STATE ZIP SPOUSE OR GUARDIAN INFORMATION

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1 REFERRED BY FAMILY DOCTOR DARRELL C. BRETT, M.D., P.C. BRET GENE BALL, LLC 10,000 SE MAIN, SUITE 360 PORTLAND, OREGON NEUROLOGICAL SURGERY PATIENT INFORMATION (PLEASE PRINT) DATE PATIENT S LAST NAME FIRST NAME MIDDLE NAME SEX AGE BIRTHDATE M F PATIENT S ADDRESS MARITAL STATUS M S D W CITY STATE ZIP PATIENT S PHONE CELL OR MESSAGE PHONE PATIENT S SOCIAL SECURITY NUMBER PATIENT S EMPLOYER EMPLOYER PHONE NUMBER OCCUPATION LAST NAME FIRST NAME MIDDLE NAME SPOUSE OR GUARDIAN INFORMATION BIRTHDATE RELATIONSHIP TO PATIENT BILLING ADDRESS (IF DIFFERENT THAN PATIENT) SPOUSE SOCIAL SECURITY NUMBER CITY STATE ZIP HOME PHONE NUMBER SPOUSE EMPLOYER Was this a WORKER S COMPENSATION INJURY? Yes No AUTO ACCIDENT Yes No Complete the section below if answered yes to one of the above. Insurance Co. Address Subscriber Employer Claim or Policy # Claim Rep Date of Injury Driver s License # Attorney s Name Phone Address HEALTH INSURANCE (Please complete for all claims regardless of type of accident) Insurance Co. Address Subscriber Employer Subscriber Group # I.D. or Soc. Sec. No. NAME OF FRIEND, RELATIVE, GUARDIAN OR PARENT NOT LIVING WITH YOU (For Medical Emergency) Name Relationship Address Phone *** AUTHORIZATION FOR RELEASE OF INFORMATION & ASSIGNMENT OF BENEFITS*** TO OUR PATIENTS: Please be informed that Darrell C. Brett, MD, PC and Bret Gene Ball, LLC have separate and independent neurosurgical practices. I authorize payment of medical benefits to Darrell C. Brett, MD, PC and Bret Gene Ball, LLC. I also authorize release of any medical information necessary to process the claim. I understand that I am financially responsible for charges not covered by my insurance plan. In the event of litigation, upon settlement, payment is to be made to Darrell C. Brett, MD, PC or Bret Gene Ball, LLC. Signature: Date:

2 Please complete the following: Name: Date: Age: Please list the age and information for your blood relatives: Age Major illnesses lf dead, age at death & cause Father Mother Brothers Sisters Sons or Daughters Operations Hospital Year Cause or Reason Give your age at onset for any of the following illnesses you have now or have had: Age Sleep Apnea Bleeding/clotting disorder Increased Blood Pressure Lung Disease Hepatitis or Angina Arthritis Diabetes Heart Disease/Attack Please list any other major illnesses or significant medical conditions: List any medicines you now take: List the medicines or substances you have had reactions to: Place an X next to any of the following tests you have had and, if you can, give the year you last had them. Year Chest X-ray Height Electrocardiogram Weight

Northwest Spine Surgery PATIENT 10000 SE Main Street, Suite 360 QUESTIONNAIRE Portland, OR 97216 Name: Birthdate: 1. What is your main concern today?

3 Northwest Spine Surgery PATIENT SE Main Street, Suite 360 QUESTIONNAIRE Portland, OR Name: Birthdate: 1. What is your main concern today? Low Back/Leg(s) Neck/Arm(s) Thoracic spine Other 2. Approximately how long have you been having pain in this region? 3. How did your pain start? (i.e. unknown, fall, lifting, car accident, etc.) 4. If 10 is the worst pain imaginable, and 0 is no pain, please circle your pain over the last TWO WEEKS: a) Please rate your WORST pain b) Please rate your LEAST pain c) Please rate your overall or AVERAGE pain Circle the words that best describe your pain: Aching Sharp Annoying Throbbing Tender Nagging Shooting Burning Pins and needles Stabbing Pinching Numb Electrical Unbearable Exhausting 6. What time of day is your pain the worst? Morning Afternoon Evening Night 7. How is your current pain, compared to when this pain episode first started? Much improved Somewhat improved No change A little worse Much worse 8. On the diagram to the right, shade the areas where you feel pain, and place an X on the area that hurts the most > 9. What makes your pain WORSE? (i.e. standing, lying down, walking, work related motions, etc.) 10. What makes your pain BETTER? 11. What is your smoking status? Current Former Never 12. Circle any TREATMENTS you have received for your current problem: Ice or Heat Massage Physical Therapy Pain Medications Antiinflammatories Chiropractor Injections Spine Surgery Rest Other 13. Circle the appropriate number to indicate the extent of the problem you are having with each of the following: (0 = NONE 10 = SEVERE) Anxiety Depression Irritability Circle any other SYMPTOMS you are having: Fever Sweating Cough Diarhea Constipation Fatigue Loss of appetite Itching Insomnia Other: Difficulty focusing Spasms Swelling Nausea Vomiting Difficulty walking Loss of balance or falls Loss of coordination or dexterity

