authorization
on file.
At all times, you, the patient, retain the right to revoke this consent. Such revocation must be
submitted to the Practice in writing. The revocation shall be effective except to the extent that
the Practice has already taken action based on the prior Consent.
The Practice may refuse to treat you if you (or an authorized representative/legal guardian) do
not sign this Consent Form. If you (or authorized representative/legal guardian) sign this
Consent and then revoke it, the Practice has the right to refuse to provide further treatment to
you as of the time of revocation (except to the extent that the Practice is required by law to
treat individuals).
I have read and understand the information in this consent. By signing this form, I am
consenting to allow Headache and Neurological Treatment Institute to use and disclose
my PHI to carry out TPO.
Signed by:
_________________________
Signature of Patient or Legal Guardian
_______________
Date
_______________
Relationship to Patient
_________________________
_____________________________________
Print Patient’s Name
Print Name of Legal Guardian, if applicable
Patient/Guardian should be provided with a signed copy of this consent form. Please ask for a copy if
one is not provided to you.
If restrictions regarding this consent are desired please request a “Limitation/Restrictions” form to
complete.
(Office Use only):
  Consent refused by patient, and treatment refused as permitted by: ______________________________
  Unable to obtain consent for reasons: _____________________________________________________
Marc Irwin Sharfman, MD PA
Board Certified Neurologist
© CHN Practice Consulting
06/09/14
2137 W State Road 434, Longwood, FL 32779-4983
Phone: 407-644-3737 / Fax: 407-644-3009
www.headache-institute.com
© CHN Practice Consulting
06/09/14
Marc Irwin Sharfman, M.D., P.A.
Headache and Neurological Treatment Institute
Notice of Privacy Practice Acknowledgement Form
Our notice of Privacy Practices provides information about how we may use and release protected
health information about you. You have the right to review our Notice before signing this form. As
provided in our Notice, the terms of our Notice may change. If we change our Notice, you may obtain a
revised copy by writing our practice or requesting a copy from our front desk staff.
You have the right to request that we restrict how protected health information about you is used or
released for treatment, payment or health care operations. We are not required to agree to this
restriction, but if we do, we are bound by our agreement.
By signing this form, you consent to our use and release of protected health information about you for
treatment, payment and health care operations as described in our Notice. You have the right to revoke
this consent, in writing, except where we have already made releases in reliance on your prior consent.
Patient Name
(Print)
(Signature)
Date:
Witness:
Revisions:
Revised date:____________ Patient Received Signature:_____________________Date:_________
Revised date:____________ Patient Received Signature:_____________________Date:_________
Revised date:____________ Patient Received Signature:_____________________Date:_________
Revised date:____________ Patient Received Signature:_____________________Date:_________
(Office use only):
I attempted to obtain the patient’s signature on this Notice of Privacy Practices Acknowledgment form
but was unable to do so as documented below:
Reason: ___________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Date: _____________________Employee signature: ________________________________________