New York Spine Surgery & Rehabilitation Medicine, PLLC: Forms

Name:	Your Age: (Year)
Birthdate:	/ / (MM/DD/YYYY)
Home Address:
Home Phone:	--
City:
State:
Zip Code:	Marital Status:
Occupation:
Social Security Number:	-- (XXX-XX-XXXX)
If you would like to receive your dictation by email please supply email address . Thank You.

Spouse's Name:
Occupation:
Business Address:
Business Phone:	--
City:
State:	Zip Code:

Patient's Employer:	Self Employed? Yes No
Business Address:
Business Phone:	--
City:
State:	Zip Code:

Name and Address of person to be billed:
City:
State:	Zip Code:

Name of nearest relative not living with you:
Phone:	--
Name Of Person to Contact in an Emergency:
Address:
City:
State:	Zip Code:
Phone:	--
Fax:	--

Please List Insurance Coverage:

Primary:

ID Number:

Address:

State:

Zip Code:

Phone Number:

Fax Number:

Secondary:

Number:

Credit Card Number:

Compensation:

Case Auto Accident Registration State:

Date of Accident:

/ / (MM/DD/YYYY)

Comp or Auto Insurance Carrier:

Carrier Case#:

Address:

City:

State:

Zip Code:

Phone Number:

Fax Number:

FINANCIAL POLICY: PLEASE READ CAREFULLY AND THOROUGHLY
I understand and agree that (regardless of my insurance status), I am ultimately responsible for the balance of my account for any professional services rendered. I have read all of the information on this sheet and have complete all of the answers. I certify that this information is true and correct to the best of my knowledge. I will notify you of any changes in my status or the above information.

Signature Date / / (MM/DD/YYYY)

PAYMENT IN FULL IS EXPECTED FOR SERVICES AT THE TIME THEY ARE RENDERED UNLESS OTHER ARRANGEMENTS HAVE BEEN MADE. THIS INCLUDES ALL COPAYMENTS, COINSURANCE, AND DEDUCTIBLES. IF WE DO NOT PARTICIPATE WITH YOUR INSURANCE, PAYMENT IN FULL IS DUE AT THE TIME OF SERVICE. WE WILL GLADLY BILL YOUR INSURURANCE COMPANY FOR YOU SO THAT YOU ARE REIMBURSED.

PLEASE BE AWARE THAT NO MATTER WHAT THE CIRCUMSTANCES ARE CONCERNING YOUR ACCOUNT, IF A BALANCE EXISTS YOU WILL ALWAYS RECEIVE A MONTHLY STATEMENT OF YOUR ACCOUNT. THIS WILL KEEP YOU CONSTANTLY AWARE OF THE STATUS SHOULD IT BE NECESSARY FOR YOU TO CONTACT YOUR INSURANCE COMPANY FOR NON-PAYMENT.

I UNDERSTAND THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT IF FOR ANY REASON MY INSURANCE COMPANY DENIES PAYMENT, IAM FULLY RESPONSIBLE FOR ANY SERVICES RENDERED. I ALSO AUTHORIZE RELEASE OF MY MEDICAL RECORDS TO MY INSURANCE COMPANY, SHOULD IT BE NECESSARY, IN ORDER TO PROCESS ANY OF MY MEDICAL CLAIMS.

Signature Date / / (MM/DD/YYYY)

Patient Name:

Date: / / (MM/DD/YYYY)

Employer:

Insurance Name:

SS#/ID#:

I hereby instruct and direct Insurance Company to pay by check made out and mailed to:

Kenneth K. Hansraj, M.D.
243 North Road, Suite 202S
Poughkeepsie, New York 12601

OR
If my current policy prohibits direct payment to the Doctor, I hereby also instruct and direct you to make out the check to me and mail it as follows:

Kenneth K. Hansraj, M.D.
243 North Road, Suite 202S
Poughkeepsie, New York 12601

For the professional or medical expense benefits allowable, and otherwise payable to me under my current insurance policy as payment toward the total charges for the professional services rendered. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above mentioned assignee, and I have agreed to pay, in a current manner, any balance of said professional service charges over and above be this insurance payment.

A photocopy of this Assignment of Benefits shall be considered as effective and valid as the original.

I also authorize the release of any information pertinent to my case to any insurance company, adjusted, or attorney involved in this case.

I authorize doctor to initiate a complaint to the Insurance Commissioner for any reason on my behalf.

Dated at The New York Spine Surgery & Rehabilitation Medicine, PLLC: // 2012 (MM/DD/YYYY)


Signature of Policyholder	Witness

NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
ASSIGNMENT OF BENEFITS FORM

(FOR ACCIDENTS OCURING ON AND AFTER 3/1/02)

I, , ("Assignor") hereby assign to, KENNETH K. HANSRAJ, M.D. ("Assignee") all rights privileges and remedies to payment for health care services provided by assignee to which I am entitled under Article 51 (the No-Fault statute) of the Insurance Law.

The Assignee hereby certifies that they have not received any payment from or on behalf of the Assignor and shall not pursue payment directly from the Assignor for services provided by said Assignee for injuries sustained on ,

not withstanding any other agreement to the contrary.

This agreement may be revoked by the assignee when benefits are not payable based upon the assignor's lack of coverage and/or violation of a policy condition due to the actions or conduct to the contrary.

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERAIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.

		Date / /
Patient name	Signature of Patient	(MM/DD/YYYY)
KENNETH K. HANSRAJ, M.D. 243 North Road, Suite 202 S Poughkeepsie, New York 12601
(Date of signature)

RELEASE OF MEDICAL INFORMATION TO OTHER PHYSICIANS:

FROM TIME TO TIME, IT MAY BE NECESSARY FOR YOUR DOCTOR TO SHARE MEDICAL INFORMATION WITH OTHER PHYSICIANS (SUCH AS YOUR FAMILY DOCTOR OR PRIMARY CARE PHYSICIAN) WHO MAY BE CURRENTLY INVOLVED IN YOUR TREATMENT. THIS ALLOWS THE DOCTOR TO CROSS REFERENCE IMPORTANT MEDICAL INFORMATION AND AIDS YOU IN PROVIDINGWITH THE BEST CARE POSSIBLE. YOUR DOCTOR CAN ONLY SHARE YOUR MEDICAL RECORDS WITH OTHER PHYSICIANS WHEN YOU RELEASE HIM/HER TO DO SO. BY COMPLETING YOUR SIGNATURE BELOW,YOU UNDERSTAND ALL OF THE ABOVE AND ALLOW THIS OFFICE TO SHARE MEDICAL INFORMATION NECESSARY FOR YOUR TREATMENT.

Signature:	(MM/DD/YYYY) Date / /
Research Consent: I agree to and hereby permit information available in this medical record to be used for scientific investigations so long as I am not personally identified. I do not agree to permit information available in this medical record to be used for scientific investigations.
Signature:	Date: / / (MM/DD/YYYY)
Witness:	Date: / / (MM/DD/YYYY)
Disability: If you have been incapacitated and unable to work, please give dates of disability:
From:	To:
Marital Status: Choose One: Married Single Widow Divorced
If You Are A Minor, Name of Parents:
Address:
City:
State:	Zip Code:
Phone Number:	--
Fax Number:	--

CLINICAL INFORMATION:

List in order of importance your main complaints. 1) 2) 3) 4) 5)
When did the problem start?
How did this problem start?
Describe the pain (include location):
On a scale of 1-10, with 0 being no pain and 10 being extremely severe, how would you rate your pain now? Back Right Leg Left Leg Neck Right Arm Left Arm
Did your back/neck pain get better once the leg/arm pain started?
Is your back/neck pain:	Constant Intermittent
Is your back/neck pain:	Getting Better The Same Getting Worse
Do you have numbness? (if yes, where)
Do you experience pins and needles (if yes, where?)
Do you have weakness in your legs or arms? (If yes, where?).
Do you have problems with your bowel or bladder?
How much time during your usual waking hours do you spend lying down?
Does bending / lifting / twisting / reaching / coughing or sneezing bother you?
Do you have night pain?
How are you with: 1) walking? 2) standing? 3) sitting? 4) driving? 5) sleeping? 6) working?
Is your balance ok?
What do you do for recreation?
What do you do socially?
What activities of daily living are you involved in (e.g. cooking, mowing the lawn, etc.)
Detail your treatments to date in chronological order: Include the names, dates and locations of treatments PLEASE INCLUDE DATES OF TREATMENT:
Physiatrist:
Family MD/ Internist/GP:
Chiropractor:
Neurologist:
Orthopaedic Surgeon:
Neurosurgeon:
Pain Specialist:
Neurologist:
Have You Been Treated With Epidural Steroid Injections: Yes / No
Others:
Detail your progress to date:
Previous Medical History: ( Such as diabetes, high blood pressure, rheumatic fever etc.):
Previous Spinal Surgery: Please note the procedure done, name of surgeon, institution and results:
Previous Surgical History: Please note all previous surgeries and dates that they were done:
What medications do you take: List all (include dosage if possible)
What medications are you allergic to:
Do you smoke? Yes No If yes, how much?
Do you drink? Yes No If yes, how much?
How tall are you: inches; How much do you weigh? pounds

These Questions Pertain To YOUR NECK & UPPER EXTREMITIES only:

CERVICAL SPINE: Please Rate (0= None, 10=Severe)
On the average, how would you rate the pain in the neck that you are having?
On the average, how would you rate the pain in the right upper extremity that you are having?
On the average, how would you rate the pain left upper extremity that you are having?
Severity of Symptoms On the average In the last month how would you describe:
The pain that you had including pain in your neck, and pain that goes through your upper extremities:
The pain in your neck:
The pain in upper extremities:
Numbness and tingling in your upper extremities:
Weakness in your upper extremities:
How often have you had neck or upper extremity pain?
Do you have problems with your balance?
In the last month on a typical day: How far have you been able to walk
Have you taken walks outdoors or in the malls for pleasure?
Have you been shopping for groceries or other items?
Have you walked around the different rooms in your house / apartment?
Have you walked from your bedroom to your bathroom?

These Questions Pertain To YOUR LOWER BACK & LOWER EXTREMITIES only:

LUMBAR SPINE: Please Rate (0= None, 10=Severe)

On the average, how would you rate the pain in the back that you are having?

On the average, how would you rate the pain in the right lower extremity that you are having?

On the average, how would you rate the pain left lower extremity that you are having?

Severity of Symptoms
On the average In the last month how would you describe:

The pain that you had including pain in your back, buttocks and pain that goes down your leg:

The pain in your back or buttocks:

The pain in your legs or feet

Numbness and tingling in your legs or feet:

Weakness in your legs or feet:

How often have you had back, buttock or leg pain?

Do you have problems with your balance?

In the last month on a typical day: How far have you been able to walk

Have you taken walks outdoors or in the malls for pleasure?

Have you been shopping for groceries or other items?

Have you walked around the different rooms in your house / apartment?

Have you walked from your bedroom to your bathroom?

Review of Systems:
Do you have any complaints with reference to your:

Head/Neurological:	Heart/ Lungs:	Kidneys:
Neck:	Appetite:	Urine:
Eyes:	Bowels:	Stomach:
Other:

Do you have any problems with your
Hips:	Knees:	Ankles:
Shoulders:	Elbows:	Wrists:
Ears, Nose, Throat

FEMALES: THE FOLLOWING QUESTIONS ARE IMPORTANT BECAUSE WE DO NOT WISH TO DO XRAYS OR IMAGING STUDIES IF YOU ARE PREGNANT OR IF THERE IS A CHANCE THAT YOU ARE PREGNANT

Date of last menstrual period:
/ /

Date of menopause:
/ /

Is there a chance that you may be pregnant?

Do you take oral contraceptives?
Yes No

Did you have a hysterectomy?
Yes No

Family History:

Diabetes: Yes No

Rheumatoid Arthritis: Yes No

Muscle/Nerve Disorder: Yes No

Spinal Disorders: Yes No

Other:

Tick tests done, with approximate date: (MM/DD/YYYY)

X-Rays:	1) / /	2) / /
MRI:	1) / /	2) / /
CT:	1) / /	2) / /
EMG:	1) / /	2) / /
Bone Scan:	1) / /	2) / /
Other:	1) / /	2) / /

FOR DOCTOR USE ONLY

PHYSICAL EXAMINATION:
REFLEXES	Right	Left
Biceps
Brachoradialis
Triceps
Knee
Ankle

	Right	Left
Hoffman
Clonus
Babinski
Pulses

SENSATION	Right	Left
C5
C6
C7
C8
T1
L2
L3
L4
L5
C1

Motor Power	Right	Left
C5
C6
C7
C8
T1
L2
L3
L4
L5
C1

	Right	Left
SLR
Bowstring
Femoral N. Stretch
Hips

FOR DOCTOR USE ONLY

Gait:
Diagnosis:
Plan:	Tests
X-Rays:
MRI:
CT-Myelogram:
EMG:
Bone Scan:
Other:
Conservative:
Surgical: