APPOINTMENT INFORMATION

Did a physician, PA, CNP or other provider send you to us for a consultation?   Yes   No   If yes, name of physician:

                         Did you make this appointment yourself:     Yes   No

Date of Accident/Injury (M/D/Y): //   OR  Date Symptoms began (M/D/Y): //

Type of Accident:    at work    at home    auto     other (explain): 

Name(s) of family, friends or others we may communicate with regarding your treatment, appointments, prescriptions, test results, billing and insurance questions, etc.:  

PATIENT INFORMATION

Name: (Last)  (First)  (M.I.)  

Mailing Address:  City:  State:  Zip:   

Date of Birth (M/D/Y)  //   Social Security Number - -   Marital Status:  

Home Phone ()  Cell Phone ()   Sex:  M   F   

Employer:    Position:   

Work Phone ()      Full Time    Part Time     No. of Years Employed:  

Spouse’s Name:  Employer:  Spouse’s SSN: -   -

Spouse’s Work Phone: ()   Cell Phone ()  

Person to call in case of an emergency:    Relationship:  

                                                                        (other than spouse)

Home Phone ()  Cell Phone ()  

PERSONAL HEALTH INSURANCE INFORMATION (Attach copy of your insurance card(s))

1^st Insurance to be billed:   Policyholders Name:  

DOB (Required if other than patient) (M/D/Y) : //    Effective Date of policy: Month Year  

Policy #:  Group #:   Employer:  

Insurance Claims Address:  

Phone Number: ()   Patient’s relationship to Policyholder:  

2^nd Insurance to be billed:   Policyholders Name:  

DOB (Required if other than patient)  Effective Date of policy: Month Year  

Policy #:  Group #:   Employer:  

Insurance Claims Address:  

Phone Number: ()   Patient’s relationship to Policyholder:  

MOTOR VEHICLE ACCIDENT (MVA) INSURANCE INFORMATION (If your appointment is the result of an MVA)

Notice: We do not bill third party motor vehicle insurance companies

Your MV insurance carrier (REQUIRED):   Claim #:  

Address:   Phone #:   Contact:  

Have you retained the services of an attorney in connection with your injury or illness?  Yes No

Attorney:   Phone #:  

WORKER’S COMPENSATION INSURANCE INFORMATION

If your appointment is the result of a work related injury or in connection with a worker’s compensation claim, please complete the information below. Your visit to our office must be authorized by the worker’s compensation insurance carrier or your employer prior to your appointment or we may be required to reschedule your appointment.

Employer at the time of your injury:   Phone #: ()  

Address:  Contact Person:  

Worker’s Compensation Insurer:   Contact Person:  

Address:  

Phone #: ()   Claim #:  

Case Manager:   Phone #: ()  

GUARANTOR OF PAYMENT

Please complete this section with parent or custodial information if the patient is a minor

Name: (Last)  (First)  (M.I.)

Address (City, State, Zip):   

Date of Birth (M/D/Y)  //  Social Security Number -   -   

Marital Status:  

Home Phone ()  Cell Phone ()   Sex:  M   F   

Employer:    Position:   

Work Phone ()      Full Time    Part Time     No. of Years Employed:  

AUTHORIZATION AND CONSENT

I certify that the information I have furnished is complete, true and accurate.

Signed:                                                                                                                           Date:                                                           

I certify that the information provided is unchanged from the original date of this registration.

Signed:                                                                                                                           Date:                                                           

 Acceptance of Financial Responsibility and Assignment of Benefits: I hereby authorize payment of benefits under my insurance plan(s) and/or any government-sponsored plan(s) directly to Neurosurgical & Spinal Surgery Associates, P.C. and/or its affiliates The Spine Center at Rapid City, Neurology Associates, Promotion Rehabilitation Center and Electrodiagnostic Services. I understand that I am responsible to Neurosurgical & Spinal Surgery Associates, P.C and/or its affiliates for amounts due, including those not paid by my insurance plan(s) due to their “maximum allowable” and/or “usual, reasonable and/or customary” guidelines. I understand I will be billed and held responsible for my account regardless of the status of any insurance claim. If I am a Medicare beneficiary, I certify that the information given by me in applying for payment under Title 18 of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim form. I request that payment of authorized benefits be made on my behalf.

Signed:                                                                                                                           Date:                                                           

Authorization to Release Protected Health Information: I hereby request and authorize Neurosurgical & Spinal Surgery Associates, P.C. and its affiliates The Spine Center at Rapid City, Neurology Associates, Promotion Rehabilitation Center and Electrodiagnostic Services to use or disclose my protected health information and/or other information to treat me, for requests by other health care providers involved in my continued or future treatment, to determine benefits, to authorize payment and to process claims for payment.  I further request and authorize any insurance company, organization, employer, hospital, physician, dentist or pharmacist to release any information required to process my claim(s) or to provide continued or future treatment.

Signed:                                                                                                                           Date:                                                           

Consent for Physical Therapy Treatment: Due to disease or injury, I consent to being treated through physical therapy. I understand that this treatment is directed toward improving my function and/or decreasing my pain. However, there is a chance my condition will not improve and there may be a risk of further injury. I understand that my therapist may work jointly with my physician(s) or other medical professionals to maximize therapeutic benefits.

Signed:                                                                                                                           Date: