LENNOX SPECIALTY GROUP

LENNOX SPECIALTY GROUP Great expectations, Great results New Patient Intake Forms Your completed intake paperwork helps our physicians and other providers get to know you and your medical history better. We rely on its accuracy and completeness to provide you with the best possible care. Please inquire at our front desk or call (404) 267-5564 if you have any questions on how to complete any section of this form. PATIENT INFORMATION Sections with an ( * ) are required fields. Patient Name*: DOB*: / / Sex: Male Female Street Address: City: State: Zip: Home Phone: Work Phone: Cell Phone*: Marital Status: (circle one) Single Married Divorced Other Social Security Number: - - Date of Accident*: Type of Accident: Slip and Fall Motor Vehicle Accident Work Related Other Attorney*: Case Manager: Telephone Number*: Emergency Contact: Name Phone Number Relation to you: Referring Physician/Office Name*: Primary Care Physician: Pain History Chief Complaint (Reason for your visit today)? Does this pain radiate? If so where? Please list any additional areas of pain: Use this diagram to indicate the area of your pain. Mark the location with an X.* Please Circle all of the following treatments you have had for pain relief: Spine Surgery Did this: Help pain Worsen Pain Not Change Pain Treating Office? Physical Therapy Help pain Worsen Pain Not Change Pain Chiropractic Care Help pain Worsen Pain Not Change Pain Brace Support Help pain Worsen Pain Not Change Pain Hot/Cold Packs Help pain Worsen Pain Not Change Pain Massage Therapy Help pain Worsen Pain Not Change Pain Medications Help pain Worsen Pain Not Change Pain TENS Unit Help pain Worsen Pain Not Change Pain Other Help pain Worsen Pain Not Change Pain Date:

Patient Medical History Patient Name: DOB: List any medication that you were taking prior to the accident*: Are you allergic to any medications*? (Please circle one) YES NO UNKNOWN If yes, which medications? Date of Last Medical Exam: With Whom? List of Major Surgeries 1.) Date: 2.) Date: Social and Occupational History Employed by: Unemployed Housewife/Househusband Student Type of work: Number of children and ages: (1.) Do you smoke cigarettes/tobacco*? YES NO (2.) Do you use any illegal substances*? YES NO (3.) Do you consume alcohol*? YES NO OCCASIONALY (4.) Are you HIV/AIDS positive*? YES NO Females Only Date of last menstrual cycle: Is there a possibility that you may be pregnant? YES NO If yes, due date: Currently taking birth control? YES NO Currently taking hormone replacement? YES NO Previous Illnesses Please advise which of the following conditions you have ever had. ASTHMA: SEIZURES: NERVIOUS CONDITIONS: ARTHRITIS/BACK PAIN: HEART PROBLEMS MENTAL ILLNESS DEPRESSION: DIABETES: CANCER: HIGH BLOOD PRESSURE STROKE HEADACHES: Family History Has your mother or father had any of the above conditions? Mother: If deceased, age and cause: Father: If deceased, age and cause: FOR OFFICE USE ONLY: ENTERED INTO ECW FOR MEANINGFULL USE? STAFF SIGNATURE Patient Pain Scale Questionnaire: 1 P a g e

PLEASE INDICATE THE LEVEL OF PAIN FOR THE AREAS THAT YOU ARE CONCERND ABOUT. PAIN SCALE IS ON A ZERO (0) TO TEN (10) SCALE. ZERO BEING NO PAIN AT ALL AND TEN BEING SEVER PAIN. FRONT: HEAD/FACE /10 NECK/SHOULDER(S) /10 CHEST /10 RIGHT/ LEFT UPPER ARM /10 ABDOMAN /10 RIGHT/LEFT LOWER ARM OR HAND /10 HIP /10 RIGHT/LEFT THIGH /10 RIGHT/ LEFT KNEE /10 RIGHT /LEFT LOWER LEG CALF /10 RIGHT/LEFT ANKLE /10 RIGHT/LEFT FOOT /10 BACK: BACK OF HEAD / 10 UPPER BACK /10 MIDDLE BACK /10 LOWER BACK /10 BUTTOCKS /10 2 P a g e

ACCIDENT INFORMATION/PERSONAL INJURY Health Insurance Information: Please provide front desk with a copy of your insurance card. Primary Insurance Company: Telephone #: Policy Holder Name: Policy Holder Birthday: Address: Identification#: Group #: Attorney Information* Firm Name: Attorney Name: Phone Number: Fax Number: Automobile Accident Information* Date of Accident: Med Pay? YES NO If yes, how much? $ Insurance Company: Claim #: Adjuster Name: Phone Number: Other Accident / Incident Information Other Accident (Describe Briefly) Date of Accident: Insurance Company: Claim #: Adjuster Name: Phone Number: Pharmacy Information*: If possible, would you like your prescriptions called into your local pharmacy? [ ] Yes [ ] No If yes: Pharmacy Name: Pharmacy Phone # E-mail address: 3 P a g e

Pain Procedure and Diagnostic Testing History Interventional Pain Treatment History Epidural Steroid Injection - (Circle all levels that apply) Cervical/ Thoracic/ Lumbar Joint Injection Joint(s) Medial Branch Blocks/ Facet Injections (circle levels) Cervical/ Thoracic/ Lumbar Nerve Blocks Area/ Nerve(s) Radiofrequency Nerve Ablation (circle levels) Cervical/ Thoracic/ Lumbar Spinal Cord Stimulator Trial only/ Permanent Implant Trigger Point Injections Where? Vertebroplasty/ Kyphoplasty Level(s) Other - Which of these procedures listed above have helped with your pain? Diagnostic Test and Imaging Mark all of the following tests that you ve had related to your current pain complaints: MRI of the Date: X-Ray of the Date: CT Scan of the Date: EMG/NCV Study of the Date: Other diagnostic testing Date: I have not had ANY diagnostic testing for my current pain complaint. Mark the following physicians or specialists you have consulted for your current pain problem(s): Acupuncturist Chiropractor Orthopedic Surgeon Neurosurgeon Internist Physical Therapist Rheumatologist Neurologist Other Please list any other treatments, procedures, surgeries, or hospitalizations (with dates) that you have had in regards to this injury. (1.) (2.) (3.) (4.) (5.) Authorizations and Releases / Financial Policy* 4 P a g e

Name: DOB: Consent for Treatment I, the undersigned, hereby authorize the Doctors of Lennox Specialty Group (LSG) and whoever they may designate as their assistants(s) to preform diagnosis test, and to administer treatment as is necessary to me. I also certify that no guarantee or assurance has been made to the results that may be obtained. Consent for Treatment of Minor I hereby authorize the Doctors of LSG, and whoever they may designate as their assistants(s) to preform diagnosis test, and to administer treatment as he/she deems necessary to my child, (Child s name) of which I am the legal guardian. Authorization to Release Medical Information I, authorize the release of any medical information necessary to process my insurance claim(s) and also to certify all insurance information given by me to this clinic is correct and complete. Request for Payment of Benefits to Provider of Care I hereby authorize my Insurance Company/Insurance Administrator to pay unto Lennox Specialty Group for any benefits allowable and otherwise payable to me under my current policy, as payment toward the total charges for professional services rendered. I have agreed to pay, in a current manner, any balance of said applicable charges out of the proceeds of my settlement and understanding that may attorney with be billed for said balance. I agree that this office be given power of attorney to endorse/sign my name on any and all draft for payment of my outstanding medical bill only. Attorney Representation and Protection of Balance I, the undersigned patient am directing my Attorney,, to pay any outstanding bills out of my settlement and, in effect, protecting any such balance. I hereby make and declare the instructions herein contained to be irrevocable. I fully understand that I am directly responsible for all medical bills and this agreement is made solely for the doctor s additional protection and consideration of his/her awaiting payment is not contingent on any settlement, judgment or verdict by which I may eventually recover said fee. I have been advised that if my attorney does not wish to cooperate in protecting the doctor s interest, the doctor will not await payment, but will require me to make payment as services are rendered. Payment Policy Health Insurance: Proof of Insurance must be provided in order for us to file claims with your insurance company. Please understand that the benefits through health insurance policies differ. Insurance companies pay according to your individual policy limits. Benefits are between you and your insurance company. You with your insurance company MUST handle any discrepancy regarding benefit coverage. Any portion of your bill that is not pain by your health insurance will be billed to your Attorney and will be paid at the time of your settlement. Auto Insurance: We cannot file against the adverse driver s insurance in an automobile accident. If Med Pay is available, we can and will file against either your auto insurance, or the owner of the vehicle you were a passenger in. If medical bills are available there may be a maximum allowable amount of coverage, which may not cover all charges in full. In that event you will be responsible for the remaining balance and your Attorney will be billed. Worker s Compensation: We will file with your employer s workers compensation insurance company upon approval of each visit or procedure by the proper authority in the case. Should the case be controverted or denied for any reason, we cannot file with the workers compensation insurance on future and you will be responsible for the unpaid claims unless financial arrangements have been made with your attorney. Patient Refund Policy The Doctors of Midtown Specialty Group expect to be paid by the first available means whether by health insurance, med pay or settlement of your case. Should an overpayment be made and you have a credit balance on your account, a refund will be issued to either you or the appropriate party. I UNDERSTAND, AGGREE TO AND WILL ABIDE BY ALL OF THE ABOVE. Patient Name or Responsible party: Print Name Signature Date 5 P a g e

LETTER OF PROTECTION CLINIC: LENNOX SPECIALTY GROUP ATTORNEY: PATIENT NAME: PATIENT #: I, hereby authorize and direct my attorney to pay directly to Midtown Specialty Group such sums as may be due, from all monies received which are intended, in whole or in part, as payment, reimbursement, or compensation for medical services rendered. These funds include, but are not limited to, all automobile medical payments, all group or private medical insurance payments and all sums received through any settlement, judgment, verdict, or arbitrator s award. I hereby further give an irrevocable lien in favor of Midtown Specialty Group on my claim for personal injuries and on all funds paid, from any source, as payment, reimbursement, or compensation for medical services rendered. This lien is to cover all outstanding charges owed to Midtown Specialty Group after auto insurance has paid. I understand that this in no way relieves me of my personal responsibility to pay all charges incurred at Midtown Specialty Group, and/or its affiliates and subsidiaries during the course of treatment. This agreement is made only for Midtown Specialty Group additional protection and in consideration of awaiting payment. I also understand that such payment is not conditional on any settlement, judgment, or verdict by which I may eventually recover said fee. I have been advised that if my attorney does not wish to cooperate in protecting Midtown Specialty Group interest, Midtown Specialty Group will not await payment, but require me to pay on my account and keep it on a current basis. Patient s Signature (Parent if Minor) Date As the attorney for the patient mentioned above, I agree to observe all the terms above. I also agree to withhold such sums as may be necessary to adequately protect Midtown Specialty Group from all monies received, which are intended, in whole or in part, as payment, reimbursement, or compensation for medical services rendered. These funds shall include, but not be limited to, all group or private medical insurance payments, all automobile medical payments, all worker s compensation medical expense payments, funds, medical payment benefits, ad all sums received through any settlement, judgment, verdict, or arbitrator s award. Attorney s Signature Date PLEASE RETURN FAX TO 404-267-5567 ATTN: PATIENT INTAKE 6 P a g e

LENNOX Specialty Group ATTN: 3286 BUCKEYE RD, ST 130 Atlanta, GA 30341 7 P a g e