ph: 402-390-6226

Welcome Packet

You have been scheduled to see Dr. Richard Belatti. Enclosed are: 1) A map to the Medical Pain Center, P.C. (MPC) office 2) Patient Registration Information 3) MPC Financial Policy 4) Pain History Questionnaire

Please complete and submit all five pages of the attached confidential pain questionnaire. Include as much information as you can. This will aid in the timely diagnosis and treatment of your problem. Many referring physicians’ offices forward no records to us ahead of your MPC visit. Completing the confidential pain questionnaire will provide us the background needed for your specialized care. The doctor will go over the questionnaire with you during your evaluation. In order to facilitate registration in our office, please also be sure to fill out and sign both sides of the “Welcome” sheet (Patient Registration Information and the MPC Financial Policy). You do not need to bring your x-ray or scan films with you to the appointment. We can usually obtain a written copy of the report and that is sufficient for our needs. If you have a co-payment requirement as part of your insurance plan, our contracts with your insurance plan require us to collect the co-pay amount from you at the time of the office visit. In addition, because of the large deductibles inherent in many plans, you may be required to pre-pay the full cost of a service, surgical procedure and/or co-insurance amount. For your convenience, MPC accepts cash, personal checks, VISA, MasterCard and Discover Card. If your visit will be covered by worker’s compensation or your plan requires pre-authorization, please inform MPC before your appointment. We are required to obtain the appropriate authorization for your visit prior to your arrival. MPC does not accept motor vehicle insurance – please refer to MPC Financial Policy #9. Regarding your appointment: You might not receive an injection at the time of your visit to the office. Many procedures require x-ray

guidance in an outpatient facility. You do not have to fast before your appointment. You may eat your meals before your appointment as usual. If you are driving, you may drive to and from your appointment. You do not need to arrange to have

someone else give you a ride. If you have any questions, please do not hesitate to call us at 402-390-6226. You also may visit the MPC web-site - medicalpaincenterpc.com We look forward to meeting you!

Welcome PATIENT REGISTRATION INFORMATION Date ______________________ Soc. Sec. # __________________________________ Birthdate ___________________________

Name_________________________________________________________________ Cell Phone (_____)_____________________ Last Name First Name Middle Initial Address ________________________________________________________________ Home Phone (_____)__________________

City ________________________ State _____________ Zip ___________ Sex: M __ F__

Marital Status: S M D W Employer _________________________________ Employer’s Phone (_____)_________________ Circle one Business Address ____________________________________________________ Occupation _____________________________

MEDICAL INSURANCE (Guarantor Information) *Please bring any health insurance cards with you to the appointment to copy. Subscriber Name _________________________________________ Relationship to Patient _______________________________

Social Security #______________________ Date of Birth_______________ Employer ___________________________________

Employer’s Address __________________________________________________ Employer’s Phone (_____)_________________ Medical Pain Center, P.C. personnel may contact the following (Please name at least one) to discuss any emergency information or any information about my medical condition, diagnosis, treatment, payment or other health care operation: Name of Contact(s) 1. ____________________________________ 2. ______________________________________

Relationship of Contact(s) ____________________________________ ______________________________________

Contact(s) Phone Number(s) ____________________________________ ______________________________________

MEDICAL INSURANCE PAYMENT, HEALTH INSURANCE PORTABILITY & ACCOUNTABILITY ACT (HIPAA), RELEASES & ASSIGNMENTS I request that payment of authorized Medicare/Medigap benefits be made either to me or on my behalf to Medical Pain Center, P.C. (MPC) for any services provided to me by MPC. I authorize any holder of medical information about me to release to the Centers for Medicare & Medicaid Service and its agents or my Medigap insurer any information needed to determine these benefits or the benefits payable for related services. I authorize MPC to furnish to my insurance company(s) any medical information about me which is necessary to process insurance claims on my behalf. I understand that I am responsible for all co-pays, deductibles, co-insurance, and any non-covered services. I understand that I am financially responsible for any charges accrued and not paid by the insurance company. If I have no insurance, I will pay my full charges before leaving the MPC office. I hereby assign to the Medical Pain Center, P.C. all right, title, and interest to any benefit payable for medical coverage. I authorize payment directly to the Medical Pain Center, P.C. of all insurance benefits otherwise payable to me for services rendered. I authorize the release of my medical information by the Medical Pain Center, P.C. to my other physicians or hospitals involved in my care, and any third party payer (whether an insurance company, government agency, employer, or self insurance employer or utilization review organization). I authorize the use of this signature on all insurance submissions. _______________________________________________ ________________________ Signature of Patient/Guardian/Power of Attorney Date

Medical Pain Center, P.C. – 7837 Chicago Plaza – Omaha, NE 68114                                                                  

 MPC Financial Policy 

The  following  is a statement of  the Medical Pain Center, P.C.  (MPC) Financial Policy. All patients must accept and sign  the MPC Financial Policy before  receiving  treatment.  If you should need any assistance or have any questions  regarding  these policies, please call between 8:00 am and 4:00 pm at 402‐341‐8023. 

