Use our online form to fill out the First Appointment Paperwork: Step 1 of 10 10% Spine and Orthopedic Specialists 8165 S. Mingo Rd., Suite 201 Tulsa, OK 74133 Phone: 918-286-3124 Fax: 918-286-3764Name* First Last Date of Birth* MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Code Sex:* M F Marital Status* Single Married Divorced Widowed Race* White Asian Native Hawaiian Other Pacific Islander Black/African American American Indian Alaskan Native Hispanic Social Security #:*Cell Phone*Home PhoneWork Phone*EmployerEmail IN CASE OF EMERGENCY:(name and phone number of nearest relative or friend)Name* First Last Phone*Relationship*Please include any COMMERCIAL information we may need:Primary Insurance:Primary Policy / ID Number:Secondary Insurance:Secondary Policy / ID NumberInsured subscriber information: Name First Last PhoneSocial Security #:Date of Birth* MM slash DD slash YYYY ACCIDENT/ONSET INFORMATION: Is Visit Accident Related?* Yes No Is Visit Work Related?* Yes No Have you filed a Worker’s Compensation claim? Yes No Date of injury MM slash DD slash YYYY County of Accident:Person responsible for accident:Responsible Party’s insurance:Insurance Company Claim Number:Attorney Name First Last Attorney Phone Financial Information Please read carefully and sign this page, which is an explanation of our policy regarding payment. Our Policy on Fee Payment All patients are responsible for the payment in full of all services rendered in their behalf. It is the policy of our practice that payment is required at the time services are rendered. Payment can be made by cash, check, Visa, Master Card or Discover. We are always willing to privately discuss any financial issues and we encourage you to contact us, by telephone or in person, with any questions or concerns you might have. If you have Health Insurance/Medicare You will be required to present your insurance card(s) with the company address and phone number. It is important that you notify us with any subsequent changes in your coverage. You will also be asked to pay any deductibles or co-pays that are due at the time of service. Our practice will assist patients with the payment of all fees by helping you complete insurance forms, processing forms and mailing statements. However, you are expected to make timely payments and to follow up with your insurance carrier, as appropriate. Generally, accounts over 45 days old are considered to be delinquent. Your insurance policy is a contract between you and your insurance carrier. This practice cannot guarantee payment of your claims by the insurance company. If the insurance company rejects your claim, in full or in part, you remain responsible for paying for services received. Medicare patients must pay co-insurance at each visit unless they have a secondary insurance. Workers Compensation and Managed Care patients must: provide the necessary authorization for treatment prior to the first visit make the appropriate co-payment at each visit meet all deductible requirements, and make payment for any services they contract to receive from this practice that are not covered by their insurance, health plans or HMO. If we are not providers for your HMO, you must pay services in full at the time of services. Personal Injury/Motor Vehicle Accident Insurance You, the patient, are 100% responsible for your own medical bills. By filing a physician’s lien it ensures you are getting the medical treatment you deserve, and as the provider, we will receive payment once your claim is settled. When your case settles or wins in court the paying insurance company must place your medical providers name on settlement check or award. In other words, that check cannot be cashed until your medical provider has been paid. However, if your case does not settle or loses, you are still responsible for paying your medical bills. As a courtesy to you our office will file a physician's lien on all charges incurred with Dr. Parchuri. A lien will be filed in lieu of requiring payment from you as you are treated. If you do not wish to have a physician's lien filed you will be responsible for all charges as the services are provided. This lien will be released once payment is received upon the settlement of your case. Hospitalization If you require hospitalization, we will generate the insurance claims necessary for the services you receive, mail these to your insurance company and assist you collection. You remain responsible for co-insurance, deductible, and the payment of non covered services. Unless prior arrangements are made, your portion of any charges for surgical procedures is due prior to surgery. Collections Occasionally, we find it necessary to place a delinquent account in the hands of an attorney or a collections agency for collections. By signing this agreement, the patient or responsible party agrees to be bound and obligated to pay any and all fees of the attorney or agency employed to collect the delinquent account.Consent* I have read the above policy of Spine and Orthopedic Specialists and agree to comply with its terms.I authorize the release of any medical information necessary to process this claim or provide prudent medical care either, by mail, phone, or fax. I also request payment of benefits to be made to the party who accepts assignment. Signature*Today's Date MM slash DD slash YYYY Patient Financial Responsibility Disclosure Statement Your signature below forms a binding agreement between Dr.Parchuri / Dr. Sparks and the Patient who is receiving medical services, or the Responsible Party for minor patients (those patients under 18 years old). Responsible Party is the individual who is financially responsible for payment of medical bills. Medical Insurance: We have contracts with many insurance companies, and we will bill them as a service to you. As the responsible party, you are responsible if your insurance company declines to pay for any reason. Your health plan may refuse payment of a claim for some of the following reasons: You have not met your full calendar year deductible The type of medical service required is not covered or deemed not medically necessary The health plan was not in effect at the time of service You have other insurance which must be filed first Insurance denied authorization for treatment Services were processed out of network No prior referral was obtained by the primary care physician The person signing on behalf of the Patient as the Responsible Party must: Inform office of the current address and phone number for the patient and the responsible party. Present all current insurance cards prior to each office visit. Pay any required copay and/or deductible amount at the time of the visit. Pay any additional amount within 90 days or set up automated payment arrangements If you are not insured, or if the services being provided are not covered by your insurance, you will be expected to provide payment in full for our services at the time they are rendered. Returned Check Policy If a payment is made on an account by check, and the check is returned as Non-Sufficient Funds (NSF), Account Closed (AC), or Refer to Maker (RTM), the patient or the Patient’s Responsible Party will be responsible for the original check amount in addition to a $25.00 Service Charge. Please understand that financial responsibility for medical services rests between you and your health plan. While we are pleased to be of service by filing your medical insurance for you, we are not responsible for any limitations in coverage that may be included in your plan. If your health plan denies this claim for any of these or other reasons, our office cannot be responsible for this bill. It is your responsibility as patient to pay the denied amounts in full. Our primary mission is to provide you with quality, cost effective, medical care. Together we are trying to adapt to the changing way that health care is financed and delivered. Again, we value you as a patient and our first priority is to provide you with the best possible care. By signing below, you agree to accept full financial responsibility as a patient who is receiving medical services, or as the responsible party for minor patients. Your signature verifies that you have read the above disclosure statement, understand your responsibilities, and agree to these terms.Patient Name* First Last Responsible Party Name:* First Last Patient Signature*Date MM slash DD slash YYYY Describe your pain Patient Name:* First Last Today's Date MM slash DD slash YYYY Have you been treated yet for this problem?* Yes No Where:Describe your pain in any of the following ways: How long have you had your pain?*Do any of the following activities affect your pain, or make it worse? Walking Sitting Housecleaning Running Stairs Driving Sleeping Getting Dressed Sports What tests have been done for this problem? X-Ray Films: Where?DateMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920MRI / CT Scan: Where?DateMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920EMG (nerve test): Where?DateMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920List any previous surgeries/hospitalizations:FEMALES: Pregnant or chance of being pregnant Yes No How much alcohol do you consume? Non-drinker Drink occasionally Drink weekends only Pharmacy Information Name First Last Today's Date MM slash DD slash YYYY Preferred PharmacyALLERGIESCurrent MedicationsAre you currently taking Coumadin/Plavix, or any other blood thinner medication:* Yes No PATIENT AUTHORIZATION FOR PRACTICE TO RELEASE PROTECTED HEALTH INFORMATION TO THIRD PARTIES By signing this authorization, I authorize the Spine and Orthopedic Specialists office to use and/or disclose certain protected health information (PHI) about me to or for the party or parties listed below. This authorization permits the Spine and Orthopedic Specialists office to use or disclose to the following individually identifiable health information (specifically describe the information to be released, such as dates(s) of service and times, level of detail to be released, origin of information, billing, rx pickup, imaging reports, etc.)Release to:Please verify what records you would like released: All records: Yes No Specify only certain records:When my information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing except to the extent that the Spine and Orthopedic office has acted in reliance upon this authorization. My written revocation must be submitted to the office at 8165 S Mingo Rd Ste. 201 Tulsa, OK 74133.Signature*Signature of patient or legal guardianToday's Date MM slash DD slash YYYY Pain Diagram Please Fill Out COMPLETELY