SPECIALTYCARE CLINICS

SPECIALTYCARE CLINICS
DR. DAVID MASEL, MD, FAANS, FACS - NEUROSURGEON

13988 Diplomat Drive, Suite 100 C Farmers Branch, Texas 75234 Phone: 469-833-2927, Fax: 214-888-4450
Patient Name
Date of Birth

Sex
Date of Birth

Month Day Year
Date
Address

Address

Street Address Line 2

City State

Zip
City

Married Widowed Divorced Single Driver's License
SSN
Driver's License #
Email
example@example.com
Home Phone
Cell Phone
Emergency Contact
Relationship
Phone
Reason for Visit

YesNo Referring Doctor's Name
Reason for Visit
Referring Doctor's Name
Primary Care Physician
Phone
City
Worker's Compensation? Employer
Insurance
Claim #
Personal Injury? Attorney
Case Manager
Phone
Phone

Parent Self Spouse
Name on Card
Insurance Company
Policy #
Member ID
SECONDARY INSURANCE

Self SpouseParent Name on Card
Name on Card
Insurance Company
Policy #
Member ID
MEDICARE / MEDICAID: Medicare Number
Medicaid Number
MEDICARE SUPPLEMENT INSURANCE:
Insurance Name
Phone
Address

Address

Street Address Line 2

City State

Zip
CLINICS
(CONTINUED FROM PREVIOUS PAGE)

WORKER'S COMPENSATION: It is important that you make our office aware if this is a worker's comp injury prior to your visit. Please have all relevant information available in order to quickly complete your check-in process.

EMPLOYER PAY: If your employer is paying for your visit instead of filing worker's comp, we must have payment up front or a signed contract in hand before your visit. We must be notified of any responsibility changes the employer makes within 80 days of first date of service.

MISSED APPOINTMENT POLICY: In an effort to provide excellent patient care, we will be implementing a missed appointment fee without a cancellation of at least 24 hours in advance. Cancellations must be done over the phone with

a staff member in the neurosurgery department. Our direct number is 469-833-2927. Cancellation fee of $25.00 will be

applied to your account in the event you fail to notify us 24 hours prior to your appointment time with Dr. David Masel,

MD. Illness will be excused with a physician's note explaining your absence.

By signing this, you are acknowledging that all the above information is accurate and correct to the best of your knowledge and that you fully understand the above mentioned.
PATIENT OR GUARDIAN SIGNATURE

Clear
Date

Month Day Year
Date
SPECIALTY CARE CLINICS - CONSENT FOR TREATMENT AND FINANCIAL AGREEMENT
Patient Name
Date of Birth

Month Day Year
Date
Iauthorize the doctor, Dr. David Masel, MD, to examine me (or the patient I am legally responsible for) and to do any x-rays or

other diagnostic tests that may be needed to make a diagnosis and to provide treatment. I consent to necessary office or other outpatient treatment after being properly informed of alternatives, benefits, and risks.

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION: I authorize Dr. David Masel, MD to release to any insurance company, health plan, or government agency such medical information that may be required to process my claim for payment of this medical bill. I also authorize Dr. David Masel, MD to release appropriate medical information to any doctor, hospital, or other health care facility that has or will participate in my (the patient's) care. I authorize a photocopy, facsimile, or other electronic transmission of the above Assignments, Authorizations, and Releases to be used in place of the original until/unless I send written notice to the contrary to the offices of Dr. David Masel, MD. I further authorize any other doctor, hospital, or health care facility to release to Dr. David Masel, MD office any medical information concerning my (the patient's) illness or injury.

FINANCIAL AGREEMENT: I agree to pay all professional fees charged by Dr. David Masel, MD for my (the patient's) care, irrespective of any insurance benefits to which I may be entitled, except if Dr. David Masel, MD has agreed to accept insurance benefits as full payment for covered services in accordance with federal or state law (e.g. Medicare, Medicaid) or by contract with a prepaid health plan or managed-care plan, and provided such insurance benefits are paid within 60 days of claims submissions, and provided there is no recovery from a third-party negligence lawsuit (see Injuries and Third-Party Negligence, below Ultimately, it is your responsibility to understand the coverage that you pay for in a monthly premium to your carrier. If an employer or its carrier denies a claim for payment for a work-related injury, or if a prepaid health plan, managed-care health plan, or Medicare, considers certain services ineligible or uncovered services, then you (patient) agree to pay for those services. It is understood that claims for services remaining unpaid 60 days after claims submission shall be presumed ineligible for insurance reimbursement, and you (patient) shall pay for those services. If patient is a minor - the parent/guardian who requests treatment for a child will be responsible for all fees.

INJURIES AND THIRD-PARTY NEGLIGENCE: I understand and agree that if Dr. David Masel, MD has granted discounts from its usual fees for any reason, including its participation in prepaid or managed-care health plans, and if I (the patient) recover(s) any monies as the result of any judgment, award, or settlement of any lawsuit arising from treated injuries or illness, then I shall give a lien to Dr. David Masel, MD against such monetary recovery in the full amount of such discounts.

DELINQUENCY: If my (the patient's) account becomes delinquent, I understand that Dr. David Masel, MD, at its sole discretion, may refer to a collection agency or an attorney as allowed by law.

INSURANCE ASSIGNMENT: I authorize my insurance company or third-party payer to whom a claim for payment has been submitted to pay any eligible benefits directly to Dr. David Masel, MD. I hereby authorize payment to go directly to Specialty (and/or Medicare) and understand Care Clinics for medical benefits payable by insurance company that I am responsible for any charge not covered by the terms of my insurance policy. I hereby assign Dr. David Masel, MD full rights to represent my (the patient's) interests in any complaints of appeals for denial of benefits or reimbursement to the Texas Department of Insurance (State Insurance Commissioner I hereby authorize said assignee Dr. David Masel, MD to furnish these agencies such information as may be necessary to support such complaints or appeals.

I agree I cannot revoke the FINANCIAL AGREEMENT or the INSURANCE ASSIGNMENT at any time while any portion of the medical bill remains unpaid. I have read, understand, and do hereby agree to the terms of the forgoing Assignments, Authorizations, and Releases. I also certify that the PATIENT INFORMATION I have provided is true and accurate to the best of my knowledge.
PATIENT OR GUARDIAN SIGNATURE

Clear
Date

Month Day Year
Date
SPECIALTY CARE CLINICS - HIPAA COMPLIANCE PATIENT CONSENT FORM
Patient Name
Date of Birth

Month Day Year
Date
Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

The notice contains a patient's rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protect health information is used and disclosed for treatment, payment, or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allow for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a

revocation will not be retroactive.

BY SIGNING THIS FORM, I UNDERSTAND THAT:

May we phone, email, or send a text to you to confirm appointments?
May we discuss your medical condition with any member of your family?

Yes No The patient has the right to revoke this consent in writing at any time and all full disclosure will then cease. The practice may condition receipt of treatment upon execution of this consent. YesNo May we leave a message on your answering machine at home or on your cell phone? YesNo Protected health information may be disclosed or used for treatment, payment, or healthcare operations. The practice reserves the right to change the privacy policy as allowed by law. The practice has the right to restrict the use of the information, but the practice does not have to agree to those
If yes, please name the members allowed
PATIENT OR GUARDIAN SIGNATURE

Clear
Date

Month Day Year
Date
Witness Signature

Clear
Date

Month Day Year
Date
SPECIALTY CARE CLINICS - PRESCRIPTION REFILLS AND PHONE MESSAGES
Patient Name
Date of Birth

Month Day Year
Date
It is your responsibility to know your insurance and bring your card with you to all appointments Is Dr. David Masel, MD a CONTRACTED PROVIDER of your insurance? Do you need PRIOR AUTHORIZATION for procedures? Are x-rays and supplies included in your COPAY? How much is your COPAY for a specialist? Do you have a YEARLY DEDUCTIBLE? If so, has it been met?

PLEASE HELP US HELP YOU. There are hundreds of insurance companies thereby making it almost impossible for our staff to know the specific requirements for each policy. Please call your insurance company prior to your appointment to obtain

PROTOCOL FOR PRESCRIPTION REFILLS:

Please reach out to your pharmacy first for refill requests Please allow 48-72 hours on refill requests

In order to be as efficient as possible, these are the policies in effect regarding all prescriptions.
HIPPA EXCEPTIONS (Please check all that apply)

OK to have a message left on my answering machine. OK to leave a message with spouse; name of spouse OK to leave a message with any adult who answers my phone. OK to leave a message regarding appointments ONLY
I have read and understand the above information regarding MY INSURANACE POLICY, PRESCRIPTION REFILLS, and the HIPAA EXCEPTIONS AUTHORIZATION for leaving messages.
PATIENT OR GUARDIAN SIGNATURE

Clear
Date

Month Day Year
Date
SPECIALTY CARE CLINICS - MEDICAL RELEASE FORM
I hereby authorize
David Masel, MD, information contained in the medical records of

History Physical Therapy Reports Care Plan Radiology Imaging to release to Specialty Care Clinics, Dr. Lab Report EMG Office Notes Immunizations Psychological Reports Other
Name of Patient
Date of Birth

Month Day Year
Date
SSN
SPECIFIC INFORMATION TO BE DISCLOSED:
DO NOT RELEASE INFORMATION RELATED TO

HIV Psychiatric/Mental Health I give permission for release of any information in my records, including information relevant to substance abuse, psychiatric mental health services or HIV (positive or negative) unless specifically excluded below. Other
THE ABOVE INFORMATION IS RELEASED FOR THE FOLLOWING PURPOSE AND THAT PURPOSE ONLY

Medical Attorney Insurance Other
I understand that I may revoke this authorization at any time except to the extent that action has been taken in reliance on it; and that in any event, this authorization automatically expires 90 days from the date of my signature or as otherwise specified by date, event, or condition as follows. I agree that a photocopy of this authorization may be
considered valid

Yes No
THIS INFORMATION IS PRIVILEGED AND CONFIDENTIAL. IT IS INTENDED FOR THE INDIVIDUAL ENTITY DESIGNATED. YOU
ARE HEREBY NOTIFIED THAT DISSEMINATION DISTRIBUTION, COPY OR OTHER USE OF THIS INFORMATION BY ANYONE
OTHER THAN THE RECIPIENT DESIGNATED ABOVE IS AUTHORIZED AND STRICTLY PROHIBITED.
PATIENT OR GUARDIAN SIGNATURE

Clear
Date

Month Day Year
Date
SPECIALTY CARE CLINICS - INTAKE
Patient Name
Date of Birth

Month Day Year
Date
Pharmacy Name
Pharmacy Phone
Address

Pharmacy Address

Street Address Line 2

City State

Zip
CHIEF COMPLAINT (Check all that apply)

Neck Pain Back Pain Arm Pain Leg Pain
Other
Age
Sex
Height

Injury? YesNo Date of injury
Height
ft.
Weight

Work Related Injury? YesNo lbs.
Weight
Date of injury

Month Day Year
Date
How did the injury occur?
How long have you had this problem/pain
Has it gotten worse recently? Yes

No How long have you had this problem/pain
If yes, when did it get worse?
Please rate the severity of your pain (10 is the greatest pain):
N/A 1 2 3 4 5 6 7 8 9 10
N/A
N/A 1 2 3 4 5 6 7 8 9 10
N/A
N/A 1 2 3 4 5 6 7 8 9 10
N/A
Which leg is worse?

Left Right
Arm(s)

Bowel Problems? Yes No How long?
Arm(s)

Bladder Problems? YesNo How long?
N/A 1 2 3 4 5 6 7 8 9 10
N/A
Which arm is worse?

Left Right
How long?
How long?
PLEASE INDICATE THE DISTRIBUTION OF YOUR
PAIN/SYMPTOMS ON THE DIAGRAM TO THE RIGHT:
0000000 Numbness, Tingling, Pins, Needles
Sitting
Feet

Hrs. Min. Hrs. Min.
Standing

Yes No Does the pain interfere with sleeping? YesNo Does the pain interfere with work or play?
What makes the pain better or worse (check all that apply)?
Which of these tests have you had before and when (check all that apply and include most recent studies)?

MRI CT / CT myelogram
Which of these tests have you had before and when (check all that apply and include most recent studies)?

EMG / NCS
Which of these tests have you had before and when (check all that apply and include most recent studies)?

Discogram
Date

Physical therapy What have you tried for the pain so far (check all that apply)? Which of these tests have you had before and when (check all that apply and include most recent studies)?
Date

Month Day Year
Date
Date

Month Day Year
Date
Date

Month Day Year
Date
How long ago?

