1 Yevgeniy Khavkin, MD Center for Spine and Brain Health 653 N Town Center Dr Ste 308 Las Vegas, NV (702) Fax (702) Dear, Welcome to our practice. Your visit is with Yevgeniy Kkavkin, MD, a Board Certified Neurosurgeon. Appointment Date: Appointment Time am pm Please take the time to fill out the enclosed packet in its entirety, as Dr. Khavkin requires the information from these forms to provide you with the best care possible. Please return all forms to the front desk the day of your visit. Please have available at the time of your visit the following insurance and identification information: Your insurance identification card so that we may copy the front and back of the card for accurate insurance information. Your driver s license so that we may copy the card for accurate demographic and patient specific data. If you have a health plan that requires its own insurance claim form, please provide us with a signed and completed claim form. Your referral or authorization for services when applicable. If your insurance company requires a referral from your primary physician and you do not have one at the time of your visit, you may not be seen for your scheduled appointment, or you will be responsible for full payment of your bill at the time of service. In addition to the above, it is required that you bring the following to our office on the day of your appointment: The CD or films from any relevant X-ray, MRI or CT scan The reports from any previous nerve testing (EMG/NCS) The reports from any prior surgery you have had for this condition (if with another practice). The information from these items will allow Dr. Khavkin to develop a safe and effective treatment plan for your condition. Thank you for visiting our office and allowing us to become partners in your healthcare. Sincerely, Scheduling Department
2 PATIENT INFORMATION Patient Name Last First Middle DOB Marital Status Gender SSN: Single Married Life Partner Divorced Separated Widowed M F Home Address City State Zip / / Mailing Address City State Zip Home Phone ( ) - Cell Phone ( ) - Work Phone ( ) - Please Check Preferred Contact Number Race Asian/Pacific Islander Black Native American White Refuse to State Ethnicity Latino Non Latino Address Preferred Language Employer Occupation Full Time Part Time Retired Disabled Address City State Zip Emergency Contact Referring Physician Primary Care Physician Relationship to you Home Phone ( ) - Phone Phone Cell Phone ( ) - Fax Date of Injury / / How were you injured? Work Related Auto Accident Other Accident Not an accident Attorney Phone Fax Address City State Zip PRIMARY INSURANCE Company ID # Group # Address City State Zip Insured Name Relationship to Insured DOB SSN Self Spouse Child / / SECONDARY INSURANCE Company ID # Group # Address City State Zip Fax Insured Name Relationship to Insured DOB SSN Self Spouse Child / / WORKERS COMP PATIENTS Company Claim Number DOI Address City State Zip / / Adjuster Phone Fax The above information is accurate to the best of my knowledge. I hereby assign all medical and surgical benefits, to include major medical benefits to which I am entitled. I hereby authorize and direct my insurance carrier(s), including Medicare, private insurance and any other health/medical plan, to issue payment check(s) directly to Yevgeniy A Khavkin MD PC medical services rendered to myself and/or my dependents regardless of my insurance benefits, if any. I understand that I am responsible for any amount not covered by insurance. I hereby authorize Yevgeniy A Khavkin MD PC to release any information necessary to insurance carriers regarding my illness and treatments, process insurance claims generated in the course of examination or treatment, and allow a a photocopy of this assignment is to be considered as valid as the original. I have requested medical services from Yevgeniy A Khavkin MD PC on behalf of myself and/or my dependents, and understand that by making this request, I become fully financially responsible for any and all charges incurred in the course of the treatment authorized. I further understand that fees are due and payable on the date that services are rendered and agree to pay all such charges incurred in full immediately upon presentation of the appropriate statement. Patient Signature Date:
3 Yevgeniy Khavkin, MD Center for Spine and Brain Health 653 N Town Center Dr Ste 308 Las Vegas, NV (702) Fax (702) Patient Name: DOB: / / Date: / /201 Office Policies We are dedicated to providing you with the best possible care and service, and we regard your understanding of our office and financial policies as an essential element of your care and treatment. Please read the following carefully. If you have questions about your account, charges, insurance, or payments, please speak with one of our representatives. Office hours are 9:00am to 5:00pm Monday through Friday. All routine telephone calls to the office should be made during these hours. Insurance Plans If you are insured, we will bill those insurance plans with which we have an agreement. However, it is ultimately your responsibility to become familiar with the details of your insurance plan coverage. To find out what your insurance plan covers and what your financial obligation may be, we strongly recommended that you call the customer service or member services department of your insurance company (the phone numbers are on your insurance card) prior to your first visit. Your employer's human resources department may also be a source of information and assistance. We cannot guarantee payment to Yevgeniy A Khavkin MD PC. We have an agreement with you, not your insurance company for payment. If you have a PPO or HMO insurance plan, we will collect the required co-payment, co-insurance, and any deductible that is due at the time of the visit. In the event that your health plan determines a service to be noncovered, we will bill you, and payment is due upon receipt of that statement. Any amount not paid by your insurance company within 30 days will be billed to you. If your insurance coverage is with a plan that we do not have an agreement, payment is expected, in full, at the time of service. As a courtesy, we will submit a claim to your insurance company on your behalf. You are responsible to notify us of your insurance, any changes to your insurance, and to provide the necessary information about your insurance plan (or plans if you have more than one coverage); therefore, please have your current insurance card(s) with you at all times, as well as your prescription card (if different). Make sure that Yevgeniy A Khavkin MD is listed as a participating provider by your insurance company. Medicare Yevgeniy Khavkin MD PC is a participating Medicare provider. Not all Medicare patients have traditional Medicare. If you have signed up for a Medicare Advantage Plan, it is your responsibility to verify if Dr Khavkin is a participating provider with your specific plan. Most Medicare Advantage Plans require prior authorization or referrals from your primary care provider or IPA. If you have a Medicare Advantage Plan, you are responsible for obtaining prior authorization and/or referral for your initial visit. We will request authorization for follow up visits and surgeries. If you have traditional Medicare we will collect the estimated co-insurance at the time of service. If you have a Medicare Advantage Plan, we will collect your specialist co-pay at the time of service. Any amount not paid by your insurance company within 30 days will be billed to you. If your insurance coverage is with a plan that we do not have an agreement or if you do not have the required prior authorization, payment is expected, in full, at the time of service. As a courtesy, we will submit a claim to your insurance company on your behalf. Medicaid: Yevgeniy Khavkin MD PC is a participating Medicaid provider for Nevada Medicaid and Arizona Medicaid. Not all patients have traditional Medicaid. If you have signed up for a Medicaid HMO, it is your responsibility to verify if Dr Khavkin is a participating provider with your specific plan. Most Medicaid HMO Plans require prior authorization or referrals from your primary care provider or IPA. If you have a Medicaid HMO, you are responsible for obtaining prior authorization and/or referral for your initial visit. We will request authorization for follow up visits and surgeries. If your insurance coverage is with a plan that we do not have an agreement or if you do not have the required prior authorization, payment is expected, in full, at the time of service.
4 Patient Name: DOB: / / Date: / /201 Liens If you are involved in an auto accident or other personal injury, prior to seeing the physician, the following information must be obtained and verified prior to your visit: Date of Injury MedPay carrier information Case or claim number Adjuster s name Adjuster s telephone number Attorney Name Signed Lien I understand that if my care is on a lien, it is my responsibility to notify Yevgeniy A Khavkin MD if there is any change in my legal representation. Self-pay Accounts If you do not have a valid insurance plan to cover the cost of our services, you will be required to make full payment at the time of service. Workers Compensation If you are involved in an on-the-job work injury, prior to seeing the physician, the following information must be obtained and verified prior to your visit: Date of Injury Case or claim number Workers Compensation carrier information Adjuster s name Adjuster s telephone number Employer Payment Policy Payment in full is expected at the time service is rendered. For your convenience, we accept cash, check or credit cards. There is a $25.00 fee for each returned check. We will bill those insurance companies with which we have an agreement. Balances that exceed 90 days from the date of service may be charged a finance fee of 1.5% per month. Please note that in the event of non-payment, the account may be placed with an outside collection agency and the expenses will be added to your account balance. If you have any questions, please feel free to ask one of our representatives. I hereby authorize and request YEVGENIY A KHAVKIN MD PC to release my complete medical records (including x-rays) when referring to other facilities concerning my medical treatment. Released records may be sent via fax or by mail. I authorize release of all medical records to referring and primary care physicians and the insurance company as applicable. I authorize fax transmission of necessary medical records. I hereby assign to YEVGENIY A KHAVKIN MD PC all benefits for medical care payable under my medical insurance policy and/or policies. I authorize release of information from YEVGENIY A KHAVKIN MD PC to my insurance carrier for services billed. I understand that YEVGENIY A KHAVKIN MD PC agrees to bill my insurance as a courtesy and that I must submit information as needed to ensure payment for services. I further understand that I am ultimately responsible for payment for all services. Initial Initial Initial Initial Signature of Patient or Responsible Party Responsible Party Name (please print) Date Date
5 Yevgeniy Khavkin, MD Center for Spine and Brain Health 653 N Town Center Dr Ste 308 Las Vegas, NV (702) Fax (702) Date: / / RE: Request for Medical Information Patient Name: DOB: SSN: I hereby request that you release: All Medical Records Operative Reports NCV/EMG Reports Xray/MRI Reports Lab Work Office Notes Other TO: Yevgeniy Khavkin, MD 653 N Town Center Dr Ste 308 Las Vegas, NV (702) Fax (702) Patient/Legal Guardian Signature Date
6 Medical History Patient Name: DOB: / / Date: / /201 Primary Complaint: What problem(s) are you here to see the doctor about today? When did it begin? Was there a cause for this injury (accident, fall, moved heavy object, etc)? When is the problem worse (Specific activities, positions, time of day, etc)? When is the problem better (Specific activities, positions, time of day, etc)? What hobbies/chores/activities are you unable to do as a result of this problem? Is this problem interfering with you ability to fall or stay asleep? What is your employment status now? Full Time Part Time Retired Student Unemployed Unable to work due to pain Do you receive disability compensation of any kind? Y N What kind? Are you presently involved in any litigation related to this problem? Have you been treated for your present problem? YES NO When By whom? Have you had any prior studies for this problem? Please write the most recent dates for each: STUDY DATE(S) BODY PART STUDIED WHERE PERFORMED X-RAY MRI CT SCAN EMG Myelogram Bone Density Other
7 Medical History Patient Name: DOB: / / Date: / /201 Indicate which of the following you have tried for your pain and if it helped: Tried Helped Tried Helped Pain Clinic/Anesthesiologist YES NO YES NO Anti-inflammatory/Anti-Depressant YES NO YES NO Trigger Point Injections YES NO YES NO Chiropractic Therapy YES NO YES NO Epidural Steroid Injection YES NO YES NO Physical Therapy YES NO YES NO How long are you able to sit/stand comfortably? How far are you able to walk? Circle the words that describe you pain: Aching Sharp Penetrating Throbbing Gnawing Tender Nagging Shooting Burning Unbearable Numbness Stabbing Occasional Miserable Continuous Severity of your pain. Mark the point on the line between 0 (no pain) and 10 (worst pain) which describes how severe your pain is: Currently At its worst: At its least: Please make the area of your pain on the diagram below Front Back
8 Medical History Patient Name: DOB: / / Date: / /201 Are you: Married? Single? Children? Y N How many? Dominant Hand Right Left Do you use tobacco (smoke/chew)? Y N If yes, how much and for how many years Do you drink alcohol? Y N If yes how many drinks per day/week? Do you or have you ever used recreational drugs? Y N Which ones? Height: Weight: Have you experienced any sudden weight loss or gain? Y N Are you or could you be PREGNANT/NURSING? Date of last period Do you have any allergies (IE: medication, latex gloves, tape?) Y N If yes, please list them Prior Medical History (List all previous illness type and date) Prior Surgical History (list previous surgeries type and date) List previous Serious Injuries (i.e. fractures with date) The medical history information provided is accurate to the best of my knowledge. Patient Signature Date:
9 Medical History Patient Name: DOB: / / Date: / /201 Please check all that apply ( Family applies to parents, brothers and sisters) Condition You Family Condition You Family Cardiovascular Hematology Anemia Hepatitis Blood Clots HIV/AIDS Heart Attack Low Blood Sugar Murmur/Palpitations Sickle Cell High Blood Pressure Musculoskeletal Pacemaker/Defibrillator Fibromyalgia Chest Pain/Pressure Gout Shortness of Breath Lupus ENT Joint Pain Deafness Muscle Pain Deviated Septum Cramps Earaches Osteoarthritis Hay Fever/Allergies Rheumatoid Arthritis Loss of Hearing Trouble Walking Nosebleeds Osteoporosis Sinus Infections Neurological Sinus Problems Multiple Sclerosis Wear Dentures Alzheimer s disease Wear Hearing Aid Brain Disorder Endocrine Seizures/Epilepsy Diabetes Dizziness Thyroid Problem Fainting Spells Eyes Headaches Blindness Neuritis Cataracts Paralysis Dilated Pupil Stroke Eye Injury Side effected L R Glaucoma Psychiatric Corrective Lenses Confusion Eye Prothesis Memory Loss Gastrointestinal Depression Abdominal Bleeding Insomnia Colitis Respiratory Gallbladder Disease Asthma Hemorrhoids Bronchitis Indigestion Chronic Cough Jaundice Coughing Blood Loss of Bowel Control Emphysema Genitourinary Pain with Breathing Blood in Urine Pneumonia Kidney Stone Shortness of Breath Loss of Bladder Control Tuberculosis Bladder Problems Skin Sexual Problems Psoriasis Female Only Other Menstrual Problems Are you pregnant now Y N Nursing Y N Last Menstrual Cycle Postmenopausal Y N How many years? Male Only Testicular Pain
10 Medication List Patient Name: DOB: / / Date: / /201 Please include all prescribed medications, over the counter medications, vitamins, herbals, and supplements taken. This list will be updated at each visit. Date Medication Dose Frequency Taken Discontinued Pharmacy Name: Location: Phone: Fax:
11 Yevgeniy Khavkin, MD Center for Spine and Brain Health 653 N Town Center Dr Ste 308 Las Vegas, NV (702) Fax (702) PATIENT HIPAA ACKNOWLEDGEMENT AND DESIGNATION DISCLOSURE FORM Patient Name: DOB: / / Date: / /201 Acknowledgement of Practice s Notice of Privacy Practices: By subscribing my name below, I acknowledge that I was provided a copy of the Notice of Privacy Practices (NPP), and that I have read (or had the opportunity to read if I so chose) and understand the Notice of Privacy Practices (NPP) and agree to its terms. Signature of Patient or Personal Representative If Not Signed by Patient Print, Name of Personal Representative Date Description of Personal Representative s Authority Above signature was not obtained because: Patient is unable and unaccompanied by a representative. Patient left with all pertinent disclosures. Patient refused to sign. Patient refused forms. Designation of Certain Relatives, Close Friends and other Caregivers as my Personal Representative: I agree that the practice may disclose certain of my health information to a Personal Representative of my choosing, since such person is involved with my health care or payment relating to my healthcare. In that case, the Physician Practice will disclose only information that is directly relevant to the person s involvement with my health care or payment relating to my health care. Print Name Relationship to you Telephone# What we may disclose Any and all info Pre/Post Procedure instructions Appointment info only Any and all info Pre/Post Procedure instructions Appointment info only Any and all info Pre/Post Procedure instructions Appointment info only Request to Receive Confidential Communications by Alternative Means: As provided by Privacy Rule Section (b), I hereby request that the Practice make all communications to me by the alternative means that I have listed below. Home Phone OK to leave message with detailed information Cell Phone Address Leave message with call back number only OK to leave message with detailed information Leave message with call back number only me at address at left with detailed info with call back number only Signature of Patient or Personal Representative Date
12 YEVGENIY A KHAVKIN MD PC Notice of Privacy Practices Notice of Privacy Practices: This notice describes how information about you may be used and disclosed and how you can get access to this information. Please review it carefully. The privacy of your personal and health information is important. This requires no action on your part unless you have a request or complaint. Yevgeniy A Khavkin MD PC understands the importance of keeping your personal and health information private. Personal health information includes both medical information and individually identifiable information, such as your name, address, telephone number or social security number. We are required by applicable federal and state laws to maintain the privacy of your personal and health information. Both under law and by our policy, Yevgeniy A Khavkin MD PC has a responsibility to protect the privacy of your personal and health information (PHI). We will: Protect your privacy by limiting who may see your PHI; Limit how we may use or disclose your PHI; Inform you of our legal duties with respect to your PHI; Explain our privacy policies; and strictly adhere to the policies currently in effect. You have received this notice because you are under the care of, or are considering being treated by, or are considering being treated with, a product offered or administered by Yevgeniy A Khavkin MD PC, or a subsidiary, or affiliate of Yevgeniy A Khavkin MD PC. This is a notice of privacy practices, our legal duties, and your rights concerning your personal and health information. We follow the privacy practices that are described in this notice while it is in effect. This notice takes effect September 1, 2013, and will remain in effect until we replace it and provide you notice of such changes. We reserve the right to change our privacy practices and the terms of this notice at any time, as allowed by applicable law, rules and regulations. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all personal and health information that we maintain, including information we created or received before we made the changes. When we make a significant change in our privacy practices, we will make the notice available to our patients, upon request, on or after the effective date of the change. For more information about our privacy practices, or for additional copies of this notice, please contact our office at the number listed at the end of this notice. Uses and Disclosures of Patient s Personal and Health Information. As a patient of Yevgeniy A Khavkin MD PC, Yevgeniy A Khavkin MD PC may use and disclose your personal and health information, without your consent/authorization, in the following ways: Treatment: We may disclose your personal and health information to a doctor, a hospital or other entity, which asks for it in order for you to receive treatment. Payment: We may use and disclose your personal and health information to receive payment for services provided to you by our doctors, hospitals or other entities. Health Care Operations: We may use and disclose your personal and health information to conduct the following activities: To conduct quality improvements, including outcome evaluation and development of clinical guidelines, population-based activities, care coordination, case management, or utilization management activities. To review the competence or qualifications of health care professionals, conduct training programs of nonhealthcare professionals, accreditation, and certification, licensing or credentialing activities. To conduct or arrange for treatment review, legal services, audit functions and compliance programs. For business planning, conducting cost management and planning-related analyses, including formulary development and administration, or improvement of methods of payment or coverage verification policies. For business management activities, such as: customer service, resolution of internal grievances, due diligence in connection with the sale or transfer of assets to a potential successor in interest and for creating de-identified health information for fundraising and marketing for which an individual authorization is not required. Health & Wellness Information: We may use your personal and health information to contact you with information about health-related treatments and services, appointment reminders or about treatment alternatives that may be of interest to you.
13 Family and Friends: If you are unavailable to communicate, such as in a emergency or disaster relief, we may disclose your personal and health information to a family member, friend or other person to the extent necessary to help with your health care or with payment for your health care. Research: We may use or disclose your personal and health information for research purposes. Death: We may disclose the personal and health information of a deceased person to a coroner or medical examiner. Organ Donation: We may use or share information for procurement, banking or transplantation of organs, or tissue. Public Health and Safety: We may disclose your personal and health information to the extent necessary to avert a serious and imminent threat to your health or safety or the health or safety of others. We may disclose your personal and health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, domestic violence or other crimes. Required by Law: We must use or disclose your personal and health information when we are required to do so by law: For example, we must disclose your personal and health information to the U.S. Department of Health and Human Services upon request for purposes of determining whether we are in compliance with federal privacy laws. Process and Proceedings: We may disclose your personal and health information in response to a court or administrative order, subpoena, discovery request, or other lawful process. Law Enforcement: We may disclose limited information to law enforcement officials concerning the personal and health information of a suspect, fugitive, material witness or missing person. We may disclose the personal and health information of an inmate or other person in lawful custody to a law enforcement official or correctional institution. Military and National Security: We may disclose to military authorities the personal and health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials personal and health information required for lawful intelligence, counterintelligence, and other national security activities. Authorizing Use and Disclosure of Personal and Health Information: Yevgeniy A Khavkin MD PC will request written authorization from you to use your personal and health information or to disclose it to anyone for any purpose or situation not included in this document. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. We will not use or disclose your personal and health information for any reason except those described in this notice without your written authorization. Individual Rights for All Patients: As a patient, the following are your rights concerning your personal and health information: Access: You have the right to review or obtain copies of your personal and health information, with certain exceptions. You may submit this request in writing by obtaining a form using the contact information listed at the end of this notice. If you request copies, we may charge you a reasonable, cost-based fee. You will be made aware of any and all charges prior to imposing such fee. Disclosure Accounting: You have the right to receive a list of instances in which we or our subcontractors disclosed your personal and health information for purposes other than treatment, payment and healthcare operations. Effective September 1, 2013, we ll begin maintaining these types of disclosures for up to six (6) years. If you request this list more than once in a12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. You may submit this request in writing by obtaining a form using the contact information listed at the end of this notice. Restriction Requests: You have the right to request that we place additional restrictions on our use or disclosure of your personal and health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in a need for your emergency treatment). You also have the right to agree to or terminate a previous submitted restriction. You may submit this request in writing by obtaining a form using the contact information listed at the end of this notice.
14 Alternate Communication: You have the right to request that we communicate with you in confidence about your personal and health information by alternative means or to an alternative location. We will accommodate your request if it is reasonable and the request specifies the alternative means or location. If such a request is urgent, we will attempt to accommodate your request for alternative communications received verbally with the understanding that your written request follow at a later date. Routine requests may be submitted in writing by obtaining a form using the contact information listed at the end of this notice. Amendment: You have the right to request that we amend your personal and health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request if we did not create the information you want amended, we do not maintain the information or the information is deemed accurate and complete. If we deny your request, we will provide you a written explanation of the denial. If we accept your request to amend the information, we will make reasonable efforts to inform others of the amendment and to include the changes in any future disclosures of that information. You may submit this request in writing by obtaining a form using the contact information listed at the end of this notice. Electronic Notice: You have the right to receive this notice in written form upon request. Please contact us using the information listed at the end of this notice to obtain this notice in written form. If You Have a Complaint: If you are concerned that we may have violated your privacy rights or you disagree with a decision we made about access to your personal and health information, you may file a complaint with us using the contact information listed at the end of this notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health & Human Services upon request. If You Have a Request: If you would like to request a patient s rights form, place an urgent request for alternate communications or file a complaint regarding your privacy rights, you may contact us at: Yevgeniy A Khavkin MD PC Attn: Privacy Officer 653 N Town Center Dr Ste 308 Las Vegas, NV We support your right to protect the privacy of your personal and health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services. It has always been goal to ensure the protection and integrity of our patients' personal and health information. Therefore, we will notify you of any potential situations where your information would be used for reasons other than payment and health treatment operations.