Download Thank you for choosing Capital City Neurosurgery

CAPITAL CITY NEUROSURGERY
Roger H. Frankel, M.D.
Diplomate, American Board of Neurosurgical Surgery
Thank you for choosing Capital City Neurosurgery.
This packet contains forms that are vital to expedite a smooth registration process on your first
visit to Capital City Neurosurgery. It is important that you read and complete all the forms
enclosed in this packet prior to your appointment. Completed forms must be accompanied with
your MRI / CT films or CD. Your insurance card(s) and identification must be presented at the
time of your appointment to complete the registration process.
 Bring completed forms (All forms must be completed prior to your arrival)
 Bring your MRI / CT films or CD (This is very important!)
 Bring your Insurance card(s) and identification
It is best to arrive 30 minutes ahead of your scheduled appointment. This allows time for us to
review your completed forms as well as scan / copy your insurance and identification cards into
your registration file. Please feel free to contact me at (404) 350-7907 should you have any
questions.
We look forward to seeing you.
Thank you,
Monique Chen
Monique Chen
Administrative Assistant to
Roger H. Frankel, M.D.
Piedmont Spine Center
2001 Peachtree Road NE ♦ Suite 550 ♦ Atlanta, Georgia 30309
Telephone (404) 350-7907 ♦ (404) 352-8020
Facsimile (404) 367-1970 ♦ (404) 851-2204
CAPITAL CITY NEUROSURGERY
Roger H. Frankel, M.D.
PATIENT DAT A SHEET
Diplomate, American Board of Neurosurgical Surgery
FORM MUST BE COMPLETED IN FULL
Today’s Date
Name
First
MI
Last
Home Address
Street
City
Home Phone
State
Cell Phone
Date of Birth
Age
Sex
Zip Code
Work Phone
Marital Status
SSN
Referred to Capital City Neurosurgery by
Address
Street
City
Employer
State
Zip Code
Phone
Occupation
Address
Street
City
Spouse Name
State
Date of Birth
Spouse Employer
Zip Code
SSN
Occupation
Phone
EMERGENCY CONTACT Nearest relative or friend not living with you
Name
Relationship
Phone
Address
Street
City
State
Zip Code
State
Zip Code
PRIMARY INSURANCE CARRIER
Insurance Carrier
Phone
Address
Street
Name of Insured
City
DOB
Policy #
Group #
SECONDARY INSURANCE CARRIER
Insurance Carrier
Phone
Address
Street
Name of Insured
City
DOB
State
Policy #
Zip Code
Group #
TERTIARY INSURANCE CARRIER
Tertiary Insurance
Name of Insured
Address
Street
Name of Insured
City
DOB
State
Policy #
Zip Code
Group #
PLEASE READ THE FOLLOWING INFORMATION CAREFULLY
 ALL CO-PAYMENTS ARE REQUIRED AT THE TIME SERVICES ARE RENDERED 
I certify that the above information is correct. I consent to be treated by the staff and providers of Capital City
Neurosurgery. I authorize payment of medical benefits to Capital City Neurosurgery and authorize the release of any
medical information necessary to process claims. I understand that I am responsible for co-payments, co-insurance, and
non-covered services.
Patient / Guardian Signature
Date
CAPITAL CITY NEUROSURGERY
Roger H. Frankel, M.D.
PATIENT HISTORY SHEET
Diplomate, American Board of Neurosurgical Surgery
FORM MUST BE COMPLETED IN FULL
Today’s Date
Patient Name
Age
Date of Birth
Height
Weight
Referring Physician:
Name
Phone
Fax
Address
Street
Suite
City
State
Zip Code
State
Zip Code
Primary Care Physician (If different from referring physician):
Name
Phone
Fax
Address
Street
Suite
City
Please describe the medical problem or symptom that you are here for today:
Were you injured at work or in an automobile accident? Yes
Date of Injury
/
/
Date you last worked
Attorney’s Name
General Health Status:
No
/
/
Phone
 Excellent
 Good
 Fair
 Poor
Are you:
 Right handed
 Left handed
PAST MEDICAL HISTORY
Do you have now or have you ever had the following:
Heart problems
 Yes  No
High blood pressure
Lung problems
 Yes  No
Liver disease (such as hepatitis)
Kidney problems
 Yes  No
GI problems (ulcers, hiatal hernia)
Diabetes
 Yes  No
Blood diseases or clotting problems
Any tumor/cancer
 Yes  No
Immune system disease
Neurologic disease (stroke, Parkinson’s, seizures, muscle/nerve disease)
Have you ever had radiation therapy or chemotherapy?
If yes, please explain
PAST SURGICAL HISTORY
Please list all surgeries you have had and the years there were performed:
ALLERGIES
Please list all allergies (include medications, food, intravenous dye). List all reactions.
1
 Yes
 Yes
 Yes
 Yes
 Yes
 Yes
 Yes







