Neurologic & Spine Institute of North Texas, PA D.Bruce Ramsey, MD 600 E.Taylor St., Ste.3011 Brenda D.Jackson, RN, ACNP-BC Sherman, Texas 75090 PH 903-893-5177 Fax: 903-813-0210

WELCOME Dear:_______________________________, Date:___________________ We are delighted to welcome you to our practice and are pleased that you chose us to service your medical needs. We are serious about providing excellent quality of care and proud of our dedication to our patients. An appointment has been scheduled for you with ______________________ on ______________ _______________, 20__, at __________ a.m. / p.m. Please arrive at least 30 minutes prior to your appointment. Please allow two (2) hours for your initial appointment. Please date all paperwork for the date of your appointment. We feel your problem deserves careful attention. To obtain an accurate diagnosis and help initiate the appropriate treatment we have designed the attached forms to learn about your condition. It is very important that you answer all portions of the enclosed forms completed online or in black ink, no pencil. Please bring the following to your appointments: 1. Completed information packet (initial visit only) 2. Drivers License 3. Insurance cards 4. List of all current medications 5. Payment for your visit It is imperative that you bring the actual films or CD of plain x-rays, Myelograms, CT’s, MRI’s, MRA’s and Bone Scans, as well as reports on these films. The report alone is NOT acceptable. The reports alone of EMG’s and Carotid Ultrasounds are acceptable. Any of the above x-rays/reports done in the past two years and related to the problem you are being seen for are appropriate to bring personally at the time of your appointment. This includes any new studies ordered from this clinic. All of this allows us to make the most informed and accurate assessments of your condition and therefore, provide the best treatment options. We look forward to seeing you and serving your needs.

Thank You,

The Providers and Staff of the Neurologic & Spine Institute

Effective 1/6/2009; Rev.10/7/13

NEUROLOGIC & SPINE INSTITUTE

PATIENT INFORMATION Last Name______________________________First Name_________________________MI______ Address__________________________________________________________________________

City____________________________________State_____________Zip______________________

Home Phone_____________________________Alternate Phone____________________________

Date of Birth_______________________ Sex M F Marital Status_______________________

Social Security #____________________ Height________________Weight____________________

Drivers License #_________________________State of Issue_______________________________

Referred by_______________________________________________________________________

Family Physician___________________________________________________________________

Employer_________________________________________________________________________

Address__________________________________________________________________________

Work Phone_______________________________Number of years employed__________________

Responsible Party_________________________________________Self Spouse Child Other Last Name First Name (circle one)

Address__________________________________________________Phone___________________

Has your insurance changed since your last visit? (circle one) YES NO N/A (new patient)

Policy holder’s name_________________________________Relationship_____________________

Policy holder’s date of birth____________________________Social Security #_________________

Is this a Workers Compensation claim? YES NO (circle one) If Workers Compensation, date of accident or date symptoms began__________________________ Name of Workers Compensation insurance carrier________________________________________ Emergency contact person__________________________________Relationship_______________

Phone_________________________Address____________________________________________

I hereby authorize the Neurologic & Spine Institute to furnish information to insurance carriers concerning my illness and treatments. I also assign any benefits to Neurologic & Spine Institute for services rendered by the provider. I understand that I am responsible for any amount not covered by insurance. Signature__________________________________________________Date___________________

Page 2

Name___________________________________________________ Date____________________

Patient History Race: White_____Black/African American_____Mexican American______American Indian______Middle Eastern______Asian_____

Ethnicity: American Indian______Hispanic/Latino_____Mexican______Non-Hispanic/Non-Latino______

Preferred Language:________________________________________________________________

Do you smoke or use tobacco? YES____NO____How much?______________________________

Are you currently in a Skilled Facility or Nursing Home? YES___ NO____ Name________________

Are you currently under Hospice care? YES____ NO____ Name_____________________________

Are you currently under the care of any Home Health Agency? YES___ NO____

Name of Home Health/Facility_________________________________________________________

Chief Complaint____________________________________________________________________

________________________________________________________________________________

Date this started_________________________How did it start?_____________________________

________________________________________________________________________________

Have you ever had the same or similar symptoms?________________________________________

________________________________________________________________________________

If so, give dates____________________________________________________________________

Have you had x-rays/CT/MRI this year? YES NO (circle one)

If yes, when and where were they taken?________________________________________________

________________________________________________________________________________

Previous surgeries: Surgeon: Date:

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________ Effective 1/5/2010;Rev.10/7/2013

DATE _____________

WHAT MEDICATIONS ARE YOU ALLERGIC TO?

DOSE

MEDICATION / ALLERGY LIST

Rev. 10/7/2013

NAME HOW OFTEN

PATIENT NAME:__________________________

PLEASE LIST YOUR CURRENT MEDICATIONS

NEUROLOGIC & SPINE INSTITUTE OF NORTH TEXAS 600 E. Taylor St., Ste.3011

SHERMAN, TX 75090 (903) 893-5177 (office) (903) 813-0210 (fax)

THIS IS NOT

WORKERS COMPENSATION Or A MOTOR VEHICLE ACCIDENT

I affirm the symptoms/conditions I will be seen for are not work related and does not fall under Workers Compensation Insurance and are not related to a Motor Vehicle Accident. The providers at the Neurologic & Spine Institute are not enrolled in Workers Compensation Insurance Plans and do not file claims associated with motor vehicle accident insurance which must be filed on your motor vehicle insurance. Please notify our office in advance if any of the two circumstances apply to you. Signed__________________________ Date________________ Printed Name_____________________________________________ Effective 1/5/2010; Rev.10/7/2013

HIPAA Notice of Privacy Practices ____________________________________________________________

__________________________________________________________[Name]

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. 1. Uses and Disclosures of Protected Health Information Uses and Disclosures of Protected Health Information Your protected health information may be used and disclosed by your provider our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operations of the provider’s practice, and any other use required by law. Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a provider whom you have been referred to ensure that the provider has the necessary information to diagnose or treat you. Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission. A patient who pays for a service in full and out of pocket, prior to the service, may request that the office, not disclose any information about that service to an insurance company. The patient has to put the request in writing, and the request has to spell out what information is restricted and what insurance company is not to receive it, prior to the service. This applies to each date of service that the restricted disclosure is pertinent. All restricted dates must be paid prior to service, with written request about restricting disclosure to insurance company prior to date of service. Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of your provider’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your provider. We may also call you by name in the waiting room when your provider is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment. No PHI will be used for the purpose of fundraising or marketing for the Neurologic and Spine Institute without your prior authorization. We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required By Law, Public Health issues as required by law, Communicable Diseases: Health Oversight: Abuse or Neglect: Food and Drug Administration requirements: Legal Proceedings: Law Enforcement: Coroners, Funeral Directors, and Organ Donation: Research: Criminal Activity: Military Activity and National Security: Workers’ Compensation: Inmates: Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500. Other Permitted and Required Uses and Disclosures Will Be Made Only With Your Consent, Authorization or Opportunity to Object unless required by law. You may revoke this authorization, at any time, in writing, except to the extent that your provider or the provider’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

(2) Your Rights Following is a statement of your rights with respect to your protected health information. You have the right to inspect and copy your protected health information. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your provider is not required to agree to a restriction that you may request. If provider believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically. You may have the right to have your provider amend your protected health information. If we deny your request for amendment, you have a right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice. Complaints You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint. This notice was published and becomes effective on/or before September 23, 2013. ------------------------------------------------------------------------------------------------------------------------------------------------------------------ The Neurologic and Spine Institute will notify you immediately in writing if any of your PHI is breached. We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our Main Phone Number. Your Signature below is only an acknowledgement that you have received this Notice of our Privacy Practices: Print Name:__________________________________Signature_____________________________________Date_______________ Rev. 9/23/2013

Neurologic & Spine Institute 600 E. Taylor, Ste. 3011 Sherman, Texas 75090

903-893-5177 903-813-0210 Fax

Optional Information Release

I authorize the following family member(s), guardian, friend(s) to inquire and receive any information regarding my medical status and to pick up any prescriptions prescribed to me upon my request. Proof of identification must be supplied at the time of request. __________________________________________________ Patient Signature __________________________________________________ Printed Name __________________________________________________ Date __________________________________________________ Name and relationship to patient __________________________________________________ Name and relationship to patient __________________________________________________ Name and relationship to patient Effective 1/5/2010, Rev. 10/7/2013

Neurologic & Spine Institute of North Texas, PA D.Bruce Ramsey, MD 600 E. Taylor, Ste. 3011 Brenda Jackson, RN, ACNP-BC Sherman, Texas 75090 903-893-5177 Fax: 903-813-0210

MEDICATION POLICY Our goal at the Neurologic & Spine Institute is to provide you with the best treatment possible in a pleasant and caring manner. The following medication policy is intended for the safety of our patients and to limit the chance of drug interactions.

• Medications should be taken as prescribed. • Patients should use one pharmacy for their medications and refills.

• Patients should contact their pharmacy for refills.

• Please allow 48 business hours for all medication refills.

• Medications will not be filled on the weekend or after hours.

• If you fail to keep your follow up appointments, you may not be able to receive your

medication refills.

• Failure to comply with this policy will result in delayed or denied medication refills.

• The Neurologic & Spine Institute does not prescribe long-term narcotic pain medications.

I certify this policy has been fully explained to me, that I have read it or had it read to me, and that I understand it. ______________________________________ _____________________________ SIGNATURE of Patient Date ______________________________________ PRINT Patient Name Effective 3/6/2009; Rev.10/7/13

Neurologic and Spine Institute of North Texas, PA D. Bruce Ramsey, M.D. 600 E. Taylor St, Suite 3011 Brenda Jackson, RN, ACNP-BC Sherman, Texas 75090 903-893-5177 fax 903-813-0210

PATIENT FINANCIAL POLICY In order to reduce confusion and misunderstanding between our patients and the practice we have adopted the following financial policy. We are dedicated to provide the best possible care and service to you and regard your complete understanding of your financial responsibilities as an essential element of your care and treatment.

• Payment for services is due in full at the time they are provided. Copays and deductibles are required at the time of service with no exceptions. For your convenience we accept cash, checks, VISA, MasterCard, and Discover. Please see credit/debit card policy below.

• Your insurance policy is a contract between you and your insurance company. It is your responsibility to

educate yourself about your individual insurance benefit coverage. Contact your insurance company if you have questions regarding insurance coverage.

• As a courtesy, we will file your insurance claim for you if you assign benefits to the provider; in other words, you

agree to have your insurance company pay the provider directly. If your insurance company does not pay the practice within sixty (60) days, we will look to you for payment.

• We will submit your primary claim and your secondary claim. Due to increasing administrative costs, we will not submit third and fourth insurance claims. However, we will assist you in any reasonable way we can to help you get your claim paid, but your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Your insurance benefit is a contract between you and your insurance company; we are not a part to that contract. Please understand that the balance of your claim is your responsibly whether or not your insurance pays your claim.

• If your insurance requires a referral, it is solely your responsibility to obtain a current referral for office visits.

Please bring the referral with you to your appointment or call ahead of time to make sure we have it in our office before your appointment. Please do not ask our receptionists to call your primary care physician to obtain the referral for you. You will be liable for all charges for the services rendered and billed if you do not have a valid referral for date of service.

• We have made arrangements with many insurers and other health plans to accept an assignment of benefits (or

in-network benefits). We will bill those plans for which we have an agreement and will only require you to pay the authorized co-payment or applicable deductible/co-insurance amount at the time of your appointment. Medicare patients without secondary insurance will be required to pay 20% of the allowed Medicare rate at time of service.

• If you have insurance coverage with a plan that we do not have an agreement with, and your insurance plan has

out-of-network benefits, we will file for out of network benefits. You will be responsible for the percentage of your visit as outlined by your insurance company at the time of service.

• All health plans are not the same and do not cover the same services. Due to the contract language between

physician and insurance company, you must understand that you are financially responsible for all charges deemed to be “non-covered benefits” by your insurance even if the insurance’s Explanation of Benefits states

the procedure is a “non-covered benefit” and “patient is not responsible”. Payment is due upon receipt of statement from our office.

• Private pay patients will be given a courtesy discount of 30%. Payment for services is collected prior to

scheduling of appointments and procedures, per our private pay policy.

• For all services provided in the hospital we will bill your health plan. Any balance due is your responsibility and will be due upon receipt of statement from our office.

• For all services rendered to minor patients we will look to the adult accompanying the patient and/or the parent

or guardian for payment.

• If you are unable to pay your statement in full, a payment plan can be set up. Interest charges will accrue on unpaid balances.

• If your account requires placement with an outside third party debt collection agency. The amount of

outstanding debt owed the practice will be increased accordingly to cover the costs incurred by the practice. The current rate is 25%.

• If at any time an overpayment is made by you to the Neurologic and Spine Institute, a refund will be processed

within ten (10) business days after notification of overpayment as long as posting of payment to Neurologic and Spine Institute has occurred. If payment was made by credit or debit card-see policy below.

• If you are unable to keep your appointment, please give us at least 48 hours notice. No shows and

cancellations with less than 48 hours notice may be subject to a reschedule fee due prior to scheduling any further appointments in this office. Reschedule fees are non-refundable and not covered by Medicare or insurance plans; they are solely the patient’s responsibility.

• Surgeries should be cancelled at least one week prior to the scheduled procedure. The practice reserves the

right to withhold up to 25% of the pre-paid cost of your surgery when issuing refunds for surgeries cancelled less than one week from the scheduled surgery date. If you cancel your surgery, you may choose to reschedule it with us and leave your credit on your account with no penalty.

• Credit/debit card policy: For your convenience, we do accept payment with debit/credit cards. If you are due a

refund from the practice for a payment you made with a credit/debit card, we will deduct 4% of the total credit due from your refund to cover processing cost of the initial credit/debit charge.

• Any credit/debit card transaction equal to or greater than $1,000.00 will be assessed a convenience fee of 4% of

the transaction.

• Checks returned for insufficient funds are subject to a $35 fee. No further checks or credit/debit cards will be accepted for future appointment copays-cash only. We will contact you if we receive a returned check and full payment (amount of check plus $35 fee) will be expected within 24 hours, or we will contact the county attorney for prosecution of insufficient funds.

I have read and understand the financial policy of the practice and I agree to be bound by its terms. I also understand and agree that such terms may be amended from time to time by the practice. __________________________________________ ___________________________________________ Name of Patient (Print or Type) Signature of Patient/Date __________________________________________ ___________________________________________ Patient Representative (Print or Type) Witness (Print or Type) __________________________________________ ___________________________________________ Relationship of Patient Representative to Patient Witness Signature/Date Rev. 10/7/2013

Red Flag Rules Dear Patient,

The Federal Trade Commission (FTC) has released a new rule to protect consumers from IDENTITY THEFT, which is now becoming known as the “Red Flag Rule.” The new rule now requires any corporation which extends credit to implement a written identity theft prevention program. Under FTC’s guidelines, physicians who regularly bill their patients for services rendered (including copayments, co-insurance and deductibles) are considered creditors and therefore must comply with the “Red Flag Rules.”

As a result, Neurologic & Spine Institute will now require the following information from all patients to ensure the identity of the person being seen:

1. Drivers License or state issued form of identification with picture 2. Proof of Medical Insurance

Once we have validated that the patient being seen matches the information provided, we will store this proof in the patient’s medical records by taking a photocopy of the identification. This eliminates the need to ask for this information in the future unless something changes.

We regret any inconvenience this may cause. We do ask that you remember that, just like many other institutions, Neurologic & Spine Institute must abide by federal law to keep your information protected. As a result, we have very rigid policies and procedures to ensure that your records remain confidential and well-safeguarded.

Thank you in advance.

NEUROLOGIC & SPINE INSTITUTE

_______________________________________________ ______________________

Patient Signature Date

_______________________________________________

Print Name

Effective 1/5/2010, Rev. 10/7/2013

Neurologic & Spine Institute 600 E. Taylor St., Suite 3011

Sherman, TX 75090 Tel: (903) 893-5177 Fax: (903) 813-0210

D. Bruce Ramsey, M.D. Brenda D. Jackson RN, ACNP-BC

Neurosurgery Nurse Practitioner If your provider deems it necessary in the future that you need to have any kind of x-rays, MRI, or any other radiological imaging, please select the facility where you would like the images taken and we will set up your appointment for you. You also have a choice of facility for any surgical injections or procedure; please feel free to discuss your facility preference with your provider.

______ TMC-Advanced Medical Imaging

______ Heritage Park Surgical Hospital

______ Texas Health Presbyterian-WNJ

______ Texoma Medical Center (TMC)

______ Other ____________________________________

______ No preference

___________________________________________ ________________________________

Signature Date

__________________________________________________

Printed Name *D. Bruce Ramsey, M.D. of the Neurologic and Spine Institute is a shareholder of Heritage Park Surgical Hospital. Rev. 10/7/2013