4 DARRELL C. BRETT, M.D., P.C. F.A.C.S., F.R.C.S., (C) D.A.B.N.S. Fellow American College of Surgeons, Royal College of Surgeons (Canada), Diplomate American Board of Neurological Surgery BRET G. BALL, M.D., PH. D. NORTHWEST SPINE SURGERY Specializing in Neurological Surgery of the Spine 10,000 SE Main, Suite 360 Portland, Oregon (503) (800) Fax (503) darrellcbrettmd.com drbretball.com Office Hours: 8:00am - 4:30pm LAURENS F. JOHANSEN, M.D. KIMO HEEN, P.A.-C Melanie Stinson Clinic Administrator meldrbrett1@hotmail.com Emerald L. Nelson-Flores Office Manager emerald.nwspine@gmail.com PATIENT FINANCIAL POLICY We are committed to providing you with the best possible care and will help you receive your maximum allowable insurance benefits. However, we need your assistance and your understanding of our payment policy. Your insurance contract is between you, your employer, and the insurance Company. (Please refer to document "Understanding Your Insurance Coverage"). Not all services are covered by all contracts. We participate and accept assignment from most major payers, which means covered charges will be paid directly to us. If we do not participate in your insurance plan, you may still choose to be seen by the practice. As a courtesy to you, we will file a claim with your insurance carrier on your behalf. Any remaining balance will be billed to you once we have received a remittance from your insurance carrier. Due to current federal and insurance regulations, all co-payments, co-insurance, and deductibles are collected at time of service. We accept cash, checks, Visa, and MasterCard. Additional fees, which typically are not covered by insurance plans, will be charged for services, such as copying of medical records and completion of disability forms. A fee of $35.00 will be charged for checks returned for insufficient funds. An additional monthly fee may be charged on all past due accounts and co-pays not paid at time of the visit. Delinquent accounts sent to an outside collection agency for further collection efforts will incur an added collection fee. We encourage you to contact us promptly for assistance in the management of your account. We are here to help you and will be happy to answer any questions you may have about your treatment or insurance coverage. PATIENT FINANCIAL AGREEMENT I understand and agree that, regardless of my insurance status, I am ultimately responsible for the balance on my account for any professional services rendered. I have read the above Patient Financial Policy and have provided the Practice with true and correct insurance information. I will notify you of any changes in my health insurance coverage. A copy of this agreement may be used in place of the original. Signature of Patient, Policy Holder or Legal Guardian Date Printed Name

