Brevard Orthopaedic Spine and Pain Clinic, Inc. THE B.A.C.K. CENTER Pt. Name: _______________________________________ Pt. DOB: ____________________ 1 TBC From Version 3.0 Update 3/2015kgl Dear _______________________________________ Date: ____________________ Welcome to THE B.A.C.K. Center We have received your paperwork and are happy you chose us for your orthopedic needs Appointment Date: _________________ Time: __________________ with _______________________ X-Rays Appointment Date: ____________________ Time:_________ Located 5th Floor in the Crane Creek Medical Building Please note –x- ray appointments may be added to schedule at a later time You will be notified of this change via telephone 2222 S. Harbor City Blvd 650 S Courtenay 6 th Floor, Suite 610 Parkway Suite 100 Melbourne, FL 32901 Merritt Island, FL 32952 Enclosed you will find your NEW PATIENT PAPERWORK. It is important that you complete this paperwork in its entirety and bring it with you for your appointment, you may go online and print this form out at www.nextmd.com or http://www.thebackcenter.net/pdf/new-patient-information.pdf. Your primary care physician or the physician that referred you should have faxed your medical records to our office. If they have not, you will need to contact them to do so. If your insurance plan requires authorization or referral from your primary care physician to be seen by a specialist. IT IS NECESSARY that you contact your PCP for the authorization. Our office must receive authorization before you are seen for your appointment. YOU MUST BRING any previous x-rays, MRI's, CT/Myleograms or other films with you to your appointment. It is necessary to hand carry the actual films themselves or discs with film on them and not just the reports. We are unable to see you without them, your appointment WILL be rescheduled without these. If you have had any previous testing such as bone density studies, NCV/EMG or bone scans; please bring the reports only to the visit. We will also need a current list of medications (including dosage and directions), allergies to medications and past surgical and medical history. THIS IS A FRAGRANCE FREE OFFICE Please help us to accommodate our patients who are chemically sensitive to fragrances and other scented products. Thank you for not wearing perfume, aftershave, scented hand lotion, fragranced hair products and/or similar products. If you have any questions, please feel free to contact our office at: 321-723-7716 ext. _______ We look forward to seeing you and participating in your care Thank you again for choosing THE B.A.C.K. Center. Brevard Orthopaedic Spine and Pain Clinic, Inc. THE B.A.C.K. CENTER Pt. Name: _______________________________________ Pt. DOB: ____________________ 2 TBC From Version 3.0 Update 3/2015kgl Authorization for treatment and Assignment of Benefits Health Information Release and Privacy Practice Notice I, _______________________________ herby authorize THE B.A.C.K. Center or any of its physicians/providers (Patient/Guarantor Name) to evaluate and treat me for conditions requiring medical, surgical and pain management treatment. I authorize THE B.A.C.K. Center to furnish my insurance company(ies) or representative with any and all information that may be contained in my medical records. I also acknowledge that I have the right to restrict health information shared with my health insurance company(ies) if I pay cash or out of pocket in full for my visit. It is my responsibility to notify THE B.A.C.K. Center and sign an Assignment of Benefits from for each visit that I do not want billed to my insurance company(ies). I further acknowledge that my health insurance company(ies) may not pay for future visits, procedures, or surgeries as a results without release of previous PHI in where my insurance company was not billed. I further authorize payments to THE B.A.C.K. Center for provider benefits otherwise payable to me, but not to exceed the regular charges for this period of treatment. I understand that I am financially responsible to THE B.A.C.K. Center for charges/benefits not covered by this assignment. I also understand THE B.A.C.K. Center is not responsible for the terms of the contract(s) which I have with my insurance company(ies) and that in certain circumstances my insurance company(ies) may determine to pay all, some, or none of the charges resulting from my medical care provided by THE B.A.C.K. Center I authorize the person(s) listed below to have access to any and all of my health information including HIV, drug and alcohol abuse, and psychiatric records. THE B.A.C.K. Center is permitted to share any medical information with them, including but not limited to test results and information disclosed during office visits. Authorized Person(s) Full Name:________________________________________________________________________ You may notify me of test results, appointment reminders and other information regarding my health information as follows, please initial what applies below _____ Detailed Message via - Please Circle which below: Email Cell Home Work _____ Okay to send Text for appointment reminders _____ I do NOT wish to have any detailed messages left on any machine regarding health information By signing this document, I acknowledge, understand, and direct that this authorization will remain in effect until revoked by me in writing. I, ___________________________ acknowledge that I have received and understand THE B.A.C.K. Center Notice of Privacy Practices for 2014 ________________________________ ______________________________________________ ________________ Printed Name Signature Patient/Guarantor Date

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