 1) Methods of payment: MPC accepts cash, personal checks, VISA, MasterCard and Discover Card.    

 2) Precertification  or  authorization  and  your  insurance:  As  a  courtesy  to  you, MPC will  submit medical  claims  to  your 

insurance company provided we have a copy of your insurance card(s). You are responsible for verifying if providers are in‐network with your insurance company. It is your responsibility to know your insurance benefits as your plan may not cover  all  of  the  services  provided  to  you.  Your  insurance  plan  may  require  MPC  to  receive  precertification  or authorization. Following insurance processing of the MPC claim, the patient has the full responsibility for payment of any balance remaining. If the patient has no insurance coverage or does not want the insurance carrier billed, payment is due at the time of service.  

 3) Co‐payments:  Co‐payments  are  established  by  your  insurance  plan  and  are  always  due  at  the  time  of  service.  Our 

contractual agreement with your insurance carrier prevents us from waiving your required co‐pay amount.  

4) Deductibles: Your deductible  is an annual dollar amount, established by your  insurance plan, which  is deducted  from insurance benefits. This deductible amount  is your obligation and must be paid at  the  time of service. Because of  the large deductibles  inherent  in many plans, you may be required to pre‐pay the  full cost of a service, surgical procedure and/or co‐insurance amount. 

 5) Workers compensation  insurance:  If your visit will be covered by workers compensation  insurance, please  inform MPC 

before your appointment as we are required to obtain the appropriate authorization for your visit prior to your arrival.  

6) Personal  injury or motor  vehicle accident:  If  your  visit  is as  the  result of a personal  injury or motor  vehicle accident, please be advised that MPC will not be a party to any litigation suits for personal injuries. MPC requires full payment at the time of your medical care. Payment from litigation is to be sought by you for reimbursement. You may inquire with your health insurance carrier to see if your carrier will cover your medical care. 

 7) Balance due &  fees: Unless you have made other arrangements with  the business office,  the “patient balance”  is due 

within 30 days of the statement date. MPC will collect all outstanding patient balances prior to each visit. A $50 service charge will be assessed for returned checks. For each month in which there is an outstanding balance, a $5 late fee will be added  to  the  patient’s  outstanding  balance  each month.  If  your  account  is  overdue,  your  account may  be  sent  to  a collection agency. 

 8) Contacts: By providing your phone number(s) to MPC at any time during our business relationship, you agree that MPC 

and  its  affiliates  and  agents  have  Expressed Written  Consent  to  contact  you  at  those  numbers  for  personal  health information or account related reasons. You also agree to being contacted via text messages, automated dialer calls, via live operator and/or pre‐recorded messages. You agree to be contacted by any or all of these channels whether or not the phone number(s) you provide  (is)are a home phone, work phone, message phone, or any  type of mobile/wireless phone or device. If you choose to provide an email address, you also agree to receive emails for account related reasons. 

 9) Signature:  I  have  read  and  agree  to  the  terms,  conditions  and  charges  stated  above  and  I  understand  that  I  am 

responsible for my balance  in full. A photocopy of this agreement shall be valid as the original. This authorization  is to remain in effect until revoked in writing by me or my legal representative. 

 __________________________________________________  _______________________________ Signature of Patient/Guardian/Power of Attorney      Date 

. , • • CONFIDENTIAL PAIN QUESTIONNAIRE

This Confidential Pain Questionnaire and Health History will help your doctor to better understand your individual problem. Please answer as accurately and completely as possible. Answers will be kept in strictest confidence.

PLEASE ANSWER THE FRONT AND BACK OF EACH PAGE.

Name: ______________________________ Age: ___ Date: __ I __ I __

Address: -------------------------------------------------Home Phone: Work Phone: ----------------------- -----------------Emergency Contact ______________________ Phone Number: _________________ _

Relationship: _____________________ _

Who Referred You To This Clinic? ---------------------------------Who is Your Primary Physician? _______________________________ ___

Where is your pain located? __________________________________________________ _

When did your pain start? (approximate date): ____________________________________________ _

How did your pain begin? (fall, lifting, accident, etc.): __________________________________________ _

Have you seen any of the following Doctors for treatment of your pain? If so, please write in their name.

Neurosurgeon ---------------- Orthopedic Surgeon __________________ _

Neurologist ________________ _ Physical Medicine ________________________ _

Internal Medicine Family Practice _____________ _ ------------------Rheumatologist _______________ _ Surgeon ____________________________ _

Psychiatrist (M.D.) ________________ _ Psychologist (PhD) ______________ _

Chiropractor ________________ ___ Others _______________________________ _

How has your pain changed since it began? __ better __ worse __ same

Do you think that the pain is due to something more serious or different from what the doctors have told you? DYES D NO

Have you had any of the following for treatment of your pain? Chiropractic treatment . . . . .. .......... . . .. D NO DyES ... ................ ................ ..... ..... .. . TENS ....... .. . ...... . ... ... ..... .... D NO DyES ......... ............. .... ..... ............. ... . Acupuncture . . . . . . . . . . . . . . . . . . . . . . . . . . . D NO DyES .......... .... ....................... .... .. ... . . Nerve Blocks ... .. .. . ... ...... . ......... D NO D yES .. .. ...... ... ......... ... ...................... . Physical Therapy. . . . . . . . . . . . . . . . . . . . . . .. D NO DyES .... ... ... .. ... ......... ... .... ...... ......... . . Psychotherapy .... . .. .. ... ...... ... . . ... D NO D yES .. .... .. ....... ...... ...... .. .... ... .. ......... .

If yes, did it help? DYES DNO DYES DNO DYES DNO

DYES DNO DYES DNO D YES DNO

, ' . • Have you had any ofthe following tests? • If yes, at what facility?

X-Rays DNO DYES

EMG DNO DYES

CAT scan DNO DYES

MRI scan DNO DYES

Myelogram DNO DYES

OTHER (list) ___________________________ _

The following words can be used to describe pain. Please CIRCLE ONLY TWO (2) or THREE (3) that apply to your pain.

shooting pulling hot

radiating throbbing cold

tingling dull burning

numb aching naggmg

sharp pounding unbearable

A PAIN EPISODE IS ACCOMPANIED BY: (circle all that apply)

numbness light sensitivity

" ) nngmg ears

tingling stuffy nose double vision

weakness nausea dizziness

other(s): __________________ _

spasms vomiting sweating

stabbing gnawmg other:

pricking cramping

itchy tender

-------------------------

color change in tissue temperature change in tissue change in sense of smell / taste

PLEASE INDICATE HOW THE FOLLOWING FACTORS AFFECT YOUR PAIN.

Worse Better No Effect Standing .................. .................. ............ . Walking .. .. ............................................ . Arising from a chair. ................. .. ......... . Lifting .. .. .............................................. . Housework (vacuuming, etc.) ............. .. Sitting .. .... ........................ .................... . Driving .... ........................................... . Bending ... ... ..... J ••••••••••••••••••••••• •• •••••• •••• •

Coughing ............................................. . Sneezing .. ........................ ... ................. . Lying Down .............. ...... ..... .............. . . Nights ....... .. .. ............... .. .... .. ...... ...... ... .

Is there anything else that worsens your pain? ____________________________________________________ _

How often do you experience your pain? D continuously Ddaily D weekly D other ______________________ _

How long does a pain attack last? D seconds D minutes D hours D days D constant

Are there times that you have no pain at all? D No 0 Yes If yes, how long? ____________________________ ___

2 --- --------------------------------------------------

e Use the fOllowin!ures to indicate the area of your pain. Please use an X to indicate where the pain begins and arrow(s) to show where it spreads.

Please rate your pain:

Head %

Neck %

Rt. Ann %

LtAnn %

Back %

Rt. Leg %

Lt. Leg %

Other %

TOTAL = 100 %

Do you have weakness in your arms or legs? ONo o Arms o Legs

Is there a limit to how far you can walk?O No 0 Yes If yes, how far? _________________ _

Has your ability to control your bladder changed? 0 No 0 Yes If yes, how? ________________ _

Has your ability to control your bowel movements changed? 0 No 0 Yes If yes, how? ____________ _

Please draw an X on the line to indicate the level of your pain at ... It's Worst:

NO PAIN 0 ---------------------------10 UNBEARABLE PAIN

It's Best: NO PAIN 0 -------------------------10 UNBEARABLE PAIN

HEALTH HISTORY please check (-Y) conditions you have or have had.in the past. o Seizures o Migraines 0 Stroke 0 Cataracts o Glaucoma o Asthma 0 Emphysema b Bronchitis o Heart Disease o Heart Attack 0 Palpitations 0 Congestive Heart Failure o Angina o Anemia 0 High Cholesterol 0 High Blood Pressure o Hepatitis o Liver Disease 0 Cirrhosis 0 Irritable Bowel Syndrome o Kidney Disease o Ulcers 0 Diverticulitis 0 Diabetes o Joint Disease o Arthritis 0 Thyroid Problems 0 Bleeding Disorders o Nerve Injuries o Polio 0 Muscle Disease 0 Multiple Sclerosis o Gout o Shingles 0 Tuberculosis 0 Prostate Problems o Cancer o Depression 0 Psychiatric Care 0 Other ____________ _

3

SURGERY - Please list all operations y_ ave had (include approximate dates). e

ALLERGIES. medication response

MEDICATIONS - Please list all medicines you take

medication dose # times per day reason

FAMILY HISTORY - Have any of your blood relatives had any of the following?

o Cancer o Heart Disease o Diabetes o High Blood Pressure o Asthma o Arthritis o Tuberculosis o Back Problems o Other _________________ _

SOCIAL HISTORY Do you smoke? DYes

ONo

Do you drink alcohol? 0 No 0 Yes

If yes, o Quit

packs per day: __ for how long: ___ years if quit, how many years ago? __ years.

drinks per day: __ drinks per week: __

Do you drink caffeinated beverages ONo 0 Yes Number per day: __

Marital status: 0 sin{;de o married o divorced o remarried o separated o widowed

Who lives with you at home? 0 spouse o children o others: __________________ _

Are you able to exercise regularly? o No 0 Yes Doing what? ____________ Times per week: __

Do you have any hobbies? o No 0 Yes Doing what? ____ .. _________________ _

Occupation: _________________ _ Spouses Occupation: ______________ _

What is your current employment status? o employed full time 0 employed part time 0 homemaker 0 retired o unemployed due to pain 0 unemployed for other reason ____ _

If unemployed, how long have you been out of work? __ months ----years

Have you had to change your type of work? o No 0 Yes In what way? ________________ _

4

H~ve y~u-retained an attorney as a resUlais problem?

If yes, what is your lawyer's name? address?

phone number?

ONo

SYMPTOM HISTORY - Please check if you CURRENTLY have any of the following.

CONSTITUTIONAL CARDIOVASCULAR o weight loss o chest pain o loss of appetite o irregular heart beats o loss of sleep o poor circulation o night sweats o ankle swelling o chills o varicose veins o fever o dizziness RESPIRA TORY o fainting o persistent cough

o short of breath EYES o wheezing o double vision o coughing up material o flashes or halos o poor vision GI o eye pain o constipation

o diarrhea EAR NOSE THROAT . 0 bloating o earache o hearing loss o ringing in ears o loss of smell o nose bleeds o sinus problems o trouble swallowing

please do not write below this line

gait DTR motor sense SLR seat SLR sup tend

o excessive thirst o gas o indigestion o nausea o rectal bleeding o hemorrhoids o vomiting

GENITOURINARY o blood in urine o frequent urination o lack of bladder control o painful urination

W: tend distra sim regional overre

WOMEN only o abnormal pap smear o vaginal bleeding o breast lump o nipple discharge o hot flashes o extreme menstrual pain o vaginal discharge

MEN .only o breast lump o erection difficulties o lump in testicles o penis discharge o sore on penis

MUSCULOSKELETAL o muscle pain Ojoint pain o gout o stiffness

SKIN o bruise easily

· 0 hives Ditching o rash o moles that change

fl ex

fl ex

5

NEUROLOGICAL o fainting o blackouts o paralysis o tremors

PSYCHIATRIC o I feel depressed o I feel unhappy o nervousness o memory problems

ENDOCRINE o thyroid problems o sweating o excessive thirst o excessive urination o heat intolerance o cold intolerance

HEMA TOLOGIC o anemia o easy bruising o easy bleeding

rr Ir rb lb

rr Ir rb Ib

© 1997 R.G.Belatti, M.D.