IMPORTANT PATIENT NOTICE

IMPORTANT PATIENT NOTICE

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

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

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

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

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

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

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

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

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

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

Thank you in advance for your patience during this transition.

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

CSNC Account# Provider# Appt. Date

PATIENT DEMOGRAPHICS

Patient Name Sex Male Female DOB SSN

Patient Address

Street Address City & State Zip Code

Mailing Address

Street Address City & State Zip Code

County Tertiary Phone

Primary Phone Secondary Phone

Email Address Preferred Language

Race Asian/Pacific Islander-1

African American-2

American Indian-5

Caucasian-3

Hispanic-4

Other-9

Refused to Report-9999

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

Responsible Party Address

Relationship to the Patient

Referring Dr. Address Phone

Primary Dr. Address Phone

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

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

Retired Disabled Address

Marital Status (Please Mark One) Phone

Single Married Divorced Widowed

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

Date of Injury Job Motor Vehicle Other

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

INSURANCE INFORMATION 1. PRIMARY Ins Co & Address

Subscriber’s Name Subscriber’s Sex Male Female

Subscriber’s DOB Subscriber’s SSN Employer

ID Number Group Number

Relationship to Patient Self Spouse Parent

2. SECONDARY Ins Co & Address

Subscriber’s Name Subscriber’s Sex Male Female

Subscriber’s DOB Subscriber’s SSN Employer

ID Number Group Number

Date

Account #

Provider #

PATIENT INFORMATION

PATIENT NAME:

Family Doctor: Family Doctor Phone:

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

What body part is involved? Please mark below:

Neck and R arm R R R R R R

radiates L arm Shoulder Elbow Hand Pelvis Knee Foot

to neither L L L L L L

Back and R leg R R R R R R

radiates L leg Arm Wrist Finger Hip Ankle Toe

to neither L L L L L L

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

Bending how severe is your pain? Standing Twisting

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

Lifting Lifting Bending Forward

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

Gradual onset No pain Constant Exercise/activity Squatting

Other Aching Comes and goes Kneeling Sitting

Burning Stabbing Coughing Driving/riding in car

Where were you hurt? Throbbing Stinging Sneezing Other

No injury Sharp Dull

Auto accident Other What makes your symptoms better?

Sports Resting Lying in bed/sleeping

Work Sitting Exercise

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

Other None Numbness Ice Medication

Bruise Tingling Other

Swelling

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

Weakness in leg X-rays

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

Days Loss of balance or falls CAT scan

Weeks Other Bone Scan

Months Nerve Test (EMG/NCV)

Years

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

Steroid injections None

Brace/cast Chiropractor

Physical/home therapy Pain Medication

Cane/crutch Epidural

Nerve root block Surgery

Anti-inflammatory

Seen another Physician for this problem?

Who?

XXX - PAIN

OOO - PINS, NEEDLES, NUMBNESS

7 VANDERBILT PARK DRIVEASHEVILLE, NC 28803

Phone: (828) 255-7776Fax: (828) 274-7855

Patient HIPPA Acknowledgment and Financial Consent Patient Name:

Patient DOB:

Notice of Privacy Practice/clinics

Patient / Representative Signature Relationship to Patient:

I acknowledge that I have received the Notice of Privacy Practice, which describes the ways in which the practice/clinic may use and disclose myhealthcare information for its treatment, payment, healthcare operations and other described and permitted uses and disclosures, I understand thatI may contact the Privacy Officer designated on the notice if I have a question or complaint. I understand that this information may be disclosedelectronically by the Provider and/or the Provider's business associates. To the extent permitted by law, I consent to the use and disclosure of myinformation for the purposes described in the Notice of Privacy Practice.

Disclosures to Friends and/or Family Members

DO YOU WANT TO DESIGNATE A FAMILY MEMBER OR OTHER INDIVIDUAL WITH WHOM THE PROVIDER MAY DISCUSS YOURMEDICAL CONDITION? IF YES, WHOM? I give permission for my Protected Health Information to be disclosed for purposes of communicatingresults, findings and care decisions to the family members and others listed below:Person Number 1:

Name: Contact Number: Relationship to Patient:

Person Number 2:


Person Number 3:


Patient/Representative may revoke or modify this specific authorization and that revocation or modification must be in writing.

Communications about My Healthcare

I agree the Provider or an agent of the Provider or an independent physician's office may contact me for the purposes of scheduling necessaryfollow-up visits recommended by the treating physician.

Consent for Photographing or Other Recording for Security and/or Health Care Operations

I consent to photographs, digital or audio recordings, and/or images of me being recorded for patient care, security purposes and/or thepractice's/clinic's health care operations purposes (e.g., quality improvement activities). I understand that the practice/clinic retains the ownershiprights to the images and/or recordings. I will be allowed to request access to or copies of the images and/or recordings when technologicallyfeasible unless otherwise prohibited by law. I understand that these images and/or recordings will be securely stored and protected. Images and/orrecordings in which I am identified will not be released and/or used outside the facility without a specific written authorization from me or my legalrepresentative unless otherwise permitted or required by law.

Consent to Email, Cellular Telephone, or Text Usage for Appointment Reminders and Other Healthcare Communications

If at any time I provide an email address or cellphone number at which I may be contacted, I consent to receiving unsecure instructions and otherhealthcare communications at the email or text address I have provided or you or your EBO Servicer have obtained, at any text number forwarded,or transferred from that number. These instructions may include, but not be limited to: post-procedure instructions, follow-up instructions,educational information, and prescription information. Other healthcare communications may include, but are not limited to, communications tofamily or designated representatives regarding my treatment or condition, or reminder messages to me regarding appointments for medicalcare.Note: You may opt out of these communications at any time. The practice/clinic does not charge for this service, but standard text messagingrates or cellular telephone minutes may apply as provided in your wireless plan (contact your carrier for pricing plans and details).

Note: This location uses an Electronic Health Record that will update all your demographics and consents to the information that you justprovided. Please note this information will also be updated for your convenience to all our affiliated locations that share an electronic health recordin which you have a relationship.

Page Number: 1Total Number of Pages: 3


Phone: (828) 255-7776Fax: (828) 274-7855

Patient HIPPA Acknowledgment and Financial Consent Patient Name:

Patient DOB:

Release of Information.

I hereby permit practice/clinic and the physicians or other health professionals involved in the inpatient or outpatient care to release healthcareinformation for purposes of treatment, payment, or healthcare operations.

Healthcare information regarding a prior service(s) at other HCA affiliated providers may be made available to subsequent HCA-affiliatedproviders to coordinate care. Healthcare information may be released to any person or entity liable for payment on the Patient's behalf inorder to verify coverage or payment questions, or for any other purpose related to benefit payment. Healthcare information may also bereleased to my employer's designee when the services delivered are related to a claim under worker's compensation.If I am covered by Medicare or Medicaid, I authorize the release of healthcare information to the Social Security Administration or itsintermediaries or carriers for payment of a Medicare claim or to the appropriate state agency for payment of a Medicaid claim. Thisinformation may include, without limitation, history and physical, emergency records, laboratory reports, operative reports, physicianprogress notes, nurse's notes, consultations, psychological and/or psychiatric reports, drug and alcohol treatment and discharge summary.Federal and state laws may permit this facility to participate in organizations with other healthcare providers, insurers, and/or other healthcare industry participants and their subcontractors in order for these individuals and entities to share my health information with oneanother to accomplish goals that may include but not be limited to: improving the accuracy and increasing the availability of my healthrecords; decreasing the time needed to access my information; aggregating and comparing my information for quality improvementpurposes; and such other purposes as may be permitted by law. I understand that this facility may be a member of one or more suchorganizations. This consent specifically includes information concerning psychological conditions, psychiatric conditions, intellectualdisability conditions, genetic information, chemical dependency conditions and/or infectious diseases including, but not limited to, bloodborne diseases, such as HIV and AIDS.

I certify that I have read and fully understand the above statements from all pages and consent fully and voluntarily to its contents.

Patient/Representative Signature Relationship To Patient Date

GENERAL CONSENT FOR CARE AND TREATMENT CONSENT

TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnosticprocedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risksand hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtainyour permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s). Thisconsent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, youare indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatmentrecommended; and (2) you consent to treatment at this office or any other satellite office under common ownership. The consent will remain fullyeffective until it is revoked in writing. You have the right at any time to discontinue services. You have the right to discuss the treatment plan withyour physician about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test ortreatment recommend by your health care provider, we encourage you to ask questions. I voluntarily request a physician, and/or mid-level provider(nurse practitioner, physician assistant, or clinical nurse specialist), and other health care providers or the designees as deemed necessary, toperform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice.I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consentforms prior to the test(s) or procedure(s). I certify that I have read and fully understand the above statements and consent fully and voluntarily toits contents.




Phone: (828) 255-7776Fax: (828) 274-7855

Patient Consent for Financial Communications

Patient Name:

Patient DOB:

Financial Agreement

I acknowledge, that as a courtesy, the practice/clinic may bill my insurance company for services provided to me.I agree to pay for services that are not covered or covered charges not paid in full including, but not limited to any co-payment, co-insurance and/or deductible, or charges not covered by insurance.I understand there is a fee for returned checks.

Third Party Collection. I acknowledge the practice/clinic may use the services of a third-party business associate or affiliated entity as anextended business office (“EBO Servicer”) for medical account billing and servicing.

