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Patient Information

First Name:
Last Name:

MI:


Address:

City:
State:

Zip:


SS#:
Birth Date:
Sex:

Marital Status:


Home Phone:
Cell Phone:

Work Phone:


Email:

Student:


Employer:

Employment:


How did you hear about us?

Refering MD:

Refering MD Phone:


Primary Care Physician:

PCP Phone:


SPOUSE INFORMATION/ RESPONSIBLITY PARTY


Name:

Relationship to Patient:


Address:

City:
State:

Zip:


Home Phone:
Cell Phone:

Work Phone:


Sex:
Date of Birth:

SS#:


Employer:

Employer Address:



ATTORNEY INFORMATION

Attorney Name:

Phone#:


Address:


I acknowledge and understand that a $40 fee for NO SHOW / NO CALL will be billed to your account.


Signature:

Date:


Patient Name:
DOB:

Today's Date:

INSURANCE INFORMATION

Coverage Type:

Insurance Company:

Subscriber Name:


Subscriber Relationship to Patient:

Subscriber DOB:


Coverage Type:

Insurance Company:

Subscriber Name:


Subscriber Relationship to Patient:

Subscriber DOB:


Coverage Type:

Insurance Company:

Injury Date:


Claim ID #:

Body Part:


Patient Information

I certify that above information is correct to the best of my knowledge. I also understand that I am financially responsible for all charges whether or not covered by insurance. I authorize treatment by the physician at NJPSSA.


Signature:

Date:


Authorization for Assignment of Benefits

Please accept this Assignment of Benefits as a blanket Assignment of Benefits for chares on services rendered and submitted by, NJPSSA, on my behalf I, the undersigned, authorized and request that


(please print your insurance name here)

For such services as listed above, change the assignee and make payment for benefits which may be due herein to: NJPSSA, LLC

Signature of Policy Holder:

Date:


ID #:

Group Number:


Patient's Name:

Relationship to Policy Holder:


AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

Patient's Name:

Date:


Birth Date:

Phone Number:


This request and authorization applies to:
Healthcare information relating to the following treatment, condition, or dates:

This request and authorization applies to:
I authorize the release of any records regarding drug, alcohol, or mental health treatment to the person(s) listed above.

Patient Name:
Patient/ Guardian Signature:

Witness Signature:

Date:

MEDICAL HISTORY FORM

Patient Name:

Today's Date:


Have you ever had or been told you have (check all that apply)

Cardiovascular:











Neurological:





Gastrointestinal:




Cancer:
Liver/Kidney/Blood:









Respiratory:





Metabolic:




Other:









ROS: Please check the box if you currently have any of the following






Social/ Family History:

Mother: living / deceased Cause

Father: living / deceased Cause


Usual Diet:
Alcohol: drinks per day

Other Drug use:


Is your injury related to an accident? if yes, please answer question 1-7 otherwise move on to question number 8.

1. What Kind of Vehicle Was Involved in Accident?

2. Were You a

3. If a Passenger, Please Indicate Your Location in the Car

4. Was Your Vehicle Moving When the Accident Occurred? If yes, Mph?
5. Did Your Vehicle Hit Other Vehicle(s)? If yes, Where?
6. Did Other Vehicle(s) Hit Your Vehicle? If yes, Where?
7. Describe Accident Including Causes and Surrounding Circumstances

Parent Signature:

Date:


Reviewed by MD:

Date:

MEDICAL HISTORY FORM (CONTINUED)

8. Please mark the area(s) in the diagram below where you are having pain:

9. Where is your pain located?

10. Does your pain radiate anywhere? Where?

11. When did it start?
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12. How long have you had the pain?

13. Did it start:

14. How often does the pain occur?

15. Has the pain intensity changed since it began?

16. How did it start?

17. What makes the pain better?

18. What makes the pain worse?

19. Check all those that describe your pain
20. What is your current level of pain on a scale from 0 to 10, with 0 being no pain and 10 being severe?

21. What tests have been done?

22.

23. What treatment have you tried for your pain?

Patient Signature:

Date:


Reviewed by MD:

Date:


MEDICAL HISTORY FORM (Continued)

Patient Name:

Today's Date:


Previous Medications Tried:

NSAIDS
Aspirin
Ibuprofen
Advil
Motrin
Naprosyn
Sleep Medicines
Ambien
Restoril
Benedryl
Halcion
Antidepressants
Elavil
Amityptilline
Prozac
Effexor
Zoloft
Deseryl
Paxil
Pamelor
Serozone
Desipiramine
Remeron
Narcotics
Vicodin
Darvocet
Tylenol 3
Tylox
Codeine
Percocet
Percodan
MS Contin
Cxycontin
Demerol
Morphine
Methadone
Dilaudid
Relaxation
Flexeril
Valium
Xanax
Ativan
Librium
Pain Medication
Neurontin
Klonopin
Dilantin
Baclofen
Ultram
Prozocin
Mexitil
Prazocin

Please list if you have any Allergies:

Allergies





Reaction





Please list all previous Surgeries:

Surgeries





Date





Medications you take at home (including pain medicines)

Medicine






Dose






How often






Last dose







Patient Signature:

Date:


Reviewed by MD:

Date:


ASSIGNMENT OF BENEFITS


Patient Name:

Address:

Date of Loss:

1. I , the undersigned, hereafter referred to as "the patient" do hereby assign all of my rights and interests to NJ Pain, Spine & Sports Associates, hereafter referred to as "the medical provider" to pursue and obtain payment on my behalf. This assignment shall include but is not limited to, all rights available to me pursuant to the Personal Injury Protection Statutes of the State of New Jersey.
2. I, assign, to the medical provider, all my rights and benefits under the insurance contract for payment for services rendered to me. However, upon consent of both parties, same shall be revocable.
3. I, the patient, do hereby understand and acknowledge that if I willfully refuse to comply with reasonable requests of the insurance carrier, payment of my medical bills may be denied and I will be held responsible for same.
4. I, the patient, authorize my bodily injury attorney to pay directly to the medical provider any monies due on my account, or, have same deducted from any settlement made on my behalf.
5. I, the patient, do hereby direct my health insurance carrier and/or other insurance carrier to issue payment on my behalf directly to the medical provider. The check should be made payable to the medical provider. Further, in the event that the health carrier and/or other insurance carrier fails to forward the check to the medical provider, I will endorse and sign the check to the medical provider within (5) days of receipt of same.
6. I, the patient, do hereby acknowledge that I will not file suit and/or arbitration for the payment of the above provider’s medical bills unless I am requested to do so by the medical provider. I understand that the above referenced medical provider has an attorney and will collect payment on my behalf from the insurance carrier.

Patient Signature:

Patient Name:

Dated: