NEW YORK SPINE INSTITUTE Medical solutions lor SIIine disorders

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e I 1l1li 1 NEW YORK SPINE INSTITUTE Medical solutions lor SIIine disorders ALEXANDRE B. DEMOURA, MD PC PA11ENT DEMOGRAPHIC NAME: DATE I I ADDRESS:,CITY: STATE: ZIP: PHONE: (HOME),(CELL) (OTHER) 5.5.# SEX M I F D.O.B.,AGE ALLERGIES TO MEDICATION: OTHER MEDICAL ISSUES: IS THE PATIENT WORKING? YES / NO LIMITED DUTY: DO YOU HAVE AN ATTORNEY? YES/ NO DID INJURY OCCUR AT: WORK: CAR ACCIDENT: OTHER HOW DID INJURY/ILLNESS OCCUR? PLEASE INDICATE BELOW HOW YOU WERE REFERED TO OUR OFFICE: DOCTOR: PHONE # '-(----1 ATTORNEY: PHONE # >-(---J BY PATIENT: INTERNET/MAGAZINE AD/OTHER EMAIL ADDRESS: NYS FORM DEMO (Rev 10/2012)

HISTORY: PLEASE DESCRIBE YOUR PAIN AS BEST YOU CAN ON THE DRAWINGS BELOW: LOCATION OF PAIN OR OTHER SYMPTOMS: ON A SCALE FROM 0-TO-l0, HOW SEVERE IS THE PAIN, (10 BEING THE WORST) 1 2 3 4 5 6 7 8 9 10 HOW OFTEN IS THE PAIN IS THE PAIN REFERRED TO ANOTHER PART OF YOUR BODY? PAIN DRAWING & () SCALE REVIEW r~ ~- ) ~!' 1 riol.. \ \ r ) l I \.f \ ( ~,...n ill \ fl ( {~d ~ I ~ ~~ -'='v4 \ \ \ 11!1' I i\\ I ( I J \( F'Ps SENSATION: HOW LONG HAVE YOU HAD THIS PROBLEM? WHAT KIND OF NON-SURGICAL TREATMENT HAVE YOU HAD TO DATE? PHYSCIAL THERAPY? YES I NO, IF YES HOW OFTEN? CHIROPRATIC CARE? YES I NO, IF YES HOW OFTEN? ACCUPUNCTURE? YES I NO, IF YES HOW OFTEN? MEDICATIONS? NONE: ANTI-INFLAMMATORY: WHICH? MUSCLE RELAXANTS: WHICH? PAIN KILLERS: WHICH? ANTI-DEPRESSANTS: WHICH? EPIDURAL STERIOD INJECTIONS: -!.!YE:.::!S:...J/~NO!:!..!H~O:!.!W~M!.!::A!!.!N'!..Y~TI!!.!M!.!:E:::!.;S?!...

Insurance Information Commercial Insurance: Primary Insurance Insurance Compo Insurance ID # Policyholder Name of Birth Secondary Insurance Insurance Compo Insurance ID # Policyholder Name of Birth No Fault Insurance: Insurance Carrier of NF Claim Policy Number Adjustor Phone Number Accident Number Name Workers Compensation Insurance: WCB Case # Carrier Case # Nature of Insured Person's SSN Workers Comp Code of Injury/Illness # Injury Insurance Carrier NAME: ADDRESS: Employer NAME: ADDRESS: I IRREVOCABLY ASSIGN TO ALEXANDRE B. DE MOURA, MD, PC AND THE NEW YORK SPINE INSTITUTE ALL MY RIGHTS AND BENEFITS UNDER ANY INSURANCE CONTRACTS FOR-PAYMENT FOR SERVICES RENDERED TO ME BY ANY MEDICAL SERVICES PROVIDER EMPLOYED BY ALEXANDRE B DE MOURA, MD, PC AND THE NEW YORK SPINE INSTITUTE. I IRREVOCABLY AUTHORIZE ALL INFORMATION REGARDING MY BENEFITS UNDER ANY INSURANCE POLICY RELATING TO ANY CLAIMS BY ALEXANDRE B. DE MOURA, MD, PC AND THE NEW YORK SPINE INSTITUTE TO BE RElEASED TO ALEXANDRE B. DE MOURA, MD, PC AND THE NEW YORK SPINE INSTITUTE. I IRREVOCABLY AUTHORIZE ALEXANDRE B. DE MOURA, MD, PC AND THE NEW YORK SPINE INSTITUTE TO FILE INSURANCE CLAIMS ON MY BEHALF FOR SERVICES RENDERED TO ME. I DIRECT THAT ALL SUCH PAYMENTS GO DIRECTLY TO ALEXANDRE B. DE MOURA, MD, PC AND THE NEW YORK SPINE INSTITUTE. I IRREVOCABLY AUTHORIZE ALEXANDRE B. DE MOURA, MD, PC AND THE NEW YORK SPINE INSTITUTE TO ACT ON MY BEHALF AND REPORT ANY SUSPECTED VIOLATIONS OF PROPRT CLAIMS PRACTICES TO THE PROPER REGULATORY AUTHORITIES. THIS ASSIGNMENT OF BENEFITS HAS BEEN EXPLAINED TO MY FULL SATISFACTION AND I UNDERSTAND ITS NATURE AND EFFECT. Patient Signature Provider Name & Address: Alexandre B. de Moura, MD, PC and New York Spine Institute 761 Merrick Avenue Westbury, NY 11590

NVSI NEW YORK SPINE INST1TlJTE lielbi uims fir.1isnr*n I irrevocably assign to Alexandre B. demoura, MO, PC and the New York Spine Institute all my rights and benefits under any insurance contracts for payment for services rendered to me by any medical service provider employed by Alexandre B. demoura, MO,PC and the New York Spine Institute. I irrevocably authorize all information regarding my benefits under any insurance policy relating to any claims by Alexandre B. demoura, MO, PC and the New York Spine Institute to be released to Alexandre B. demoura, MO, PC and the New York Spine Institute. I irrevocably authorize Alexandre B. demoura, MO, PC to file insurance claims on my behalf for services rendered to me. I direct that all such payments go directly to Alexandre B. demoura, MO, PC and the New York Spine Institute, I irrevocably authorize Alexandre B. demoura, MO, PC and the New York Spine Institute to act on my behalf and report any suspected violations of proper claims practices to the proper regulatory authorities. This assignment of benefits has been explained to my full satisfaction and I understand its nature and effect. Signature of Patient: :...1...J/t...- Signature of Parent or Guardian: Hospital for Joint Diseases Orthopaedic Surgery Nassau County 761 Merrick Avenue Westbury, NY 11590. (516) 357-8777. Fax (516) 357-0087 Manhattan 530 1 st Avenue, Suite 8U. New York, NY 10016. (212) 213-5470 Queens 111-20 Queens Boulevard Forest Hills, NY 11375 (718) 261-0480 Suffolk County One Corporate Drive. Bohemia, NY 11716. (631) 218-7616 www.nyspine.com

NVSI NEW YORK SPINE INSTITUTE rekaj ~1Iia1lS IlIllIne.8 I understand that "The NEW YORK SPINE INSTITUTE" is participating only with the following insurance: MEDICARE WORKERS COMPENSATION NO FAULT All other NEW YORK SPINE INSTITUTE providers, including MRI, Pain Management, Physical Therapy, Chiropractic and X-ray DO NOT participate with any insurance companies other than MEDICARE, WORKERS COMPENSATION, NO FAULT. I understand that if my insurance is not listed above, I will be utilizing my OUT-OF NETWORK benefits for services rendered by the New York Spine Institute. I understand it is the policy of the New York Spine Institute to accept my insurance payments as payment in full, and I will only be held responsible for my deductible, copayment and co-insurance. The New York Spine Institute will accept the percentage paid by the insurance after the deductible met. I understand that if my insurance does not provide OUT-OF-NETWORK benefits, I will be responsible for payment, in full unless other arrangements have been made with the billing department. I, ' understand that I may receive the payment(s) directly from my insurance carrier for services rendered to me at New York Spine Institute. In such event, I will immediately forward such payment(s) to New York Spine Institute. If I fail to do so, I will remain responsible for the payment(s) in full. Payments turned over in excess of thirty (30) days of receipt of payment(s) from the Insurance carrier will be subject to monthly finance charges of 1.5%. I acknowledge that New York Spine Institute may seek remedies in recovering payment(s) for services rendered. X / / SIGNATURE DATE

Patient's Name: ------------ PATIENT CONSENT FORM I, the undersigned, do hereby authorize New York Spine Institute to provide me (or the patientminor mentioned above) with medical and physical care and treannent that is considered necessary and proper in diagnosing and/or treating my (or the patient-minor's) physical condition including, but not limited to, diagnostic X-Rays or Magnetic Resonance Imaging, Physical Therapy or Chiropractic services, the administration and/or injection of medications and pharmaceutical products, including, but not limited to tripper point injections, and the drawing of blood (the "Procedure(s)"), as in the judgment of personnel and/or physicians ofnew York Spine Institute deems necessary. I acknowledge that no guarantees or assurances have been given to me concerning the results or [mdings intended from the treatment or examination at New York Spine Institute. I understand that the Procedure(s) and any other treannent that I may receive appears indicated by the diagnostic and/or clinical observations performed by New York Spine. I attest that a medical staff member of New York Spine has explained to me the nature of the recommended Procedure(s), the purpose of and need for the recommended Procedure(s), the possible risks and complications of the recommended Procedure(s) and the alternatives, if any, to the recommended Procedure(s). I understand all explanations given to me and give this consent voluntarily. I conflrm that I have read and fully understand the above, and have been given the opportunity to ask questions, and that all my questions have been answered fully and to my satisfaction. This consent with cover every visit made by me (or the patient-minor) as long as I (or patientminor) remain an active patient of New York Spine Institute. Signature of Patient or Legal Guardian Relationship to Patient I declare that I have personally explained the above information to the patient or the patient representative. Provider's Signature FOR FEMALE PATIENTS ONLY: I understand that in the course of my treatment I may have x-rays or other diagnostic tests. I agree to inform the health care providers if I am or may be pregnant prior to administering any diagnostic tests. Signature of Patient or Legal Guardian Relationship to Patient Witness

H/PAA BOOKLET AVA/ALBE AT THE FRONT DESK We reserve the right to revise this notice, and to make a new notice effective for all protected health information we maintain. Any revised notice will be posted in our office, and copies will be available there. If you want to complain about violations of your privacy rights, you have the right to file a complaint with the Secretary of the Department of Health and Human Services of the United States. You may also file a complaint with us. No retaliatory action will be taken against you for any complaints you may make. New York Spine Institute has made available for review a copy of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) with regard to the use and/or disclosure of certain protected health information about me. I authorize my medical information to be released to the following: 1. Primary Care Physicians, and other Physicians & Medical Staff involved in my care. 2. Physical Therapists & Occupational Therapists involved in my care. 3. School Nurses and Physicians involved in my care. 4. Orthotics involved in my care. 5. Attorneys involved in my care. 6. Athletic Trainers and coaches involved in my care. 7. OTHER I make the following special request for confidential communications:

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