i Neurosurgery - Chattanooga Neurosurgery Spine

n
I Chattanooga
i Neurosurgery
)
Spine
Date:
Dear:
You are scheduled to see Dr.
Chattanooga Neurosurgery & Spine on:
of
1010 East Third Street
Suite 202
Chattanooga, TN
37403
Phone : (423) 265-2233
Fax :
(423) 756-8265
Peter E. Boehm, Sr., M.D.
Timothy A. Strait, M.D.
Date:
Time:
(am/pm).
Enclosed is patient information and medical history forms that you need to complete
and bring with you on your appointment. Please do not mail these back to us.
FAILURE IN BRINGING ANY OF THE FOLLOWING REQUESTED ITEMS WILL
RESULT IN YOUR APPOINTMENT BEING RESCHEDULED.
D. Philip Megison, M.D.
Michael R. Gallagher, M.D.
R. Lee Kern, Jr., M.D.
Daniel B. Kueter, M.D.
Peter E. Boehm, Jr., M.D.
Physical Medicine
and Rehabilitation
Interventional Spine
Paul E. Hoffmann, M.D.
X-RAYS FILMS, CT & MRI SCANS
It is necessary for you to bring with you any records from physicians you have seen
pertaining to the problem we will be seeing you for. This includes original X-ray films,
CT, MRI scans, etc. and the original report of the studies.
INSURANCE & AUTHORIZATIONS
Please bring your current insurance cards, as we will file your insurance for their portion
of payment on your bill. Your insurance company may also require an authorization or a
referral from your primary care physician. It is YOUR responsibility to make certain that
we have this authorization by the time of your appointment by bringing it with you or
having your primary care physician to fax it to our office.
PHOTO IDENTIFICATION
Patients are required to bring a photo ID or 2 forms of identification. If the patient is a
minor, then their guardian's ID will be requested. If the address on the ID does not
match your current address, you will need to bring a utility bill or other correspondence
showing your current address.
Retired
Robert A. Waters, M.D
(1921-1972)
Augustus McCravey, M.D.
(1910-1989)
PAYMENT FOR SERVICES
Payment will be expected at the time of your appointment. We will ask for your copayment or deductible amount to be paid. For your convenience, we accept most Major
Credit Cards as well as cash and checks.
Walter E. Boehm, M.D.
(1914-1994)
Neil C. Brown, M.D.
(1934-1996)
Barry P. Norton, M.D.
(1934-2008)
Roger G. Vieth, M.D.
Ralph McGraw, Jr., M.D.
W. Charles A. Sternbergh, Jr., M.D.
Walter M. Boehm, M.D.
Our physicians make every attempt to keep to their appointment schedule. However,
they are surgeons and may be called to the hospital for emergencies. Should this
situation arise, we will make every attempt to contact you to reschedule your
appointment. We ask for your understanding if we cannot reach you before you arrive for
your appointment.
We look forward to meeting you and providing you with medical care. If you have any
questions prior to your appointment, please give us a call.
Sincerely,
Chattanooga Neurosurgery & Spine
n
/Chattanooga
E.
Neurosurgery
) Spine
INSURANCES THAT REQUIRE REFERRALS FROM
YOUR PRIMARY CARE PROVIDER (PCP)
The following insurance companies require a referral before patients are seen in our
office. The insurance company will not pay your bill without a referral.
Medicare HMO plans
Georgia Medicaid
Tri-Care Prime
Health Spring HMO
United Health Care — some of their plans may require a referral
Humana — some of their plans may require a referral
The patient will need to contact their PCP prior to their appointment.
* If you do not have a referral at the time of your appointment, your appointment will
need to be rescheduled.
Please have your PCP fax your referral to Chattanooga Neurosurgery & Spine
(423) 756-8265.
INSURANCE COMPANIES THAT WE DO NOT PARTICIPATE WITH
TNCARE — including: BlueCare, Americhoice, Amerigroup of TN.
CoverTN
Auto Insurance
Secure Plus
If you have any questions, please contact our office.
Thank you.
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Our Address •
Chattanooga Neurosurgery & Spine
1010 East 3 rd Street, Suite 202
Chattanooga, TN 37403
Phone: 423-265-2233
*Wheelchair access and parking located at back of building*
From Nashville:
From Knoxville:
1-24 East to Hwy 27 North. Exit at 4 th Street (4th Street
will become 3rd Street). Stay on 3rd Street to Erlanger
Hospital. The McCravey Building is across the street
from Erlanger
1-75 South to 1-24 West, to Hwy
27 North. Exit at 4 th Street, (not
4th Avenue). 4th Street will
become 3rd Street. The
McCravey Building is across
the street from Erlanger Hosp.
From Alabama:
From North Georgia:
1-59 North to 1-24 East, to Hwy 27 North. Exit at
4th Street. (4 th Street will become 3rd Street). Stay
on 3rd Street to Erlanger Hospital. The McCravey
Building is across the street from Erlanger.
1-75 North to 1-24 West to Hwy
27 North. Exit 4 th Street, (not
4th Avenue). 4th Street will
become 3rd Street. The
McCravey Building is across
The street from Erlanger Hosp.
ALLERGIC
PATIENT INFORMATION
(PLEASE PRINT)
THIS FORM MUST BE COMPLETELY FILLED OUT
DATE
TO SEE DR
DO NOT OMIT ANY REQUESTED INFORMATION
PATIENT
DOB
Age
Name
Address
City/State/Zip
Mailing Address
City/State/Zip
Cell (
Phone Numbers- Home (___)
Work (
)
❑
)
Occupation
Employer
Male
SS #
Single ❑
Female
SPOUSE ❑
GUARDIAN
Married ❑
Widowed ❑ Divorced ❑
❑
Age
Name
DOB
SS #
City/State/Zip
Address
(if different than patient's)
Phone Numbers- Home
)
Cell (
Work (
)
Occupation
Employer
EMERGENCY CONTACT (someone outside the home)
Phone (
Name
Relation
)
Date Of Accident
ACCIDENT- Work Related ❑
Other ❑
If accident is work related there will be additional paperwork to fill out.
INSURANCE
PRIMARY INS.
ID #
Group #
DOB
Insured's Name
SS #
Group #
SECONDARY INS.
ID #
DOB
Insured's Name
SS #
REFERRED BY- Doctor ❑ Relative ❑ Friend ❑ Name
PRIMARY CARE PHYSICIAN
Name
Address
Phone (
)
Phone (
)
City/State/Zip
PHARMACY
Name
AUTHORIZATION TO RELEASE INFORMATION AND TO PAY BENEFITS TO PHYSICIANS
I hereby authorize Chattanooga Neurosurgery & Spine (The Neurosurgical Group Of Chattanooga, P.C.) to release any
information to the insurance company covering my procedures or any service rendered. I also authorize direct payment to
Chattanooga Neurosurgery & Spine (The Neurosurgical Group Of Chattanooga, P.C.) by the insurance company of any
payments due. I understand that I am financially responsible for all charges whether or not they are covered by insurance.
SIGNED
-•
Chattanooga
'Neurosurgery
Spine
DISCLOSURE OF PROTECTED HEALTH INFORMATION
According to office policy, test results or release of medical information will be provided
to the patient only. Please specify below to whom information may be released to other
than' the patient.
❑
Patient only
❑
Spouse - Name:
❑
Children — Name(s):
❑
Other (state relationship) - Name:
❑
Doctors Office:
May we leave messages at your:
❑
Home Answering Machine #
[1]
Cell Phone #
❑
Work Voice Mail #
❑
Other (please specify) #
I have received a copy of Chattanooga Neurosurgery & Spine Privacy Notice explaining
the uses and disclosures of my health information:
❑
Yes
❑
No
Patient Initials:
NOTICE REGARDING PRESCRIPTION REFILLS
Please note that the patient must call in requests for refills of prescription pain medication
personally. Requests must be made during normal business hours.
Please sign your name to verify permission for all information above.
Patient Signature:
Date:
HEALTH HISTORY
Chattanooga Neurosurgery & Spine
1010 East Third Street, Suite 202, Chattanooga, TN 37403
Office: (423)265-2233 Fax (423)756-8265
All information is treated as strictly confidential.
The more fully you complete this form, the better we will be able to diagnose and treat you.
PATIENT NAME _______________________________________DATE________________
What are you seeing the doctor for today? ___________________________________________
When did this start?_____________________________________________________________
What, if anything, do you think caused it?____________________________________________
Where on your body does it bother you?_____________________________________________
Describe your symptoms:_________________________________________________________
At its worst, how bad is your pain on a scale of 1-10?___________at its best?_______________
What makes it better?____________________________________________________________
What makes it worse?____________________________________________________________
Does anything else bother you in association with this problem?__________________________
What medications have you taken for this problem?____________________________________
What medical tests have been performed?____________________________________________
What treatments or therapeutic remedies have you undertaken?___________________________
Have you seen other doctors for this condition?________________________________________
If indicated, are you interested in surgery for this problem?______________________________
Have you been disabled, fired, or unable to work due to this problem?______________________
Are you currently involved in any litigation regarding this problem?_______________________
ALLERGIES: List medications and other things you are allergic to, and the symptoms they
cause:
PAST MEDICAL HISTORY (OK to attach separate form)
What Chronic Medical conditions do you have?_______________________________________
What recent illnesses have you had?________________________________________________
When have you been recently hospitalized?___________________________________________
PAST SURGICAL HISTORY: Please list all surgeries you have had (OK to attach separate
form)
Surgery
Year
Any Complications
MEDICATIONS: (Including prescription, over the counter, supplements, BC Powder, etc;
Or you can attach a separate form)
Medicine
Strength
How often do you take it
FAMILY HISTORY: Please list medical problems that run in your family
Relative
Medical problem
Cause of death
Mother________________________________________________________________________
Father________________________________________________________________________
Sibling_______________________________________________________________________
Sibling________________________________________________________________________
Child_________________________________________________________________________
Other_________________________________________________________________________
SOCIAL HISTORY
Occupation___________________________________________________________________
Marital Status:
Children?:
Single
Yes
Do you smoke?: Yes
No
No
Married
Divorced
Widowed
How Many____
__Cigarettes ________packs per day for _______years
__Cigars/Pipe
__Smokeless tobacco
__I quit smoking __ years ago. I had smoked for __ years total.
How often do you drink alcohol:
Never
Rarely
Socially
Frequently
12 POINT REVIEW OF SYSTEMS
Describe or circle problems associated with the following body systems
General Body: (Fatigue, weight gain, weight loss, etc.)
Neurologic: (Seizures, Weakness, speech difficulty, blackout spells, headaches, numbness,
memory loss, etc)
Heart/Cardiac: (CHF, stents, heart attacks, chest pain, high blood pressure, etc)
Respiratory / Lung (Asthma, COPD, Lung cancers, pleurisy, shorthness of breath, home
oxygen, home CPAP, etc)
Ear, Nose, Throat, Mouth (Ringing in ears, hearing loss, inability to smell, nosebleeds, ear
pain, etc)
Endocrine (Excessive thirst, urination, hormone problems, etc)
Eyes (Cataracts, glaucoma, vision loss, eye injury, etc)
Gastrointestinal (Abdominal pain, nausea, vomiting, blood in vomit, blood in stool,
constipation, etc)
Genitourinary (incontinence, trouble starting/stopping stream, bloody urine, Urinary tract
infection, etc)
Hematology / Blood system (Anemia, free bleeder, on blood thinners, etc)
Skin / Integumentary system (skin ulcers, thin skin, easy bruising, sores or abscesses, etc)
Psychiatric (Depression, Bipolar, any psychiatric treatments, etc)
The above information is accurate to the best of my knowledge.
PATIENT SIGNATURE________________________________DATE:________________
Chattanooga Neurosurgery & Spine
Notice of Privacy Practices for Protected Health Information
This notice describes how medical information about you may be used and disclosed and how you can get access to this
information. Please review it carefully!
Our office is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment,
payment, and health care operations. Protected health information is the information we create and obtain in providing our services to
you. Such information may include documentation of your symptoms, examination and test results, diagnoses, treatment, and
application for future care or treatment. It also includes billing documents for those services.
Examples of uses or disclosures of your health information for treatment purposes:
•
•
Our staff obtains treatment information about you and records it in the medical record.
During the course of your treatment, the physician determines he will need to consult with another specialist in the area. He
will share the information with such specialist and obtain his/her input.
Examples of disclosure of your health information for payment purposes;
We submit requests for payment to your health insurance company. The health insurance company or business associate helping us
obtain payment requests information from us regarding your medical care given. We will provide information to them about you and
the care given.
Examples of disclosure of your health information for health care operations:
We may obtain services from business associates that perform various activities for the practice such as quality assessment, quality
improvement, outcome evaluation, protocol and clinical guidelines development, training programs, credentialing, medical review,
legal services, and insurance. We will share information about you with such business associates as necessary to obtain these services.
Your Health Information Rights
The health and billing records we maintain are the physical property of the doctor's office. You have the following rights with
respect to your Protected Health Information.
1.
Right to request restriction on certain uses and disclosures of your health information by delivering the request in writing
to our office, we are not required to grant the request but we will comply with any request that we have granted;
2. Right to obtain a paper copy of the Notice of Privacy Practices for Protected Health Information ("Notice") by making a
request at our office;
3. Right to inspect and copy your health record and billing record, with limited exceptions you may exercise this right by
delivering the request in writing to our office using the form we provide to you upon request; you may appeal a denial of
access to your protected health information except in certain circumstances;
4. Right to request that your health care record be amended to correct incomplete or incorrect information by delivering a
written request which provides the reason to support the requested amendment to our office using the form we provide
you upon request; you may file a statement of disagreement if your amendment is denied, and require that the request for
amendment and any denial be attached in all future disclosures of your protected health information;
5. Right to receive an accounting of disclosures of your health information as required to be maintained by law by
delivering a written request to our office using the form we provide to you upon request; an accounting will not include
internal uses of information for treatment, payment or operations, disclosures made to you or made at your request, or
disclosures made to family members or friends in the course of providing care; and
6. Right to confidential communication by requesting that communication of your health information be made by
alternative means or at an alternative location by delivering the request in writing to our office using the form we give
you upon request.
If you want to exercise any of the above rights, please contact Pam Hartline, 423-265-2233, in person or in writing, during normal
hours. She will provide you with assistance on the steps to take to exercise your rights.
Our Responsibilities
The office is required to:
•
•
•
•
•
Maintain the privacy of your health information as required by law;
Provide you with a notice as to our duties and privacy practices as to the information we collect and maintain about you;
Abide by the terms of this Notice;
Notify you if we cannot accommodate a requested restriction or amendment; and
Accommodate your request for an accounting of disclosures subject to certain exceptions, restrictions and limitations.
We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new
provisions regarding all the protected health information we maintain at that time. If our information practices change, we will amend
our Notice. You are entitled to receive a revised copy of our Notice by calling and requesting a copy of our "Notice" or by visiting our
office and picking up a copy.
Chattanooga Surgery Center
400 N. Holtzclaw Ave. • Chattanooga, TN 37404 • 423-698-6871 • 423-622-8993 (fax)
PATIENT NOTIFICATION
PATIENTS RESPONSIBILITIES:
D
D
D
D
D
D
D
D
D
D
D
D
The patient has the responsibility to provide accurate and
complete information concerning his/her present complaints,
past illnesses, hospitalizations, medications (including over
the counter products and dietary supplements), allergies and
sensitivities and other matters relating to his/her health.
The patient and family are responsible for asking questions
when they do not understand what they have been told about
the patient's care or what they are expected to do.
The patient is responsible for following the treatment plan
established by his/her physician, including the instructions of
nurses and other health professionals as they carry out the
physician's orders.
The patient is responsible for keeping appointments and for
notifying the facility or physician when he/she is unable to
do so.
Provide a responsible adult to transport him/her home from
the facility and remain with him/her for 24 hours unless
exempted from that requirement by the attending physician.
In the case of pediatric patients, a parent or guardian is to
remain in the facility for the duration of the patient's stay in
the facility.
The patient is responsible for his/her actions should you
refuse treatment or not follow your physician's orders.
The patient is responsible for assuring that the financial
obligations of his/her care are fulfilled as promptly as
possible.
The patient is responsible for following facility policies and
procedures.
The patient is responsible to inform the facility about the
patient's advance directives.
The patient is responsible for being considerate of the rights
of other patients and facility personnel.
The patient is responsible for being respectful of his/her
personal property and that of other persons in the facility.
Therefore, it is our policy, regardless of the contents of any
Advance Directive or instructions from a health care surrogate or
attorney-in-fact, that if an adverse event occurs during your
treatment at this facility, we will initiate resuscitative or other
stabilizing measures and transfer you to an acute care hospital for
further evaluation. At the acute care hospital, further treatments
or withdrawal of treatment measures already begun will be
ordered in accordance with your wishes, Advance Directive, or
Healthcare Power of Attorney. Your agreement with this
facility's policy will not revoke or invalidate any current health
care directive or health care power of attorney.
If you wish to complete an Advance Directive, copies of the
official state forms are available at our facility.
If you do not agree with this facility's policy, we will be pleased
to assist you in rescheduling your procedure.
PATIENT COMPLAINT OR GRIEVANCE
If you have a problem or complaint, please speak to the
receptionist or your care giver. We will address your
concern(s) promptly.
' If necessary, your problem or complaint will be advanced to
the Administrator and/or Quality Assurance coordinator for
resolution. You will receive a letter or phone call to inform
you of the actions taken to address your complaint.
D If you are not satisfied with the response of the Surgery
Center, you may contact:
D
Patient complaints or grievances may be filed through the State of Tennessee
Office of Investigations. Please send your complaint or grievance to:
Tennessee Department of Health
Office of Investigations
Heritage Place, Metro Center
227 French Landing, Suite 201
Nashville, Tennessee 37243
(615) 741-8485 Phone
1-800-852-2187 TN Toll Free
ADVANCE DIRECTIVE NOTIFICATION:
In the state of Tennessee, all patients have the right to participate
in their own health care decisions and to make Advance
Directives or to execute Power of Attorney that authorize others
to make decisions on their behalf based on the patient's
expressed wishes when the patient is unable to make decisions or
unable to communicate decisions. The Chattanooga Surgery
Center respects and upholds those rights.
However, unlike in an acute care hospital setting, the
Chattanooga Surgery Center does not routinely perform "high
risk" procedures. Most procedures performed in this facility are
considered to be of minimal risk. Of course, no surgery is
without risk. You will discuss the specifics of your procedure
with your physician who can answer your questions as to its
risks, your expected recovery, and care after surgery.
D All Medicare beneficiaries may also file a complaint or
grievance with the Medicare Beneficiary Ombudsman. Visit
the Ombudsman's webpage on the web at:
www.cms.hhs.govicenter/ombudsman
Patient label
BY SIGNING THIS DOCUMENT, I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND ITS CONTENTS
BY:
DATE:
(Patient/Patient Representative Signature)
)
nattanooga
ga
l■ Neurosurgery
Spi ne
Spinal Worksheet
Name:
Date:
Location of Pain: (circle)
Back
Upper
Mid
Low
Legs
Right
Left
Both
Arms
Right
Left
Both
Neck
Severity: (1 — 10 scale)
Quality/Type:
Timing:
❑ Burning
❑ Aching
❑ Electrical
Other:
When did it start?
Has it ever happened before?
Was there an injury?
If yes, date of injury:
Was injury work related:
Progression: Has it gotten - ❑ Worse
Neurological Symptoms: ❑ Numbness
❑Yes
❑ Better
❑ No
❑ Stayed the Same
❑ Tingling
III Weakness
Where:
Associated Symptoms:
❑ Difficulty Walking
❑ Loss of Bladder / Bladder Control
❑ Sexual Dysfunction
What activity makes the pain worse?
What improves the pain?
❑ Exercise
❑ Medication
Other:
Any previous treatments?
❑ Physical Therapy
Other:
Any additional information:
❑ Injections
❑ Chiropractic