5 DARRELL C. BRETT, M.D., P.C. F.A.C.S., F.R.C.S., (C) D.A.B.N.S. Fellow American College of Surgeons, Royal College of Surgeons (Canada), Diplomate American Board of Neurological Surgery BRET G. BALL, M.D., PH. D. NORTHWEST SPINE SURGERY Specializing in Neurological Surgery of the Spine 10,000 SE Main, Suite 360 Portland, Oregon (503) (800) Fax (503) darrellcbrettmd.com drbretball.com Office Hours: 8:00am - 4:30pm LAURENS F. JOHANSEN, M.D. KIMO HEEN, P.A.-C Melanie Stinson Clinic Administrator meldrbrett1@hotmail.com Emerald L. Nelson-Flores Office Manager emerald.nwspine@gmail.com UNDERSTANDING YOUR INSURANCE COVERAGE Your insurance policy is an agreement between you and your insurance company. The policy lists a package of medical benefits, such as tests, drugs and treatment services. The insurance company agrees to cover the cost of certain benefits listed in your policy. These are called "covered services." Your policy also lists the kinds of services that are not covered by your insurance company. You have to pay for any uncovered medical care that you receive. Keep in mind that a medical necessity is not the same as a medical benefit. A medical necessity is something that your doctor has decided is necessary. A medical benefit is something that your insurance plan has agreed to cover. In some cases, your doctor might decide that you need medical care that is not covered by your insurance policy. Insurance companies determine what tests, drugs and services they will cover. These choices are based on their understanding Of the kinds of medical care that most patients need. Your insurance Company s choices may mean that the test, drug or Service you need isn't covered by your policy. Your doctor will try to be familiar with your insurance coverage so he or she can provide you with covered care. However, there are so many insurance plans that it s not possible for your doctor to know the specific details of each plan. By understanding your insurance coverage, you can help your doctor recommend medical care that is covered by your plan. Take the time to read your insurance policy. It s better to know what your insurance Company will pay for before you receive a service, get tested, or fill a prescription. Some kinds of care may have to be approved by your insurance company before your doctor can provide them. If you still have questions about your coverage, call your insurance company and ask a representative to explain it. Remember that your insurance company, not your doctor, makes decisions about what will be paid for and what will not. Remember that your physician, not your insurance company, makes medical decisions and recommendations about what will benefit your health status. Most of the things your doctor recommends will be covered by your plan, but some may not. When you have a test or treatment that isn't covered or if you get a prescription filled for a drug that isn't covered, your insurance company won't pay the bill. This is often called "denying the claim." You can still obtain the treatment your doctor recommended, but you will have to pay for it yourself. If your insurance company denies your claim, you have the right to appeal (challenge) the decision. Before you decide to appeal, know your insurance company's appeal process. This should be discussed in your plan handbook. Source: American Academy of Family Physicians, 2001 Informational purposes only. Does not necessarily reflect Darrell C. Brett, MD, PC or Bret Gene Ball, LLC policy.

6 DARRELL C. BRETT, M.D., P.C. F.A.C.S., F.R.C.S., (C) D.A.B.N.S. Fellow American College of Surgeons, Royal College of Surgeons (Canada), Diplomate American Board of Neurological Surgery BRET G. BALL, M.D., PH. D. NORTHWEST SPINE SURGERY Specializing in Neurological Surgery of the Spine 10,000 SE Main, Suite 360 Portland, Oregon (503) (800) Fax (503) darrellcbrettmd.com drbretball.com Office Hours: 8:00am - 4:30pm LAURENS F. JOHANSEN, M.D. KIMO HEEN, P.A.-C Melanie Stinson Clinic Administrator meldrbrett1@hotmail.com Emerald L. Nelson-Flores Office Manager emerald.nwspine@gmail.com ACKNOWLEDGEMENT AND CONSENT I understand that my health information may include information both created and received by This Practice, may be in the form of written or electronic records or spoken words, and may include information about my health history, health status, symptoms, examination, test results, diagnoses, treatments, procedures, prescriptions, and similar types of health-related information. I understand and agree that This Practice may use and disclose my health information in order to: make decisions about and plan for my care and treatment; refer to, consult with, coordinate among, and manage along with other health care providers for my care and treatment, determine my eligibility for health plan or insurance coverage, and submit bills, claims, and other related information to insurance companies or others who may be responsible to pay for some or all of my health care; and perform various office, administrative and business functions that support my physician's efforts to provide me with, arrange, and be reimbursed for quality, cost effective health care. I also understand that I have the right to receive and review a written description of how This Practice will handle health information about me. This written description is known as a Notice of Privacy Practices and describes the uses and disclosures of health information made and the information practices followed by the employees, staff, and other office personnel of This Practice and my rights regarding my health information. I understand that I have the right to ask that some or all of my health information not be used or disclosed in the manner described in the Notice of Privacy Practices, and I understand that This Practice is not required by law to agree to such requests. By signing below, I agree that I have reviewed and understand the information above. BY: (Patient) Date: BY: (Patient representative) Date:

Tracy Blum Physical Therapy, Inc NEW PATIENT REGISTRATION FORM PATIENT INFORMATION. Last Name: First Name: Middle Initial: Social Security no.

Tracy Blum Physical Therapy, Inc NEW PATIENT REGISTRATION FORM PATIENT INFORMATION Last Name: First Name: Middle Initial: Date of Birth: / / Age: Sex: M F Social Security #: / / Marital Status (circle