No
No
No
No
No
No
No
CAPITAL CITY NEUROSURGERY
Roger H. Frankel, M.D.
PATIENT HISTORY SHEET
Diplomate, American Board of Neurosurgical Surgery
FORM MUST BE COMPLETED IN FULL
MEDICATIONS
Please list all medications taken including dosage and schedule:
PREFERRED PHARMACY INFORMATION
Name
Phone
Fax
Address
Street
City
State
Zip Code
Yes  No
Are you on a special diet?
If yes, please specify:
FAMILY HISTORY
Has anyone in your family had:
If yes, please specify who:
High Blood Pressure
Heart Disease
Cancer
Diabetes
Asthma / Bronchitis
Stroke
Seizures
Other (Please List)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes








No
No
No
No
No
No
No
No
PARENTS
Mother:
Father:
Alive?
Alive?
Yes No
Yes No
Age
Age
Illnesses:
Illnesses:
SIBLINGS
Number of Brothers:
Number of Sisters:
Illnesses:
Illnesses:
CHILDREN
Number of Sons:
Number of Daughters:
SOCIAL HISTORY
Marital status:
 Married
 Single
 Divorced
 Widowed
 Separated
Tobacco:
Alcohol:
Drugs:
Yes  No
Yes  No
 Yes  No
Illnesses:
Illnesses:
Work Status:
 Employed
 Retired
 Unemployed
 Disabled
 Worker’s Comp
Employed By:
Position:
How much per day?
How much per day?
How much per day?
If no, have you ever used tobacco?
If no, have you ever used alcohol?
If no, have you ever used drugs?
2
Yes  No
Yes  No
Yes  No
CAPITAL CITY NEUROSURGERY
Roger H. Frankel, M.D.
PATIENT HISTORY SHEET
Diplomate, American Board of Neurosurgical Surgery
FORM MUST BE COMPLETED IN FULL
SYMPTOMS REVIEW Do you have or have you recently experienced any of the following?
General
Weight loss ( 10 lbs)
Weight gain ( 10 lbs)
Chills
Night sweats
Yes
No








Reproductive (Female)
Yes
No
Age at first menstrual period
____/_____/____
Date of last menstrual period
____/____/_____
Are your periods regular


History of sexually transmitted disease 

Decreased sexual desire


Eyes, Ears, Nose, Throat
Blurred vision
Double vision
Seeing spots
Ringing in ears
Worsening hearing
Hoarseness












Musculoskeletal
Muscle pain
Neck pain
Arm pain
Leg pain
Joint pain/swelling










Respiratory
Wheezing
Shortness of breath
Coughing blood








Cardiovascular
Chest pain/tightness
Shortness of breath lying flat
Racing heart/palpitations
Leg swelling
Leg pain on exertion
Blue/purple color of hands/feet












Neurologic/Psychiatric
Headaches
Dizziness
Room spinning
Double vision
Weakness/paralysis of arms
Weakness/paralysis of legs
Loss of sensation
Loss of balance
Loss of coordination
Speech difficulties
Memory difficulties
Depression
























Gastrointestinal
Nausea/vomiting
Diarrhea
Constipation
Black stools
Bloody stools










Skin
Change in hair texture
Hair loss
Change in skin texture
Nail changes
Skin ulcers










Urinary
Pain/burning on urination
Difficulty starting/stopping urination
Unusually large volumes of urine






Hematologic
Easily bruised
Poor blood clotting
















Reproductive (Male)
Change in testicular size
Decreased sexual desire
History of sexually transmitted disease
Endocrine






Change in body hair
Deepening of voice
Excessive thirst / hunger
Excessive urination
Bulging eyes
Poor tolerance to heat / cold
3
CAPITAL CITY NEUROSURGERY
Roger H. Frankel, M.D.
Diplomate, American Board of Neurosurgical Surgery
Today’s Date
Name
First
MI
Last
 Place “X” over the area where you are experiencing pain 
 Place “O” over the area where you are experiencing numbness, tingling, or any other sensation 
Piedmont Spine Center
2001 Peachtree Road NE ♦ Suite 550 ♦ Atlanta, Georgia 30309
Telephone (404) 350-7907 ♦ (404) 352-8020
Facsimile (404) 367-1970 ♦ (404) 851-2204
CAPITAL CITY NEUROSURGERY
Roger H. Frankel, M.D.
Diplomate, American Board of Neurosurgical Surgery
HIPPA Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND
HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out
treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by la. It also describes your
tights to access and control your protected health information. “Protected health information” is information about you, including
demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition
and related health care services.
1. Uses and Disclosures of Protected Health Information
Uses and Disclosures of Protected Health Information
Your protected health information may be used and disclosed by our physician, our office staff and other outside of our office that are
involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support
the operation of the physician’s practice, and any other use required by law.
Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any
related services. This includes the coordination or management of your health care with a third party. For example, we would
disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your
protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the
necessary information to diagnose or treat you.
Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example,
obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to
obtain approval for the hospital admission.
Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business
activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review
activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may
disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in
sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name
in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary,
to contact you to remind you of your appointment.
We may use or disclose your protected health information in the following situations without your authorization. These situations
include: as Required By Law, Public Health issues as required by law, Communicable Diseases: Health Oversight: Abuse or Neglect:
Food and Drug Administration requirements: Legal Proceeding: Law Enforcement: Coroners, Funeral Directors, and Organ Donation:
Research: Criminal Activity: Military Activity and National Security: Workers’ Compensation: Inmates: Required Uses and
Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and
Human Services to investigate or determine our compliance with the requirements of the Section 164.500.
Other Permitted and Required Uses and Disclosures: Will be made only with your consent, authorization or opportunity to object
unless required by law.
You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has
taken an action in reliance on the use or disclosure indicated in the authorization.
1 of 2
Piedmont Spine Center
2001 Peachtree Road NE ♦ Suite 550 ♦ Atlanta, Georgia 30309
Telephone (404) 350-7907 ♦ (404) 352-8020
Facsimile (404) 367-1970 ♦ (404) 851-2204
CAPITAL CITY NEUROSURGERY
Roger H. Frankel, M.D.
Diplomate, American Board of Neurosurgical Surgery
HIPPA Notice of Privacy Practices
Your Rights
Following is a statement of your rights with respect to your protected health information.
You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or
copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or
administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health
information.
Your physician is not required to agree to a restriction that you may request. If the physician believes it is in your best interest to
permit use and disclosure of your protected health information, your protected health information will not be restricted. You then
have the right to use another Healthcare Professional.
You have the right to request to receive confidential communications from us by alternative means or at an alternative
location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this
notice alternatively i.e. electronically.
You may have the right to have your physician amend your protected health information. If we deny your request for
amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will
provide you with a copy of any such rebuttal.
You have the right to receive an accounting or certain disclosures we have made, if any, of your protected health information.
We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object
or withdraw as provided in this notice.
Complaints
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy right have been violated by us.
You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a
complaint.
This notice was published and becomes effective on or before April 14, 2003.
We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices
with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance
Officer in person or by phone at our main phone number.
Signature below is only acknowledgement that you have received this Notice of our Privacy Practices.
Print Name:
_________________________________________
Signature:
_________________________________________
Date:
____________________________________
2 of 2
Piedmont Spine Center
2001 Peachtree Road NE ♦ Suite 550 ♦ Atlanta, Georgia 30309
Telephone (404) 350-7907 ♦ (404) 352-8020
Facsimile (404) 367-1970 ♦ (404) 851-2204
CAPITAL CITY NEUROSURGERY
Roge r H. Frank e l, M. D.
Diplomate, American Board of Neurosurgical Surgery
PATIENT BILL OF RIGHTS
PATIENT BILL OF RIGHTS
1. The patient has the right to considerate and respectful care.
2. The patient has the right to obtain from his physician complete, current information concerning his diagnosis,
treatment and prognosis in terms the patient can be reasonably expected to understand. When it is not medically
advisable to give such information to the patient, the information should be made available to an appropriate person on
his behalf. A patient has the right to know by name the physician responsible for coordinating his care.
3. The patient has the right to receive from his physician any information necessary to give informed consent prior to the
start of any procedure and/or treatment. Except in emergencies, such information for informed consent should include
but not necessarily be limited to the specific procedure and/or treatment, the medically significant risks involved, and the
probable duration of incapacitation. Where medically significant alternatives for care or treatment exist, or when the
patient requests information concerning medical alternatives, the patient has the right to such information. The patient
also has the right to know the name of the person responsible for the procedure and/or treatment.
4. The patient has the right to refuse treatment to the extent permitted by law, and to be informed of the medical
consequences of this action.
5. The patient has the right to expect that all communications and records pertaining to his care should be treated as
confidential.
6. The patient has the right to every consideration of his privacy concerning his own medical care program. Case
discussion, consultation, examination and treatment are confidential and should be conducted discreetly. Those not
directly involved in his care must have the permission of the patient to be present.
7. The patient has the right to expect that within its capacity an office must make reasonable response to the request of
the patient for services. Medical facilities must provide evaluation, service, and/or referral as indicated by the urgency of
the case. When medically permissible, the patient may be transferred to another facility only after receiving complete
information and explanation concerning the needs for alternatives to a transfer.
8. The patient has the right to obtain information as to the existence of any professional relationships among individuals,
by name, who are treating them.
9. The patient has the right to expect reasonable continuity of care. He has the right to know in advance what
appointment times and physicians are available.
INITIAL HERE: __________________
Piedmont Spine Center
2001 Peachtree Road NE ♦ Suite 550 ♦ Atlanta, Georgia 30309
Telephone (404) 350-7907 ♦ (404) 352-8020
Facsimile (404) 367-1970 ♦ (404) 851-2204
CAPITAL CITY NEUROSURGERY
Roger H. Frankel, M.D.
Diplomate, American Board of Neurosurgical Surgery
INSURANCE AGREEMENT
Thank you for choosing Capital City Neurosurgery for your neurosurgical care. As the patient, you are
responsible for knowing the conditions and restrictions set forth on pre-certifications for diagnostic procedures
and/or surgical procedures as well as physical therapy.
Capital City Neurosurgery will assist with understanding insurance details, however, Capital City Neurosurgery
is not responsible for confirmation of coverage or benefits by your insurance company. Insurance plans may
vary on aout-of-pocket amounts based on the location where the service is performed. Deductibles, coinsurance and co-payments may also apply according to your insurance plan to which you are financially
responsible.
Your insurance carrier may require a referral from your primary care physician to see a specialist. If your plan
requires a referral, contact your primary care physician to initiate a referral. We request that all referrals be in
our office 48 hours prior to your visit. If you are unable to obtain a referral, you will be advised to reschedule
your appointment. Your insurance company may not pay for your visit if our office has not received a referral
from your primary care physician. Referrals can be faxed to (404) 367-1970.
Capital City Neurosurgery collects co-payments at the time service is rendered. Additional payment may be
required based on your insurance plan. In the event that an office appointment is missed or not re-scheduled, a
fee will be incurred on your account.
We appreciate your understanding of the ever changing requirements of managed care plans and our position to
adhere to their policies.
STATEMENT OF AGREEMENT
By signing this agreement, I understand the conditions that apply . I understand that I am financially
responsible for any co-payments, deductibles, co-insurance and non-covered services as outlined in my
insurance plan.
_______________________________________________
Signature of Patient or Responsible Party
_____________________________
Date
Piedmont Spine Center
2001 Peachtree Road NE ♦ Suite 550 ♦ Atlanta, Georgia 30309
Telephone (404) 350-7907 ♦ (404) 352-8020
Facsimile (404) 367-1970 ♦ (404) 851-2204
CAPITAL CITY NEUROSURGERY
Roger H. Frankel, M.D.
Diplomate, American Board of Neurosurgical Surgery
AUTHORIZATION AGREEMENT
I, on behalf of_______________________________________________________________________________
(the "Patient"), authorize CAPITAL CITY NEUROSURGERY, to release any medical information pertaining to
the Patient's diagnosis and treatment to: (1) representatives of local, state or federal agencies in accordance with law;
(2) any insurance carrier, employer, government or social service agency, or other payor or provider of medical
benefits which may or will pay for any part of Patient's medical or hospital expenses; (3) the designated utilization
review or peer review organization of the Patient's insurer, employer, or other payor or provider of medical benefits;
or (4) such other parties as may be necessary to obtain payment for Patient's care. I understand that release of this
information may be required in order to obtain payment for the Patient's medical expenses; (5) the referring
physician, institution, insurance company, rehab attorney or employer.
This authorization applies to all information regarding the Patient's care, which may include information otherwise
privileged or confidential by law (including, but not limited to, information regarding treatment for mental illness,
mental retardation, and alcohol or substance abuse, communications with psychiatrists and diagnosis or treatment for
Acquired Immunodeficiency Syndrome (AIDS), AIDS-related complex, HIV (human immunodeficiency virus)
infection or any other disease.
I hereby release the Center and its agents and employees from any and all liabilities, damages, losses, claims and
expenses which may arise from the release of the information authorized above.
__________________________________________________
SIGNATURE OF PATIENT
______________________________________________________
SIGNATURE OF PATIENT'S REPRESENTATIVE
__________________________________________________
DATE
___________________________________________________
DATE
__________________________________________________
WITNESS
___________________________________________________
RELATIONSHIP TO PATIENT
Special circumstances which necessitate signature by Patient's Representative:
_______________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Please use this section for physician's address:
Please mail to: ____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Piedmont Spine Center
2001 Peachtree Road NE ♦ Suite 550 ♦ Atlanta, Georgia 30309
Telephone (404) 350-7907 ♦ (404) 352-8020
Facsimile (404) 367-1970 ♦ (404) 851-2204
CAPITAL CITY NEUROSURGERY
Roger H. Frankel, M.D.
Diplomate, American Board of Neurosurgical Surgery
PHYSICIAN ASSISTANT ACKNOWLEDGEMENT
If you are scheduled for surgery, please be advised that Capital City Neurosurgery employs the services of a
Physician Assistant and a Nurse Practitioner. A Physician Assistant or Nurse Practitioner may assist at your
surgery. Physician Assistants and Nurse Practitioners are medical professionals who are licensed by the state of
Georgia and are specifically trained and licensed to assist in surgery.
Many insurance companies cover the fee charged by a Physician Assistant / Nurse Practitioner for surgical
assistance. Some, however, do not. In the event that your insurance company fails to cover such an expense,
you will be financially responsible for paying this fee.
Our office will contact your insurance company to pre-certify your admission. The purpose of pre-certification
is to inform the insurance carrier of pending hospitalization. It is not a guarantee of payment.
**It is advisable for you to contact your insurance company prior to your anticipated surgery for an
explanation of coverage regarding any expenses that you might anticipate as a result of surgical
treatment.
____________________________________________
Patient
______________________________
Date
____________________________________________
Person financially responsible, if other than patient
______________________________
Date
Piedmont Spine Center
2001 Peachtree Road NE ♦ Suite 550 ♦ Atlanta, Georgia 30309
Telephone (404) 350-7907 ♦ (404) 352-8020
Facsimile (404) 367-1970 ♦ (404) 851-2204
CAPITAL CITY NEUROSURGERY
Roger H. Frankel, M.D.
Diplomate, American Board of Neurosurgical Surgery
COMPLETION OF DISABILITY / FMLA FORMS POLICY
Surgical Patients
A request for one form to be completed by your providing doctor for a surgical patient will be free of charge.
There will be a twenty-five dollar ($25.00) charge thereafter, upon each request of any/all forms to be
completed by your providing doctor.
Non-Surgical Patients
There will be a twenty-five dollar ($25.00) charge upon each request of any/all forms to be completed by your
providing doctor.
___________________________________________________
Signature of Patient or Responsible Party
_____________________________
Date
PRESCRIPTION REFILL POLICY
♦ A mandatory twenty-four hour (24 hour) notice is required on all requests for prescription refills. When
contacting our office for refills, please include the name and phone number of your pharmacy.
♦ Calls after 3:00 PM for prescription refills will be returned the next business day.
♦ There will be no prescription refills on Fridays, with the exception of anti-seizure medications.
___________________________________________________
Signature of Patient or Responsible Party
_____________________________
Date
Piedmont Spine Center
2001 Peachtree Road NE ♦ Suite 550 ♦ Atlanta, Georgia 30309
Telephone (404) 350-7907 ♦ (404) 352-8020
Facsimile (404) 367-1970 ♦ (404) 851-2204