221 Madison Ave Morristown, New Jersey (973) Fax (973) PATIENT INFORMATION. Mailing Address: City: State: Zip: Birth Date:

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1 221 Madison Ave Morristown, New Jersey (973) Fax (973) PATIENT INFORMATION Marc A. Cohen, MD, FAAOS, FACS Diplomate American Board of Spinal Surgery Fellow American College of Spinal Surgery Patient Name: Mailing Address: Sex: M / F Age: City: State: Zip: Birth Date: Telephone: Home# ( ) Cell/Work# ( ) Social Security # Driver s License # Marital Status: ( ) Married ( ) Single ( ) Divorced ( ) Widowed ( ) Minor 17+under Spouse/Parent s Name: In Emergency Notify: Name Relationship Emergency Home# ( ) Emergency Work# ( ) INSURANCE INFORMATION Insured s Employer: Occupation: Employer s Address: PRIMARY Insurance Company: Under Whose Name is Policy? Primary Insurance Company Address: Group# ID# Copay (if applicable) $ Insured s SS# Insured s DOB Referral from primary care (if needed) Yes ( ) No ( ) SECONDARY Insurance Company: Under Whose Name is Policy? Secondary Insurance Company Address: Group# ID# Copay (if applicable) $ Insured s SS# Insured s DOB Referral from primary care (if needed) Yes ( ) No ( ) All professional services rendered are charged to patient. Necessary forms will be completed to expedite insurance carrier payments. The patient is responsible for all fees. Regardless of insurance coverage, it is customary to pay for services when rendered unless other arrangements have been made in advance. I irrevocably assign to The Spine Institute of Dr. Marc A. Cohen all my rights and benefits under any insurance contracts for payment for services rendered to me by The Spine Institute of Dr. Marc A. Cohen. I irrevocably authorize all information regarding my benefits under any insurance policy relating to any claims by The Spine Institute of Dr. Marc A. Cohen to be released to The Spine Institute of Dr. Marc A. Cohen. I irrevocably authorize The Spine Institute of Dr. Marc A. Cohen to act on my behalf and report any suspected violations of proper claims practices to the proper regulatory authorities. Their assignment of benefits has been explained to my full satisfaction and I understand its nature and effect. Patient Signature: Date: Minor may not sign guardian only (PLEASE COMPLETE MEDICAL INFORMATION ON OTHER DOCUMENTS AS SPECIFIED)

2 MEDICAL INFORMATION Reason for Visit: Please list all of your current medications and their dosages. Are you allergic to any medications? If so, please list: Have you had any serious illness, operations or orthopedic problems? Please give dates. Date: Date: If you have any of the following illnesses, please check and give date of onset. Arthritis (Date) Gout (Date) High Blood Procedure (Date) Diabetes (Date) Ulcers (Date) Are you currently under the care of a physician? Yes ( ) No ( ) If yes, please give name. Referred by: ( ) Friend ( ) Other ( ) Doctor ( ) Doctor s Phone # ACCIDENT INFORMATION To be filled out by patients who are here as a result of a motor vehicle accident or work related injury. ( ) MOTOR VEHICLE ( ) WORKERS COMP DATE OF ACCIDENT Attorney s Name Phone Number How did the accident happen? (Please give specific information. For example, driver of auto struck in rear by another vehicle, or passenger in auto struck by truck, etc. Names of other parties and location of accident are not necessary.) Give a brief summary of treatment. (Were you admitted to a hospital, was surgery performed? If so, please give dates and type of surgery.) What form of treatment and medications did you receive at time of treatment?

3 Marc A. Cohen, MD, FAAOS, FACS Diplomate American Board of Spinal Surgery Fellow American College of Spinal Surgery 221 Madison Ave Morristown, New Jersey (973) Fax (973) Date: Please Sign ONLY if Motor Vehicle Accident RE: Claim#: Date of Accident: Dear, Your client, our patient, recently began treatment for the above mentioned accident. Please provide this office with the following information. Amount of PIP medical benefits for this policy: $ Co Payment: % Deductible: $ Remaining Balance: $ Please fax this form back to # to us as soon as possible or send via mail to the above address. I authorized and request the disclosure of my information as described above. Print name of patient or other legal representative Signature of patient or other legal representative Date Other Locations in: Morristown Jersey City Newark Edison Clifton

4 Marc A. Cohen, MD, FAAOS, FACS Diplomate American Board of Spinal Surgery Fellow American College of Spinal Surgery 221 Madison Ave Morristown, New Jersey 0960 (973) Fax (973) To All Patients, This letter is to inform you that our office is out of network with all insurance companies. Therefore, reimbursement for your medical procedures may be sent to you. If you should receive any checks from your insurance company, please call to verify if they belong to our office. If the checks received do belong to our office, please forward them with a copy of the explanation of benefits and if the check is written out to you, please sign the back of the check and make it payable to the order of NNJOS. Should you have any questions, please contact the billing department at Ext 212. Sincerely, Billing Department Please sign and return this letter to the front desk or in surgery packet to acknowledge receipt of letter. A copy of your signature will be given to you for your records. Print Name Date Signature Other Locations in: Morristown Jersey City Newark Edison Clifton

5 Marc A. Cohen, MD, FAAOS, FACS Diplomate American Board of Spinal Surgery Fellow American College of Spinal Surgery 221 Madison Ave Morristown, New Jersey (973) Fax (973) NEW PATIENT INFORMATION Date Last Name First Name MI DOB Age Sex Weight Height Is your problem related to: Job Injury Date Right Handed Car Accident Date Other Date Left Handed Briefly describe your main problem /complaint. Also, describe the injury that caused these symptoms, if applicable. How long have you had this problem? FOR PHYSICIAN USE ONLY HISTORY OF PRESENT ILLNESS (These are preliminary notes; refer to dictation for more details)

6 Using the symbols below, please draw in the location of your symptoms on the diagrams. X = Pain O = Numbness I = Aching * = Pins & Needles If you have NECK PAIN, what percentage of pain is % Neck and % Arm (Total 100%) If you have BACK PAIN, what percentage of pain is % Back and % Leg (Total 100%)

7 Mark an X on the line indicating the Degree of the Pain (0 meaning NO Pain, 10 meaning WORST Pain) LEAST WORST What position /activity makes the pain worse /better? Worse Better Comments Bending Bowel Movement Coughing General Activity Home Remedies Lying Down Sitting Standing Walking How long can you STAND with no or minimal pain minutes. WALKING DISTANCE with no or minimal pain 0 50 ft ft ft 500+ft ½ mile+ Do you need SUPPORT to help you walk? Yes No If yes, what kind of support? Do you wear a back or neck BRACE? Yes No If yes, what kind of brace? List below the PREVIOUS PHYSICIANS (MD, DO, Chiropractor) you have seen for your main complaint /problem. Physician Specialty Dates Treatment

8 Indicate which DIAGNOSTIC TESTS you have had in evaluation of your main complaint /problem (include dates). Test Date Test Date Test Date Plain X ray EMG/NCV/SSEP CT Scan Bone Scan Arthogram Dexa Scan Myelogram MRI Diskogram Other: Past MEDICAL HISTORY Check if you have had any of the following. Comments Comments Bowel Disorders Cancer (where?) Depression Diabetes Heart Disease High Blood Pressure Kidney Disease Lung Disease Multiple Myeloma Pacemaker Polio Psoriasis Rheumatism Seizures Serious Infection Stroke Thyroid Ulcers Other List any SURGERY (S) you have had. Type Date Outcome

9 Have you had a work capacity assessment? Yes No Are you disabled through Social Security? Yes No TOBACCO USE Do you currently use Tobacco products? Yes No Started Age /Year Stopped If yes indicate the quantity per day: Cigarettes Cigars Chewing Tobacco (snuff) ALCOHOL USE Do you currently consume alcoholic beverages? Yes No If yes, indicate the quantity per day: Beer Wine Distilled Spirits Have you ever been treated for drug of alcohol addiction? Yes No DRUG ALLERGIES Drug Type of Reaction List ALL CURRENT MEDICATIONS as follows Name Dose (milligrams, grams) How Often (how many times a day) How Long WORK STATUS Full Duty Light Duty Off Duty per Physician Unemployed Retired If you are NOT working full duty: How long have you been off work?