Please Complete this form carefully. Your accurate marking will give us a better understanding of you and your problems. From this information we can provide you the best care possible.Name First Last Today's Date MM slash DD slash YYYY Gender Male Female Date of Birth* MM slash DD slash YYYY Current AgeHeightWeightBPPulse Tell us where you are in pain Type of Pain* Pins & Needles Numbness Burning Stabbing Ache Pins & Needles LocationNumbness LocationBurning LocationStabbing LocationAche Location SPINE AND ORTHOPEDIC SPECIALISTS REVIEW OF SYSTEMS Please answer all questions below. This will become a part of your medical record.General:Seen primary care physician past 12 months? Y N Recent weight loss more than 10lbs? Y N Recent weight gain more than 10lbs? Y N Fever? Y N Chills? Y N Night Sweats? Y N Bones/Joints:Shoulder Pain? Y N Wrist or Hand Pain? Y N Hip Pain? Y N Knee Pain? Y N Muscle Weakness? Y N Lupus? Y N Fibromyalgia? Y N Back / Neck Pain? Y N Cardiac:Chest Pain? Y N Shortness of Breath? Y N Swelling of Ankles? Y N Respiratory:Wheezing? Y N Chronic Cough? Y N Pneumonia? Y N Do you Smoke? Y N Skin:Open Sores? Y N New Moles? Y N Poor Healing? Y N Skin Infections? Y N Hematologic/Oncologic:Easy Bruising? Y N Blood Thinning Meds? Y N Blood Transfusion? Y N Organ Transplant? Y N Nervous System:Headaches? Y N Tremors? Y N Poor Speech? Y N Changes in Vision? Y N Gastrointestinal:Abdominal Pain? Y N Nausea/Vomiting? Y N Diarrhea? Y N Liver Problems? Y N Genitourinary:Abnormal Kidney Function? Y N Pain with Urination? Y N Frequent Urinary Infections? Y N Mental Health / Endocrine:Sleep Disturbances? Y N Feeling of Hopelessness? Y N Thyroid Problems? Y N Other Concerns:Current Pain Scale: 1 (no pain) 2 3 4 5 6 7 8 9 10 (most severe) Spine & Orthopedic Specialists, PLLC Industry Relationships The physicians at Spine & Orthopedic Specialists are at the forefront of advancements designed for patients with disabling spine problems. For over 10 years, Dr. Parchuri has assumed leadership roles in clinical research, new technological procedures, and helped to develop new medical products to improve patient care. Therefore, Dr. Parchuri is frequently sought out by medical device manufacturers to participate in product development, research, and education. Manufacturers and research organizations realize that surgeons are necessary contributors to the development and improvement of devices and instruments used in the treatment of many orthopedic and spinal conditions. Without contributions by surgeons, engineers working in the medical device industry would lack the real-life experience necessary to fully develop and improve their inventions and advancements in spine care. Dr. Parchuri works with many companies, both large and small, to help create and improve products for patient care. As such, he is compensated for his intellectual efforts and time. This is a standard industry practice. He participates as a consultant and on scientific advisory boards. Compensation for such services may come in various forms including, but not limited to: (1) consulting fees for services provided by Dr. Parchuri, (2) royalty fees for patents based on the sale of products for which Dr. Parchuri made important contributions, and (3) equity interests in the manufacturers of medical products. Some of the products or devices made or distributed by these companies may be used in your medical treatment. However, Dr. Parchuri's decision as to which, if any, product or device to be used in your care and treatment is made based upon what is in your best medical interest. The following is a current list of companies with whom Dr. Parchuri has a financial relationship. Please feel free to learn more about these companies from their websites, and to ask Dr. Parchuri or the office manager any specific questions or concerns you may have about a company, product, or his relationship with the company. Precision Spine www.precisionspine.com Stryker www.stryker.com Signature*Today's Date MM slash DD slash YYYY Spine & Orthopedic Specialists, PLLC Facility Relationships Dr. Parchuri has a financial interest in facilities in the Tulsa area. These facilities and Dr. Parchuri are committed to providing clinical excellence to our patients in a safe, high quality environment. His financial interest in these facilities often provides a voice in administration and in clinical and operational policies. This involvement helps to ensure the highest level of patient care and customer service. Patients of Dr. Parchuri always have the option of utilizing an alternative health care facility. Please ask one of our representatives for a list of alternative facilities. Dr. Parchuri or the office manager welcome any questions regarding this aspect of your care. The following is a list of facilities with whom Dr. Parchuri has a financial interest: Advanced Outpatient Surgery of Oklahoma (AOSO) Center for Orthopaedic Research and Excellence (CORE) Tulsa Diagnostic Imaging Patients of Spine & Orthopedic Specialists always have the option of utilizing an alternative health care facility. Dr. Parchuri welcomes any questions regarding this aspect of his patient's care. Please sign below acknowledging receipt of this disclosure:SignatureToday's Date MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.