No Are you satisfied with the effort? Yes NSAIDs (e.g. ibuprofen, Naprosyn, meloxicam, Celebrex) YesNo YesNo Oral steroids (e.g. Medrol dose pack, prednisone, methylprednisolone) YesNo Did it help? YesNo Muscle relaxers (e.g. cyclobenzaprine, methocarbamol, baclofen) YesNo Membrane stabilizers / nerve pain (e.g. gabapentin, Lyrica) YesNo Pain meds (e.g. Hydrocodone, Norco, Percocet, Vicodin) YesNo Injections (e.g. epidural steroidal injection, facet, nerve block) YesNo Neck / Back Surgery (include dates):
How long ago?
Neck / Back Surgery (include dates):
Medications: Please list all medications you currently take along with its dosing and schedule
Please report if you have had or are currently experiencing any of the following

YesNo Heart Disease
Please report if you have had or are currently experiencing any of the following

Yes No Lung Disease
Please report if you have had or are currently experiencing any of the following

YesNo Kidney Disease
Please report if you have had or are currently experiencing any of the following

YesNo Neurologic Disease
Please report if you have had or are currently experiencing any of the following

YesNo Cancer
Please report if you have had or are currently experiencing any of the following

YesNo Liver Disease / Hepatitis
Please report if you have had or are currently experiencing any of the following

YesNo Prostate Disease
Please report if you have had or are currently experiencing any of the following

YesNo Psychiatric / Depression
Please report if you have had or are currently experiencing any of the following

YesNo Stroke
Specify
Specify
Specify
Specify
Specify
Specify
Specify
Specify
Specify
Allergies: Please list any allergies with medications along with reaction type
Past Surgical / Hospitalization History:
Yes

Yes No
If yes, please describe

Have you ever had problems with anesthesia? YesNo Have you ever had general anesthesia (i.e. being put to sleep for an operation)? YesNo
If yes, please describe

If no, which ones Are your immunizations up to date? YesNo
If yes, please describe
If no, which ones
Alive / Deceased Age

AD Father D A Mother D A Sister / Brother AD Sister / Brother D A Sister / Brother AD Sister / Brother
Health Status / Cause of Death
Age
Family Member History of

Yes No Cardiac disease
Family Member History of

YesNo Stroke
Family Member History of

YesNo Diabetes
Family Member History of

YesNo Neurologic Problems
Family Member History of

YesNo Spine Problems
Who
Who
Who
Who
Who
Social History

Children? Yes NoIf yes, ages Occupation
Social History

Live alone? YesNo If yes, do you have help or family nearby? Yes No Who
Occupation
If yes, ages
Live alone? YesNo

Smoker? YesNo How many packs per day?
Live alone? YesNo

Chew tobacco? YesNo How much per day?
How many packs per day?
For how long?
How much per day?
For how long?
Quit smoking?

< 1 year 2-4 years 5-10 years Other
< 1 year

No Drugs (e.g. marijuana, cocaine) Yes
If yes, what?
Drink alcohol?

Daily 1-2x/week 1-2x/month 1-2x/year None
Alcohol preference
Exercise?

Daily Weekly Monthly Rarely Never
Exercise?
What type of exercise?
Review of Systems

YesNo High blood pressure Yes No Anemia Yes No Muscle spasms YesNo Abdominal pain YesNo Nausea YesNo Balance problems YesNo Osteoarthritis YesNo Bleeding problems YesNo Palpitations YesNo Bloody stool YesNo Rash YesNo Bloody urine YesNo Shortness of breath YesNo Blood clots YesNo Speech changes YesNo Chest pain / angina Yes No Swelling Yes No Constipation YesNo Swollen glands YesNo Cough YesNo Stomach ulcers YesNo Diabetes YesNo Seizures / epilepsy YesNo Diarrhea YesNo Thyroid disease YesNo Fainting YesNo Female organs / menstrual YesNo Tremor YesNo Urine retention YesNo Fever YesNo Vision changes YesNo Hearing changes YesNo Heat / cold intolerance No Yes Weight loss YesNo Hair / nail changes
Comments regarding any health issues not covered on this form
PATIENT OR GUARDIAN SIGNATURE
Should be Empty:

SPECIALTYCARE CLINICS

ARE HEREBY NOTIFIED THAT DISSEMINATION DISTRIBUTION, COPY OR OTHER USE OF THIS INFORMATION BY ANYONE

N/A 1 2 3 4 5 6 7 8 9 10

N/A 1 2 3 4 5 6 7 8 9 10

N/A 1 2 3 4 5 6 7 8 9 10

N/A 1 2 3 4 5 6 7 8 9 10

PAIN/SYMPTOMS ON THE DIAGRAM TO THE RIGHT:

PATIENT OR GUARDIAN SIGNATURE