PATIENT REGISTRATION INFORMATION Steven K. Jacobs, M.D, Ph.D New York Neurosurgical, PLLC 4 Lafayette Court Fishkill, NY 12524 845-896-9200 fax 845-896-3262 PLEASE COMPLETE ALL SECTIONS BELOW IN PRINT

PATIENT INFORMATION Name:__________________________________________Date of Birth_______________________Age______________ Address:__________________________________________________________________________________________ City__________________________________________________State__________________Zip____________________ Social Security:______________________________

Marital Status: Single Married Divorced Widowed

Optional: Ethnicity_______________________Language:_____________________________Race:__________________ Home #_________________________________Cell # ______________________________Work#__________________ Emergency Contact / Relationship___________________________________________Phone # ____________________ Are you currently working? YES NO

Employer/Name of School __________________________________________

Occupation:_____________________________________________

Job Duties: ________________________________

PRIVATE INSURANCE INFORMATION Primary Insurance: ______________________________

Secondary Insurance: _______________________________

Member ID# ___________________________________

Member ID#______________________________________

Group # _______________________________________

Group # __________________________________________

Relationship to Insured: __________________________

Relationship to Insured: _____________________________

Employers Name ________________________________

Employers Name __________________________________

Phone # _______________________________________

Phone # _________________________________________

PATIENT REFERRAL INFORMATION Who referred you to our office? ______________________________________Phone # __________________________

WORKERS COMPENSATION Is this a work related injury? YES NO

Insurance Carrier:_____________________________________________________Date of accident_________________ Insurance Address:___________________________________________________________________________________ __________________________________________________________________________________________________ Carrier Case# ________________________________________WCB# _________________________________________ Employer at the time of the accident: ___________________________________________________________________ Employers address & Phone# __________________________________________________________________________ Job title (when injured) ___________________________________________ Did you report the injury YES NO Briefly describe how the injury occurred: ________________________________________________________________ __________________________________________________________________________________________________ Have you had prior treatment for this injury? YES NO If yes please explain _________________________________________________________________________________ __________________________________________________________________________________________________ Do you have an attorney? YES NO If yes attorney name _______________________________________________Phone #___________________________

NO-FAULT (AUTO ACCIDENT) Is this a motor vehicle accident related injury? YES NO Your car insurance carrier: ____________________________________________Date of accident___________________ Carrier address: _____________________________________________________________________________________ __________________________________________________________________________________________________ Claim# __________________________________________ Adjuster name: _____________________________________ Adjuster phone# ______________________________________________________________ Do you have an attorney? YES NO If yes attorney name _______________________________________________Phone #___________________________

PATIENT HEALTH QUESTIONNAIR New York Neurosurgical, PLLC Steven K. Jacobs MD., Ph.D Chief Complaint: ____________________________________________________________________________________ __________________________________________________________________________________________________ List any medical problems that run in your family (heart disease, high blood pressure, diabetes, etc…) __________________________________________________________________________________________________

SOCIAL HISTORY Do you smoke? YES NO

If yes how much/how often ____________________________

Do you drink? YES NO

If yes how much/how often____________________________

Do you have any tattoos? YES NO If yes where? _________________________________________________________ Do you have any piercings? YES NO If yes where?________________________________________________________ L or R handed? Height ______________ Weight _______________BMI _________________

PAST SURGICAL HISTORY Please list any surgeries or major illnesses you have had in the past Surgery / Hospital ________________________________________________________________Year_______________ Surgery / Hospital ________________________________________________________________Year_______________ Surgery / Hospital ________________________________________________________________Year_______________ Surgery / Hospital ________________________________________________________________Year_______________ Have you had any complications? ______________________________________________________________________ Anesthetic Complications? ____________________________________________________________________________

ALLERGIES / MISCELLANEOUS Pacemaker? YES NO Latex Allergy? YES NO Do you have any metal in your body? YES / NO List any allergies to medications or metals _______________________________________________________________

CURRENT MEDICATIONS Medication:_______________________________Dosage: ______________________Frequency____________________ Medication:_______________________________Dosage: ______________________Frequency____________________ Medication:_______________________________Dosage: ______________________Frequency____________________ Medication:_______________________________Dosage: ______________________Frequency____________________ WHAT PHARMACY DO YOU USE?________________________________________________________ ADDRESS OF PHARMACY ______________________________________________________________

