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