Download 1 Please bring the following items with you the day of your

17 Western Maryland Parkway, Suite 100
Hagerstown, MD 21740
755 Norland Avenue, Suite 102
Chambersburg, PA 17201
Phone: 301-797-9240
Fax: 301-797-0008
Toll Free: 1-800-797-3666
www.pnsi.org
Dear Patient:
Your appointment with Dr.
at
is scheduled for
.
Please bring the following items with you the day of your appointment, if applicable:
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Your insurance card(s)
Your driver's license (or other photo identification)
Any radiology films (MRI, CT, X-rays, etc . . .) You may bring the actual films or a CD. Also a copy of the
report. If you do not have your films/CD, your appointment will be rescheduled.
Any test results related to your problem.
The enclosed Patient Information and Patient History forms filled out completely.
A referral from your primary care physician if you belong to an HMO or managed care plan. Your
insurance company will not allow our physician to see you without your referral.
If you are claiming an injury from an auto accident or workmen's compensation accident, please bring
complete billing information with you: the name, address and phone number of the insurance company,
the claim number, and the authorization for your consultation. If you do not bring all the above
information, your appointment will be rescheduled.
We accept many insurance plans, HMO's, and Medicare. We will submit these claims to your insurance
company.
We do ask that you be prepared to pay any applicable co-payment at the time of service.
If you have any questions prior to your appointment, please call our office at 301-797-9240 or
1-800-797-3666 between 8:30 am and 4:15pm. Thank you.
OFFICE LOCATIONS
Parkway Neuroscience & Spine Institute is located just West of Hagerstown off Route 40 at 17 Western
Maryland Parkway, Suite 100. It is just several blocks from the Centre at Hagerstown Shopping Center and
down the street from First Data Corporation. A satellite office is located at the Keystone Pavilion in Chambersburg.
Please see the reverse side of this page for detailed directions.
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NPP Rev 5/11
DIRECTIONS:
HAGERSTOWN, MARYLAND
17 WESTERN MARYLAND PARKWAY, SUITE 100
From the North (Chambersburg, Carlisle and Harrisburg)
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Follow I-81 South to Maryland Exit 6 (Route 40)
Travel East towards Hagerstown and take the first right onto Western Maryland Parkway.
The Institute is located on your right just past First Data Corporation.
From the North (Waynesboro)
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Follow Route 66 (Leitersburg Pike) South to Maryland Route 40 (Franklin Street)
Travel West towards I-81 and the Centre at Hagerstown Shopping Center and turn left onto
Western Maryland Parkway
The Institute is located on your right just past First Data Corporation
From the South (Martinsburg, Winchester)
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Follow I-81 North to Maryland Exit 6 (Route 40)
Travel East towards Hagerstown and take the first right onto Western Maryland Parkway.
The Institute is located on your right just past First Data Corporation.
From the West (Cumberland)
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Take I-70 East to I-81 and travel North to Maryland Exit 6 (Route 40)
Travel East towards Hagerstown and take the first right onto Western Maryland Parkway.
The Institute is located on your right just past First Data Corporation.
From the East (Frederick, Shady Grove, Germantown)
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Take I-70 West to I-81 and travel North to Maryland Exit 6 (Route 40)
Travel East towards Hagerstown and take the first right onto Western Maryland Parkway.
The Institute is located on your right just past First Data Corporation.
CHAMBERSBURG, PENNSYLVANIA
755 NORLAND AVENUE, SUITE 102
From the North (Carlisle, Harrisburg)
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81 South to Chambersburg Exit 17
Right onto Walker Road
Right onto Norland Avenue
Right into Summit Health Campus
First building on the left - Summit Keystone Pavilion
From the South (Maryland, West Virginia)
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81 North to Chambersburg Exit 17
Left onto Walker Road
Right onto Norland Avenue
Right into Summit Health Campus
First building on the left - Summit Keystone Pavilion
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Date____________________
PATIENT INFORMATION
Last Name______________________________First__________________________Middle_____________
Address________________________________City__________________________State_____Zip_______
Home Phone# (____)_______________ Cell# (____)_______________ Work# (____)_________________
Date of Birth _____/_____/_____ Age_____ Social Security #___________________Sex (circle) M F
Marital Status (circle) Married Single Widow(er) Divorced Separated
Primary Care Physician _________________Address____________________________________________
Office Phone # (must be completed)(_____)_______________________
Referring Physician_____________________Address___________________________________________
Office Phone # (must be completed) (_____)_______________________
Employer ____________________________Address____________________________________________
Occupation __________________________Work Phone # (_____)___________________________
Spouse or Parent’s Name______________________ Date of Birth _____/_____/_____
Spouse or Parent’s Occupation_________________ Employer____________________________________
Employer’s Address__________________________________ Employer’s Phone # (_____)_____________
EMERGENCY CONTACT
Name___________________________Relationship____________________Phone #(_____)____________
INSURANCE INFORMATION
PPO/HMO/Commercial__________________________________________________________________
Name of Insurance Co.
Policy Number
Address
Do you have Medicare? (circle) Yes No If yes, Medicare #________________ Effective date_______
Do you have Medicaid? (circle) Yes No If yes, Medicaid #________________Effective date________
Is Medicare your primary or secondary insurance? (circle) Primary Secondary
Is Medicaid your primary or secondary insurance? (circle) Primary Secondary
Medicare Supplemental Insurance:________________________________________________________
Name
Address
Policy Number
Does your insurance require a second surgical opinion?
Yes No
Does your insurance require precertification?
Yes No
If yes, please supply your insurance’s phone number (_____)_________________________
Is this a work related injury? Yes No
If yes, date of accident _____/_____/_____
Claim#____________________ Compensation Insurance______________________________________
Carrier’s Address __________________________________Phone# (_____)______________________
Claim’s Representative______________________________ Employer’s Name____________________
Is this injury related to a motor vehicle accident? Yes No If yes, date of accident_____/____/_____
Auto Insurance Carrier_______________________________ Policy #____________________________
Auto Insurance Address _____________________________Phone # (____)_______________________
________________________________________
Date________________
Signature of patient or legal guardian (Required for Medicare, Medicaid, and Commercial Insurances)
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Please read carefully and sign the section(s) that apply to you:
Non-Medicare patients:
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All charges are due at the time professional services are rendered.
The patient is responsible for all fees.
The fee ticket may be used to file insurance claims.
For guardian of a minor: I understand that I am fully responsible for this minor’s medical charges
and agree to pay all charges for services rendered by Parkway Neuroscience & Spine Institute.
I hereby authorize Parkway Neuroscience & Spine Institute to furnish information to any insurance
company or authorized agency specified regarding information concerning my medical care.
For those services provided and submitted to my insurance company, I hereby authorize payment of
medical benefits to Parkway Neuroscience & Spine Institute.
Signature:_________________________________
Date:________________________
Medicare Patients Only:
I authorize any holder of medical or other information about me to release to the Social Security
Administration and Health Care Financing Administration or its intermediaries or Carriers any
information needed for this or related Medicare claim. I permit a copy of this authorization to be
used in place of the original and request payment of medical insurance benefits to the party who
accepts assignment. Regulations pertaining to Medicare assignment of benefits apply. I also
understand that I am responsible for the deductible, coinsurance, and any non-covered services as
determined by Medicare.
Signature:_________________________________
Date:________________________
Medicare Supplemental Insurers’ MEDIGAP Assignment of Benefits:
Section 4081 of the Omnibus Budget Reconciliation Act of 1987 provides an additional participation
incentive for participating physicians by providing payment directly for assigned Medicare
supplemental (MEDIGAP) insurance benefits.
I understand my signature gives authorization for my physician to bill claims directly to my
recognized MEDIGAP insurance carrier and for payments to be received directly. This allows
for medical information to be forwarded to the insurance carrier as necessary.
The Explanation of Medicare Benefits received from Medicare will display the following message to
notify you that a claim has been submitted to your MEDIGAP carrier: “Because you are assigned
MEDIGAP benefits, information regarding your claim will be sent to your private insurer within
30 days.” I also understand that any deductibles, coinsurances, and non-covered services will be
my responsibility.
Signature:_________________________________
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Date:______________________
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Patient Name:_____________________________________ Date of Birth:_________________________________
Marital Status:
□ Single
□ Married
□ Divorced
□ Widowed
Height:_____________________________________Weight:_____________________________________________
Referring Doctor:____________________________Primary Care Dr.:_____________________________________
Preferred Pharmacy: (name/address)__________________________________________________________________
ALLERGIES:
Do you have any drug allergies? □ Yes □ No
If yes, please describe the allergy and the reaction:_____________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Do you have any other allergies we should know about? □ Yes □ No
If yes, please describe the allergy and the reaction:_____________________________________________________
_____________________________________________________________________________________________
FAMILY HISTORY:
Family Member
Mother
Father
Sister/Brother (please circle)
Sister/Brother (please circle)
Sister/Brother (please circle)
Alive/Deceased
A
D
A
D
A
D
A
D
A
D
Age
Medical Problems
Are there diseases which are common in your family? (If yes, please list.)___________________________________
_____________________________________________________________________________________________
Has any family member had a history of surgery for their back or neck, or had problems with their back or neck?___
_____________________________________________________________________________________________
_____________________________________________________________________________________________
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PAST MEDICAL HISTORY: Please circle yes or no.
Y
N
Use of Blood Thinners
Y
N
Anxiety Disorder
Y
N
Aortic Aneurysm
Y
N
Arthritis
Y
N
Asthma
Y
N
Bipolar Disorder
Y
N
Cancer _____________________________
Y
N
Congestive Heart Failure
Y
N
COPD (Chronic Obstructive Pulmonary Disease)
Coronary Artery Disease
Y
N
Y
N
Stroke (CVA)
Y
N
Degenerative Joint Disease
Y
N
Depression
Y
N
Diabetes
Y
N
Fibromyalgia
Y
N
Glaucoma
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Head Injury, with skull fracture
Head Injury, without skull fracture
HIV
High Cholesterol
High Blood Pressure
Heart Attack
Infectious Diseases (i.e. MRSA, TB)
Osteoarthritis
Osteoporosis
Rheumatoid Arthritis
Seizure Disorder
Sleep Apnea
Thyroid Disease
Tuberculosis
Vertebral Artery Stenosis
Complications from any surgery? □ Yes □ No Please explain:_________________________________________
_____________________________________________________________________________________________
Do you take antibiotics before procedures? □ Yes □ No Why:_________________________________________
_____________________________________________________________________________________________
PAST SURGICAL HISTORY: Please list all previous surgical procedures and date your surgery was performed.
□ Carpal Tunnel_____________________________
□ Spinal Cord Injury____________________________
□ Craniotomy_______________________________
□ Spinal Cord Stimulator_________________________
□ Disectomy________________________________
□ Spinal Fusion-Cervical_________________________
□ Endarterectomy____________________________
□ Spinal Fusion-Lumbar_________________________
□ Intrathecal Pump___________________________
□ Spinal Fusion-Thoracic________________________
□ Kyphoplasty______________________________
□ Ulnar Nerve Release___________________________
□ Laminectomy-Cervical______________________
□ Vertebroplasty________________________________
□ Laminectomy-Lumbar______________________
□ Other_______________________________________________________________________________________
□ Appendectomy____________________________
□ Hysterectomy________________________________
□ C-Section________________________________
□ Sinus Surgery________________________________
□ Gall Bladder Removal______________________
□ Pancreatic Surgery____________________________
□ Dental___________________________________
□ Prostatectomy________________________________
□ D&C____________________________________
□ Large Bowel Resection_________________________
□ Eye Surgery_______________________________
□ Small Bowel Resection_________________________
□ Fracture Repair____________________________
□ Stomach Resection____________________________
□ Heart Surgery_____________________________
□ Rotator Cuff Repair___________________________
□ Angioplasty____________________________
□ Thyroidectomy_______________________________
□ Bypass________________________________ □ Subtotal__________________________________
□ Stent__________________________________ □ Total____________________________________
□ Valve Replacement______________________
□ Tonsillectomy________________________________
□ Other_________________________________
□ Tubal Ligation_______________________________
□ Hernia Repair_____________________________
□ Vasectomy___________________________________
□ Other_______________________________________________________________________________________
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SOCIAL HISTORY:
Occupation:____________________________________________________________________________________
A: Physically, do you consider your job: □ Heavy
□ Moderate
□ Light
B: If retired, what was your prior occupation?___________________________________________________
Is someone available to care for you in your home if the need arises? □ Yes □ No
Do you live in a: □ House
□ Apartment
□ Other:_____________# of stories: 1 2 3
Do you exercise regularly? □ Yes □ No Describe:__________________________________________________
Do you have a history of drug abuse or drug addiction? □ Yes □ No
Alcohol Use:
I use alcohol: □ Never □ Occasional □ Moderate □ Heavy
I have a history of heavy alcohol use: □ Yes □ No
Tobacco Use:
Do you smoke? □ Yes □ No
I currently smoke___packs per day and have for___years.
I smoked in the past___packs per day for___years.
Are you at risk for AIDS (e.g. sexual history, drug use, previous transfusion)? □ Yes □ No
CURRENT MEDICATIONS: Please list all.
Medication
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REASON FOR VISIT:
Describe your current problem and how it began. Please list all symptoms leading to today’s visit:_______________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Date symptoms began:___________________________________________________________________________
Is your current problem a result of: □ Car Accident
□ Work Accident
□ Other/Unknown
Date of injury/accident:___________________________________________________________________________
Are you currently off work because of your problems? □ Yes □ No
Is a lawyer involved in your case? □ Yes □ No If yes, name of lawyer:__________________________________
PAIN HISTORY: (if not applicable, skip to next section)
What makes your symptoms better?_________________________________________________________________
What makes your symptoms worse?_________________________________________________________________
What specific activities are you having difficulty with that you hope to change as a result of treatment?___________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
In order to get better, you will be expected to participate in your treatment. This may include doing exercises or
avoiding certain activities. How committed are you to participating in your treatment?
□ Very committed □ Somewhat committed □ Not very committed
Is there anything that will limit your ability to participate in therapies? □ Yes □ No
Explain:_______________________________________________________________________________________
_____________________________________________________________________________________________
What tests have you had done for your problem? □ X-rays □ CT scan □ MRI □ Blood tests
□ Other:______________________________________________________________________________________
What treatments have you had for your problem? □ Medications □ Physical Therapy □ Chiropractic □ Injections □ Surgery □ Other________________________________________________________________________
Please describe their effect:_______________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Would you consider surgery if it were recommended? □ Yes □ No
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REVIEW OF SYSTEMS: Please circle yes or no.
General:
Y
Y
Y
N
N
N
Weight Gain greater than 10 lbs.
Weight Loss greater than 10 lbs.
Obesity
N
Bruising
Skin:
Y
HEENT:
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
Blurred Vision
Head Injury
Double Vision
Visual Disturbances
Visual Loss
Hearing Loss
Ringing in the Ears
Seasonal Allergies
Hoarseness
N
N
Neck Mass
Swollen Glands
Neck:
Y
Y
Respiratory:
Y
Y
N
N
Chronic Cough
Difficulty Breathing
Breast:
Y
N
Nipple Discharge
Cardiovascular:
Y
N
Chest Pain
Y
N
Irregular Heart Beat
Y
N
Elevated Blood Pressure
Y
N
Rapid Heart Rate
Y
N
Shortness of Breath
Y
N
Swelling of the Feet
Gastrointestinal:
Y
N
Change in Bowel Habits
Y
N
Indigestion
Y
N
Jaundice
Y
N
Nausea
Y
N
Vomiting
Genitourinary:
Y
N
Change in Bladder Habits
Y
N
Frequency
Y
N
Hesitancy
Y
N
Incontinence
Musculoskeletal:
Y
N
Back Pain
Y
N
Muscle Cramps
Y
N
Arm Weakness
Y
N
Arm Pain
Y
N
Leg Weakness
Y
N
Leg Pain
Y
N
Neck Pain
Y
N
Neck Stiffness
Neurological:
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
Decreased Memory
Difficulty Speaking
Dizziness
Fainting
Headaches
Incoordination
Loss of Consciousness
Seizures
Stroke
Weakness in Extremities
Leg Pain with Walking
Psychiatric:
Y
Y
Y
N
N
N
Anxiety
Depression
Inability to Concentrate
Endocrine:
Y
N
Thyroid Problems
Hematology:
Y
Y
Y
N
N
N
Abnormal Bleeding
Anemia
Blood Clots
Other:________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
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THE ABOVE INFORMATION IS ACCURATE TO THE BEST OF MY KNOWLEDGE
_____________________________________________
Patient signature _____________________________________________
Date
I HAVE REVIEWED THE ABOVE INFORMATION (PARKWAY OFFICE USE ONLY)
_____________________________________________
Physician Signature
_____________________________________________
Date
_____________________________________________
Physician Name (printed)
_____________________________________________
Date reviewed & initials
_____________________________________________
Date reviewed & initials
_____________________________________________
Date reviewed & initials
_____________________________________________
Date reviewed & initials
_____________________________________________
Date reviewed & initials
Revised 8/2010
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Parkway Neuroscience and Spine Institute
NPP Rev 5/11