Dear Patient, Welcome to Colorado Brain & Spine Institute (CBSI). Where we Heal & Enhance Lives through Advanced Neurosurgical Solutions.

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1 Dear Patient, Welcome to Colorado Brain & Spine Institute (CBSI). Where we Heal & Enhance Lives through Advanced Neurosurgical Solutions. Please visit our website, for additional information including: MD bios, directions to our offices, direct phone extensions, patient education, and much more.. We are required to have you complete the forms on-line via the patient portal. If you do not have access to a computer, please complete the following new patient packet. Your paperwork must be completed and received in our office at least 48 business hours prior to your appointment. Failure to send these forms in will result in delay of your appointment time. If you are unable to keep your appointment for any reason, please provide notice 48 hours in advance. Please complete and return PRIOR to your appointment: Demographics form Insurance Information New Patient History Form Please include a copy of the front and back of your insurance card Keep a copy of the forms for your records and bring that copy to your appointment, in case there are any problems with us receiving the forms, then you will have a backup copy. Please bring the following items to your appointment: All radiographic studies (x-rays, MRI, CT on disc or films) Reports of any test or treatments related to your brain, spine or joint condition Your insurance card and all insured party information Copayment (we accept checks, Visa, Master Card, Discover) A copy of your referral/authorization (if required by insurance) A copy of the above forms you faxed/mailed to our office Thank you for choosing CBSI for your neurosurgical needs. Phone: Fax:

2 PATIENT DEMOGRAPHICS FORM Patient s Name: First MI Last Preferred Name: Address: DOB: / / (mm/dd/yyyy) Age: SSN: - - Sex Male Female Mailing Address: Home: ( ) - City: State Cell: ( ) - Zip Code: - Work: ( ) - ext. Marital Status: Married Single Divorced Widowed Other Referring Provider Phone: ( ) - Primary Provider Phone: ( ) - If you were referred by a different source than your PCP or referring physician, please indicate how you found our practice: Friend/Family Internet/Website Other Emergency Contact Name Phone: ( ) - Relationship Pharmacy Preference Address: City: State Zip Phone: ( ) - Fax: ( ) - The following questions are required for Meaningful Use, a federal mandate established by CMS. These categories were established by CMS, not by our office. These questions will not influence your medical care. These statistics are reported to CMS. Preferred Language: English French German Vietnamese Mandarin Spanish not listed Race: Hispanic Asian Caucasian African American Black or African American American Indian or Alaska Native Native American Other Undetermined Chinese Filipino Japanese Native Hawaiian Multiracial Pacific Islander Ethnicity: Hispanic or Latino Non-Hispanic or non-latino other or Undetermined Release: I hereby consent to the release of information provided to, or generated by CBSI, to my PCP, referring provider, psychologist, attorney, therapist, agency or any other party with a bonafide, pertinent interest, via verbal, written, or fax/ /protected copied disc for communication. A copy or scanned image of my signature shall be as valid as the original. Patient Signature Date

3 INSURANCE INFORMATION Please complete this form completely. Please print. Patient Name as it appears on card: Primary Insurance: Health Work Comp Auto (for Work Comp or Auto, please see below regarding accident) Name of Insurance Company ID # Group # Phone ( ) - Insurance address: City State Zip Name of Insured Member: Patient Relationship: Self Spouse Child/Other Date of Birth of Insured Member: / / (mm/dd/yyyy) (If your insurance requires a referral authorization from your PCP, please provide a copy to our office.) Secondary or Supplemental Insurance: Name of Insurance Company Check here if no secondary or other insurance: (*Please see below if Medicare is secondary) ID # Group # Phone ( ) - Insurance address: City State Zip Name of Insured Member: Patient Relationship: Self Spouse Child/Other Date of Birth of Insured Member: / / (mm/dd/yyyy) *If Medicare is your secondary insurance please indicate the reason below (required for us to file claim): Working Aged Beneficiary or Spouse with Employer Group Plan Disabled Beneficiary under age 65 with Group Health Plan No-fault insurance (including Auto) is Primary Veteran s Administration Worker s Comp is Primary Other Liability Insurance is Primary Accident Related Visits: (Complete this section only if to be billed to: Work Comp or Auto) (If billed to Auto Medical, we can only bill on your policy and only if you have proof of Medical Payments on your policy We cannot bill a third party auto insurance or other liability carrier. If no Medical Payments on your policy we must bill your health insurance.) Exact date of injury: / / (mm/dd/yyyy) WC/Auto Claim #: For Work Comp Claims ONLY: Employer at time of Injury: Occupation Work Address: City State Zip Current employment status: Employed Unemployed Retired Self-Employed Retired Authorization: I hereby authorize release of information necessary to file a claim on my behalf with CMS (Medicare) and its agents and all other insurance carriers. I authorize Colorado Brain & Spine Institute LLC PC (CBSI) to appeal on my behalf, any insurance carrier s payment or decision. Assignment: I hereby assign medical benefits otherwise payable to me to CBSI. I understand and agree I am financially responsible for any unpaid balance for services rendered along with legal fees incurred in collecting payment from me. If applicable, I understand that I am responsible for all copays, deductibles, co-insurance and balances. Release: I hereby consent to the release all information provided to, or generated by CBSI, to my PCP, referring physician, psychologist, attorney, therapist, agency, or any other party with a bona-fide or pertinent interest via verbal, written, or fax/ communication. A copy or scanned image of my signature shall be as valid as the original. Patient Signature Date

4 Patient Name: DOB: / / (mm/dd/yyyy) Present Complaint Duration of complaints/problems: PAST MEDICAL HISTORY: NEGATIVE/UNREMARKABLE OR BOX THAT APPLIES TO YOU Medical Medical Neurologic Pertinent to surgery GERD/Reflux Aneurysm Anticoagulation Therapy Anxiety Glaucoma CVA/Stroke Bleeding Disorder Gout Brain Tumor Chronic Pain Atrial Fibrillation Heart Hydrocephalus Clotting Disorder Autoimmune Disorder Hepatitis type: Migraines DVT BPH HIV Multiple Sclerosis Hemophilia - Breast cholesterol/lipids Parkinson s Narcotic use > 6 months Lung Peripheral Neuropathy w/ Anesthesia - Renal Irritable Bowel Syndrome Pituitary tumor Pulmonary Embolism - Colon Heart Attack Seizure Disorder Other: - Prostate Nasal Allergies Spinal Cord Injury Cataracts Osteoarthritis TIA Please list any other COPD Traumatic Brain Injury diagnosis not on this list: Renal Trigeminal Neuralgia - Type 1 Rheumatoid Arthritis - Type 2 Sleep Apnea Fibromyalgia : high low Vision loss PAST SURGICAL HISTORY: NO PREVIOUS SURGERIES Year of surgery: Type of surgery: If you require more room, please write surgeries on separate piece of paper and attach.

5 Patient Name: DOB: / / (mm/dd/yyyy) ALLERGIES: No known drug List medication, food, and environmental Allergic to: Reaction: If you require more room, please write on separate piece of paper and attach. CURRENT MEDICATIONS: NONE Medication name & dose Example: Atenolol 50mg How often Example: one tab daily, one tab twice daily, two tabs at bedtime If you require more room, please list your medications, doses & frequency on a separate sheet of paper and attach. SOCIAL HISTORY/ADDITIONAL INFORMATION: Tobacco use: Alcohol Use Current every day smoker Current some day smoker Former Smoker Never Smoker Passive Smoke Exposure Yes No No Yes, Type: How many drinks per day Recreational Drug Use: No Yes, Type: How often Employment Status: Employed Unemployed Retired Disabled Self-employed What is or was your occupation: Marital Status: Married Partner Single Divorced Widowed Handedness: Right-hand dominant Left-hand dominant Ambidextrous Height Weight: lbs.

6 Patient Name: DOB: / / (mm/dd/yyyy) FAMILY HISTORY: UNKNOWN ADOPTED NO FAMILY HISTORY OF CHRONIC DISEASE the diagnosis that apply for each of your immediate family members: Mother Bowel Breast Colon Heart Liver Lung Skin Other Father Bowel Breast Colon Heart Liver Lung Skin Other Sister Bowel Breast Colon Heart Liver Lung Skin Other Brother Bowel Breast Colon Heart Liver Lung Skin Other Maternal Grandmother Bowel Breast Colon Heart Liver Lung Skin Other Maternal Grandfather Bowel Breast Colon Heart Liver Lung Skin Other Paternal Grandmother Bowel Breast Colon Heart Liver Lung Skin Other Paternal Grandfather Bowel Breast Colon Heart Liver Lung Skin Other This information is true and complete to the best of my knowledge. Patient Signature: Date: