HEALTH INSURANCE INFORMATION (Please provide copies of all insurance cards) PRIMARY INSURANCE POLICY # GROUP # PHONE #

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1 PATIENT INFORMATION LAST NAME FIRST NAME MI (PLEASE PRINT) ADDRESS CITY STATE ZIP CODE HOME # CELL # WORK # DATE OF BIRTH SEX SOCIAL SECURITY # MARTIAL STAUS REFERING PHYSICIAN/ PRIMARY CARE PHYSICIAN PHONE # FOUND ON WEBSITE /INTERNET REFERED BY FRIEND /FAMILY REASON FOR VISIT Name: IS THIS RELATED TO AN ACCIDENT? TYPE OF ACCIDENT? DATE OF INJURY YES NO AUTO EMPLOYMENT RELATED OTHER IN CASE OF EMERGENCY, CONTACT (Name of friend or relative not living with you) LAST NAME FIRST NAME MI RELATIONSHIP ADDRESS CITY STATE ZIP CODE HOME # CELL # WORK # HEALTH INSURANCE INFORMATION (Please provide copies of all insurance cards) PRIMARY INSURANCE POLICY # GROUP # PHONE # POLICY HOLDER NAME POLICY HOLDER DATE OF BIRTH RELATIONSHIP SECONDARY INSURANCE POLICY # GROUP # PHONE # POLICY HOLDER NAME POLICY HOLDER DATE OF BIRTH RELATIONSHIP The above information is true to the best of my knowledge. I authorize treatment for the above- mentioned individual or myself and I understand that I am ultimately responsible for charges associated with medical services and agree to pay all bills within 30 days from receipt of a statement, unless other arrangements are made. INSURANCE AUTHORIZATION AND ASSIGNMENT (Please read and sign) I hereby authorize Texas Spine & Neurosurgery Center, P.A. to furnish information to insurance carriers concerning my illness and treatment and I hereby assign all payments for all medical services rendered to the above-mentioned individual or myself. I understand that I am responsible for all charges regardless of insurance coverage. SIGNATURE Conti.. DATE

2 We are committed to providing you with the best possible care. If you have medical insurance we are eager to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance, and your understanding of our payment policy. 1. PRIVATE INSURANCE: All contracted insurance companies are billed directly as a courtesy. Any remaining balance for non-covered benefits and deductibles are your responsibility. Payment for this is expected within 30 days from receipt of your statement. 2. CO-PAYS: All co-pays are expected at the time the service is rendered. 3. REFFRALS: All referral for the each office visit are your responsibility and you need to provide a copy or make sure your PCP sends us a copy before services are provided. In absence of the referral office visit is your responsibility and the charges need to be paid in full before services are rendered. 3. METHOD OF PAYMENT: We accept cash, checks, or cashier checks. 4. PAYMENT ARRANGEMENTS: We understand that there may be times when financial difficulties come upon us without warning. Under special circumstances temporary payment arrangements may be made if approved in advance. Accounts on a temporary payment plan are required to make payment each and every month. Missed payments could result in collections. Accounts on a payment plan also must continue to pay at the time of the service. Our goal is to help you from attaining a greater debt and to assist you by keeping your account at a manageable level. 5. NO SHOW/CANCELLATION POLICY: There may be a fee for no-show appointments or cancellation of appointments without 24-hour notice. If you have any questions about the above information or any uncertainty regarding insurance coverage, PLEASE don't hesitate to ask us. We are here to help you. Print Name: Signature: Date:

3 MEDICAL HISTORY GENERAL INFORMATION NAME: AGE: MALE FEMALE HT: WT: RIGHT-HANDED LEFT -HANDED NAME OF FAMILY DOCTOR: REASON FOR OFFICE VISIT Injury/Date of Injury Illness/Date Illness began Symptoms/Date symptoms began Second Opinion/IME How would you describe your symptoms since they began? BETTER WORSE CHANGE What symptoms do you have today? How did this problem begin? (Give details) Do you have urinary or fecal incontinence? YES Do you have foot drop or paralysis? YES Were you treated or seen at a hospital emergency room or urgent care center for this injury/illness? YES Where?/When? Have you received further treatment for this injury/illness? YES Check any of the following tests or treatments you have had for this illness or injury? (Specify when and where tests or treatments were done.) Blood tests or lab tests X-Rays CT or MRI scan Physical therapy Chiropractic care Epidural Steroid Injections

4 PATIENT NAME: REASON FOR OFFICE VISIT (continued) Are you able to do everything you did before the injury/illness? (Explain NO answers) YES NO Drive Housework Yard work Sports Hobbies Second job Sex Have you ever seen a doctor for neck or back problems? YES If yes, specify problem, doctor, date, and any surgery. MEDICATIONS Are you taking any medications for this injury/illness, including medications from a doctor or over-the-counter medications such as aspirin, Tylenol, or Advil? YES If yes, specify medications. Are you taking medications now for any other reason (including vitamins, birth control pills)? YES If yes, specify medications. Do you drink or eat any beverages or food that contain caffeine? YES If yes, specify. Coffee Tea Cola Chocolate How much per day? FAMILY HISTORY Has anyone in your family had any of the following conditions (please explain who and what they had)? NO YES Cancer Heart problems Diabetes Kidney disease Depression/mental problems Alzheimer s/memory loss High blood pressure Stroke/brain tumor/aneurysm Lung problems Parkinson s Multiple Sclerosis Other Problems

5 PATIENT NAME: PERSONAL MEDICAL HISTORY Do you have a history of medical problems or surgery of the following (please explain)? NO YES Eyes Ears Skin Heart Circulation/Blood flow Lungs/Asthma Stomach Bowels/Intestines Kidneys Uterus/Prostate Depression/Mental problems Arthritis/Joints Blood clots/other problems High blood pressure Diabetes Cancer Brain seizures/epilepsy Headaches/Migraines Dizziness/Fainting Hepatitis Other problems Have you ever had any neck or back operation/surgery? YES When/Where? Is there any reason you cannot receive blood or blood products? YES Explain. Do you have any allergies (medication, iodine, tape, latex, creams, dust, food, animals, pollen, etc.)? YES Specify allergies. Do you have problems falling asleep or staying asleep? YES Explain. FEMALE PATIENTS Are you pregnant? NO YES Due date? Have your periods stopped? NO YES Have you had your uterus and/or ovaries surgically removed? NO YES Do you take hormones? NO YES

6 PATIENT NAME: LIFESTYLE/SOCIAL Do you use any tobacco products? YES Specify: Cigarettes Snuff Tobacco Cigars Pipe How much per day? How many years? Did you use any tobacco products in the past? YES Specify: Cigarettes Snuff Tobacco Cigars Pipe How much per day? When did you quit? Do you drink alcohol? YES Specify: Beer Wine Liquor How much per day? How many years? Did you drink alcohol in the past? YES Specify: Beer Wine Liquor How much per day? When did you quit? Have you ever received treatment for drug and/or alcohol problems? YES Specify when and where? Indicate your marital status: Single Married Widowed Other Do you live alone? YES Do have any children? If yes, indicate age(s) and whether they live at home. YES Age(s)? Do you have a relative with a physical or mental health problem living at home? If yes, indicate whether you take care of this relative. YES Explain. Do you exercise regularly? If yes, indicate the activity and how often you do it. YES Explain. WORK INFORMATION EMPLOYER Length of employment? JOB TITLE Does your job require you to perform the following activities: How long have you done this job? Lift pounds Sit Use a computer Lift over head Bend Drive a truck or forklift Reach over head Stand Are you working now? YES If no, how long have you been off work? If you are married, does your spouse work? YES If no, how long has he/she been off work? Patient s signature Date Physician s signature Date

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8 PATIENT AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION By signing this authorization, I authorize all of my previous healthcare providers and testing facilities disclose certain protected health information (PHI) about me to Texas Spine & Neurosurgery Center, P.A.. This authorization permits the use and/or disclosure of following individually identifiable health information about me: Hospital and office notes, and test results. The information will be used or disclosed in order to assist in my medical treatment. This authorization will not expire. The Practice will not receive payment or other remuneration from a third party in exchange for using or disclosing the PHI. I do not have to sign this authorization in order to receive treatment from Texas Spine & Neurosurgery Center, P.A. In fact, I have the right to refuse to sign this authorization. When my information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization. My written revocation must be submitted to the Privacy Officer at: South West Frwy., Ste 285 Sugar Land, TX Dr. Bindal and Dr. Park are active in the Sugar Land medical community. They have helped to develop some of the health care institutions in the area, offering increased choice to our residents. As such, they have an ownership interest in institutions such as St. Luke s Sugar Land Hospital. This involvement ensures that the highest level of care is given to our patients. Signed by: Signature of Patient Date Patient s Name If patient is a minor or unable to sign, then legal guardian must sign and indicate relationship to patient.