CURRENT MEDICAL CONDITIONS Please check if you currently have or had any problems with: ______________Fever

______________ Nausea / Vomiting

______________Weight Loss

______________ Indigestion or Pain when eating

______________Glaucoma

______________Jaundice

______________Date of last eye exam

______________ Change in bowel movements

______________Hearing Loss

______________Ulcer or Gastritis

______________Ringing L or R

______________Urinary Tract Infection

______________Balance Problem

______________Difficulty starting or stopping stream

______________Sinus problems

______________Renal / Kidney Problems

______________Headaches

______________ Diabetes

______________High Blood Pressure

______________ Increased Appetite

______________Chest pain / Angina

______________Anemia

______________Date of last EKG

______________ Hemophilia

______________Asthma

______________Anxiety

______________Chronic Cough

______________Depression

______________Shortness of breath

______________Back Pain

______________ Neck Pain

______________Hepatitis C (current or past)

The above information is true to the best of my knowledge: Signature: ___________________________________________________Date: ________________________________

NEW YORK NEUROSURGICAL ,PLLC 4 Lafayette Court Fishkill, NY 12524

Insurance Authorization

I request that payment of authorized Medicare Benefits and or my insurance company be made on my behalf to New York Neurosurgical , PLLC for any services furnished to me by this group. I authorize any holder of medical information about me to release to the insurance companies and its agents any information needed to determine these benefits or the benefits payable for related services. I understand my signature requests that payment be made and authorizes release of medical information necessary TO PAY THE CLAIM. If “other health insurance” is indicated in item 9 of the HCFA-1500 form, or elsewhere on the other approved claim forms or electronically submitted claims, my signature authorizes release of the information to the insurer or agency shown. I know that I am responsible for any balance not covered by my insurance.

Signature: ______________________________________________Date: _____________________________________

I authorize New York Neurosurgical, PLLC to deposit any payment(s) issued to me for claims(s) paid by “my insurance” for services rendered by New York Neurosurgical, PLLC that have been mailed directly to New York Neurosurgical, PLLC. I request all payments for claims to be mailed directly to New York Neurosurgical, PLLC.

Signature: _______________________________________________Date: _____________________________________

Assignment of Benefits/Financial Agreement

I hereby give lifetime authorization for payment of insurance benefits to be made directly to New York Neurosurgical and any assisting physicians, for services rendered. I understand that I am financially responsible for all charges whether or not they are covered by my insurance. In the event of default, I agree to pay all costs of collection, and reasonable attorney’s fees. I hereby authorize this healthcare provider to release all information necessary to secure the payment of benefits. I further agree that a photocopy of this agreement shall be as valid as the original.

Signature: ________________________________________________ Date: ____________________________________

PATIENT RECORD OF DISCLOSURE In general, the HIPPA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual’s office instead of the individual’s home.

The numbers you have provided us with will be used to contact you May we speak to other members of your household?

YES NO

If no, please specify who we can’t speak to______________________________________________ Can we leave detailed messages at your Home Phone Number

YES NO

Cell Phone Number

YES NO

Work Phone Number

YES NO

(If NO is selected we will not leave a detailed message, instead we will leave contact information for you to reach us)

Signature ___________________________________________________ Date _________________________________

The Privacy Rule generally requires healthcare providers to take reasonable steps to limit the use of disclosure of, and requests for PHI to the minimum necessary to accomplish the intended purpose. These provisions do not apply to uses or disclosures made pursuant to an authorization requested by the individual. Healthcare entities must keep records of PHI disclosures. Information provided below, if completed properly, will constitute an adequate record. NOTE: Uses and disclosures for TPO may be permitted without prior consent in an emergency. Record of Disclosures of Protected Health Information (Please fill out this section if you wish a specific person to be able to obtain your medical information) Please list any persons who can obtain your medical records, such as a primary care doctor

Name of Person / Facility

Address

Phone#

1. ___________________________________________________________________________________________ 2. ___________________________________________________________________________________________ 3. ___________________________________________________________________________________________ 4. ___________________________________________________________________________________________

Signature ___________________________________________________ Date _________________________________