Assignment of Benefits. I hereby assign to the practice/clinic any insurance or other third-party benefits available for health care servicesprovided to me. I understand the practice/clinic has the right to refuse or accept assignment of such benefits. If these benefits are not assigned tothe practice/clinic, I agree to forward all health insurance or third-party payments that I receive for services rendered to me immediately uponreceipt.

Medicare Patient Certification and Assignment of Benefit . I certify that any information I provide, if any, in applying for payment underTitle XVIII (“Medicare”) or Title XIX (“Medicaid”) of the Social Security Act is correct. I request payment of authorized benefits to be made on mybehalf to the practice/clinic by the Medicare or Medicaid program.

Consent to Telephone Calls for Financial Communications. I agree that, in order for the practice/clinic, or Extended Business Office (EBO)Servicers and collection agents, to service my account or to collect any amounts I may owe, I expressly agree and consent that the practice/clinicor EBO Servicer and collection agents may contact me by telephone at any telephone number, without limitation of wireless, I have provided or thepractice/clinic or EBO Servicer and collection agents have obtained or, at any phone number forwarded or transferred from that number, regardingthe services rendered, or my related financial obligations. Methods of contact may include using pre-recorded/artificial voice messages and/or useof an automatic dialing device, as applicable.

A photocopy of this consent shall be considered as valid as the original.




Phone: (828) 255-7776Fax: (828) 274-7855

Carolina Spine & Neurosurgery Center Narcotic Prescription Policy

Due to the increasing rate of narcotic dependence/abuse nationwide, we at Carolina Spine & Neurosurgery Center have developed a NarcoticPrescription Policy limiting the use of these drugs in accordance with DEA and FDA guidelines.

Please read this document carefully as this policy will be strictly enforced.

**This policy is meant to inform all patients of Carolina Spine & Neurosurgery Center’s Narcotic Policy and does not negate or supersede anotherpain management agreement with another provider or organization. **

Carolina Spine & Neurosurgery Center will only provide pain medication for patients while they are under the active care of one of our providers.Our practice does not provide long-term pain management services.

The following provides an outline of our prescription and pain medication policy:

MEDICATION POLICY

Pain medication must be taken as prescribed. Patients should not increase the medication dosage or frequency without consulting a physician orphysician’s assistant of Carolina Spine & Neurosurgery Center.

Unless the patient is under an active treatment plan, we require that the patient has been seen by one of our health care providers in the priorthree months. If the patient has not seen us within the recommended time frame for follow-up, an appointment may be necessary before refills canbe authorized.

If it is determined that the patient requires surgical intervention, pain medication will be prescribed prior to surgery if needed. During the surgicalrecovery phase, the amount of medication will be gradually reduced to help the patient avoid a dependency of the drug.

Carolina Spine & Neurosurgery Center strictly adheres to the guidelines of the STOP Act of 2017:

The Strengthen Opioid Misuse Prevention (STOP) Act of 2017 was recently signed into law in order to combat the opioid epidemicthat has had a severe impact in North Carolina. Several provisions apply to North Carolina Medical Board licensees prescribing targetedcontrolled substances. Practitioners cannot prescribe more than a five-day supply of any Schedule II or Schedule III opioid or narcotic upon the initialconsultation and treatment of a patient for acute pain unless the prescription is for post-operative acute pain relief for immediate usefollowing a surgical procedure, in which case the prescription cannot exceed a seven-day supply.Upon subsequent consultation for the same pain, practitioners may issue any appropriate renewal, refill, or new prescription for a targetedcontrolled substance.

If long-term pain management is required, the patient will be referred to a pain clinic or to his or her primary care physician.

PRESCRIPTION REFILL POLICY

Patients are strongly encouraged to plan ahead! Please avoid waiting until your medication has almost run out before contacting our office for arefill.

All requests for prescriptions or refills of medications must be completed during regular office hours.

Our providers are not always in clinic when the patient calls, so we require a 24 hour notice for your prescription refills. Refill requests made after3:00 pm on Friday will not be filled until the following Monday.

For patient safety, Carolina Spine & Neurosurgery Center requires the patients to get their pain medications from one medical doctor only. Prior toreceiving a narcotic prescription, all patients will be screened through the North Carolina Controlled Substances Reporting System (NC CSRS).

**Please note that narcotics will not be refilled after hours, on weekends, or on National Holidays. **

Patient name Patient DOB

Patient signature Date

Witness signature Date

Account #

Carolina Spine & Neurosurgery Center

An Affiliate of Mission Health

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

**PLEASE PRINT ALL REQUESTED INFORMATION**

Patient Name:

Date of Birth: / /

Pharmacy Name:

Street Name:

City: State:

Phone Number (if known):

Documents

IMPORTANT PATIENT NOTICE