Patient Information Form
PATIENT INFORMATION
FULL NAME ___________________________________________________________ SEX _______________
ADDRESS ________________________________________________________________________________________
HOME PH (____) ________________ CELL PH (____) ________________ DATE OF BIRTH _____/_____/_____
SOCIAL SECURITY ______-______-______ RACE __________________
EMAIL ___________________________________________________________________________________________
EMPLOYER________________________________________________________ PHONE (____) _________________
GENERAL
Who referred you to our office? ________________________________________ PHONE (____) __________________
Primary Care Physician ______________________________________________ PHONE (____) __________________
In case of emergency notify:______________________________________________
RELATIONSHIP __________________________________________________ PHONE (____) __________________
Do you have Advance Directives? Y/N _______________________________
INSURANCE INFORMATION
PRIMARY INSURANCE _____________________________ POLICY HOLDERS NAME ______________________
ID#___________________________ GROUP# __________________________ PHONE (____) __________________
SECONDARY INSURANCE __________________________ POLICY HOLDERS NAME ______________________
ID#___________________________ GROUP# __________________________ PHONE (____) __________________
PHARMACY
PREFERRED PHARMACY ___________________________________________ PHONE (____) __________________
PHARMACY ADDRESS_____________________________________________________________________________
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
*Only complete this section if you were seen as a Trauma Patient at Gulf Coast Medical Center AND applies to current situation.
AUTO INJURY
Date of Injury:
Adjustors Name:
Adjustors Number:
Adjustors Fax:
WORKERS COMPENSATION INJURY
Date of Injury:
Adjustors Name:
Adjustors Number:
Adjustors Fax:
Medical History
FULL NAME _____________________________________________________ DATE OF BIRTH _____/_____/_____
CHIEF COMPLAINT:
What is the reason for your visit today? __________________________________________________________________________
__________________________________________________________________________________________________________
Are you experiencing any pain (circle one) YES or NO, if yes, where is the pain located __________________________?
IF YOU MARKED YES , please rate pain on a scale of 0-10 with 10 being the highest. 1 2 3 4 5 6 7 8 9 10
Date symptoms began. ____________________ weeks/ months/ years
Severity (X on choice) Mild____ Moderate ____ Severe ____ Incapacitating ____
Aggravated by: _____________________________________ Relieved by: _____________________________________
PAST TREATMENTS FOR SYMPTOMS:
o Over the counter medications: ____________________________
o Prescription Medications: _______________________________
o Physical Therapy: _____________________________________ (Include dates and Locations of facility)
o Pain Management: ______________________________________ (Physician and most recent appointment)
o Spinal Injections: ______________________________________ (Physician and Dates)
o Epidural
o Facet Blocks
o Facet Rhizotomies
o Trigger Point Injections
o SI Joint
o Other Injections (s): ____________________________
Have you seen any other specialist or had additional testing for today’s chief complaint? (CT Scan, MRI, EMG/ Nerve study) If yes,
please describe? _________________________________________________________________________
__________________________________________________________________________________________________
PAST MEDICAL HISTORY: Check (X) conditions you have been diagnosed with.
o No Medical History
o Anemia
o Anxiety
o Arrhythmia
o Asthma
o Bleeding Disorders
o Blood Clots
o Brain Aneurysm / AVM
o Brain Mass/ Tumor
o Cardiovascular accident/
MI
o Cirrhosis/ liver disease
o Constipation
o Cancer
Type: _______________
o Congestive Heart Failure
o COPD
o Coronary Artery Disease
o Depression
o Diabetes
o Fibromyalgia
o Hepatitis C
o HIV/ AIDS
o Hypertension
o Hyperthyroidism
o Hypothyroidism
o IBS
o Irregular heartbeat
o Kidney Failure
o Liver Disease
o Lung Cancer
o Migraine Headaches
o Murmurs
o Multiple Sclerosis
o Osteopenia
o Osteoporosis
o Parkinson’s Disease
o Peripheral Nerve Disorder
o Renal Disease
o Rheumatoid Arthritis
o Seizures
o Spinal Cord Tumor
o Stroke
o Tuberculosis
o Tremor
o Ulcers
o Other: ______________
____________________
o Other: _____________
____________________
Please list any other health issues not referenced above: ______________________________________________________________
SURGICAL HISTORY: List all Major Surgeries and Dates
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
MEDICATON LIST: Please list ALL medications/ supplements below OR provide a printed list.
CURRENT MEDICATION
DOSE
FREQUENCY
o I do NOT take any medications
ALLERGIES: List all drug and food allergies: ___________________________________________________________
__________________________________________________________________________________________________
o I do NOT have any known allergies
SOCIAL HISTORY:
Occupation:_________________________________
Marital Status: _______________________________
Are you a smoker? N or Y: ____ Packs per day for ____ years Former smoker: Quit ________(date)
Do you drink Alcohol? N or Y: On occasion ______ or moderately __________
FAMILY HISTORY: List all pertinent family history of immediate family
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
To the best of my knowledge the above information is complete and correct. I understand that reporting
incomplete information can be dangerous to my health. I understand that I am solely responsible for any error or
omissions that I may have made in the completion of this form. I understand that it is my responsibility to inform
my doctor if I ever have a change in health.
____________________________ ______________________________ __________
Patient signature or Authorized Printed Name Date
Representative
_____________________________
Authorized Representatives Relationship
to patient
Office Policies
Medical Consent: I consent to all care, treatment, diagnostic imaging, laboratory testing and other medical procedures
performed or prescribed by a physician of Gulf Coast Brain and Spine Center and his/her designees
Right of Refusal of Treatment: I understand that I have the right to make informed decisions regarding all aspects of my care.
I should ask my health care provider to furth clarify and explain anything I do not understand. I have the right to refuse
treatment.
Acknowledgement of Receipt of Patient Rights and Notice of Privacy Practices: I have acknowledged that I have received
both notices, Notice of Patient Rights/Responsibilities and HIPAA Notice of Privacy Practices.
Release of Medical Information: I authorize Gulf Coast Brain and Spine Center to release any information necessary to
facilitate healthcare processing of claims, or audit of payments in relation to my care and treatment. I also consent to the release
of any information needed to other facilities, agencies or healthcare providers as per Gulf Coast Brain and Spine Center’s
discretion. This order will remain in effect until revoked by me in writing.
Financial Policy: I certify that the insurance information that I have provided to Gulf Coast Brain and Spine Center is accurate,
complete, and current. I certify that no other coverage of insurance exists. It is my responsibility to understand the terms and
benefits of my insurance plan. I understand I am financially responsible for charges not paid by my insurance. I may be required
to pay co-payments, co-insurance, or deductibles at the time of service unless other arrangements have been made in advance.
Gulf Coast Brain and Spine Center will make every attempt to notify me in advance if a service is not covered. If my insurance
has not paid my bill in full within 60 days, I will be expected to pay the remaining balance within 30 days. In the even of a large
balance due from an operation, Gulf Coast Brain and Spine Center may be able to arrange a payment plan suitable for all parties
concerned.
Forms and Medical Records: If you require our office to complete any disability, FMLA, school/work or personal forms; the
first form is free; however, each additional form is a charge of $15 per form. Forms will be completed within 10-14 business
days. If you Require a copy of your medical records, you must sign a Medical Records Release Form. Your request will be
completed within 10-14 business days.
Appointment No Show/ Cancellations: If it is necessary to cancel/reschedule your appointment, please do so 24 hours PRIOR
to the time of your scheduled appointment. If you do not cancel and appointment or no show, you will be responsible for a
$25.00 charge. This fee is the responsibility of the patient and is not billable to any insurance.
Surgery Cancellations: If you must cancel a scheduled surgery, please notify our office by 12:00PM THREE (3) BUSINESS
DAYS (Monday- Friday) prior to surgery to avoid a cancellation fee of $150.
Dispensing of Opioid (Narcotic) Pain Medications: In response to the “Opioid Crisis,” The State Legislature of Florida
passed the Controlled Substance Bill (CS/CS/HB 21) which regulates the prescribing of Schedule II and Schedule III
pharmaceuticals. These regulations affect the prescriptions your providers are allowed to prescribe you after surgery. Schedule
II narcotics are limited to a three (3) day supply for “acute pain.” A seven (7) day supply can be provided under special
circumstances. Our office will limit dispensing Schedule II and III prescriptions to 14 days post-op. It is important to understand
that Gulf Coast Brain and Spine Center does not manage chronic pain. If you need chronic pain management, we are happy to
provide a referral to a pain management specialist.
Return of Imaging CDs/Films: It is important for our providers to review your images for proper diagnosis and treatment:
however, our office does not have the capacity to store these films. A copy of your images will be downloaded to our system at
your appointment. Your images will be returned to you at the end of your appointment. If you leave your images for any reason
past your appointment date, we will store them for 90 days as a courtesy. During 90 days, you have the option to pick them up at
the office at no charge, or we can ship them to you for $10 service and handling fee. After 90 days, any remaining CDs/ Films
will be disposed per HIPAA guidelines.
____________________________ ______________________________ __________
Patient signature Printed Name Date
General Consent for Treatment
Medical Consent: I consent to all medical care, treatment, laboratory, imaging and other medical procedures performed or
prescribed by a physician of Gulf Coast Brain and Spine Center and his/her designees as directed in his/her judgement
Right to Refuse Treatment: I understand that I have the right to make informed decisions regarding all my care and treatments,
and that I should ask my healthcare professional to clarify or explain anything I do not understand. This right includes the right
to refuse any treatment I do not want.
Acknowledgement of Receipt of Patients’ Rights and Notice of Privacy Practices: I acknowledge that I have received both
notices, Notice of Patient Right and Notice of Privacy Practices.
Advance Directives: I understand that I have an opportunity to make known my wishes, in writing regarding my health care
and/ or end of life decisions. This directive is in the form of a living will and/ or durable power of attorney for health care.
Release of Medical Information: I authorize Gulf Coast Brain and Spine Center to release any information necessary to
facilitate healthcare processing of claims, or audit of payments in relation to my care and treatment. I also consent to the release
of any information needed to other facilities, agencies, or healthcare providers as per Gulf Coast Brain and Spine Center’s
discretion. This order will remain in effect until revoked by me in writing.
Financial Policy: I certify that the insurance information that I have provided to Gulf Coast Brain and Spine Center is accurate,
complete, and current. I certify that no other coverage of insurance exists. It is my responsibility to understand the terms and
benefits of my insurance plan. I understand I am financially responsible for charges not paid by my insurance. I may be required
to pay co-payments, co-insurance, or deductibles at the time of service unless other arrangements have been made in advance.
Gulf Coast Brain and Spine Center will make every attempt to notify me in advance if a service is not covered. If my insurance
has not paid my bill in full within 60 days, I will be expected to pay the remaining balance within 30 days. In the event of a
large balance due from an operation, Gulf Coast Brain and Spine Center may be able to arrange a payment plan suitable for all
parties concerned.
Assignment of Insurance Benefits: I hereby assign all medical benefits, to include major medical benefits to which I am
entitled. I hereby authorize and direct my insurance carrier(s), including Medicare, Medigap, Medicare Replacement, private
insurance, and any other health/ medical plan, to issue payment check(s) directly to Gulf Coast Brain and Spine Center for
medical services rendered to myself. I understand that I am responsible for any amount not covered by insurance.
Medicare Certification: I certify that the information given by me in applying for payment under Title XVIII of The Social
Security Act is correct. I authorize any holder of medical or other information about me to release to The Social Security
Administration, or its intermediaries or carriers, any information needed for this or related to Medicare claim. I request that
payment of authorized benefits be made on my behalf (consent applies only when applicable).
ePrescribe Medication: I authorize Gulf Coast Brain and Spine Center to submit all prescriptions electronically to preferred
pharmacy.
____________________________ ______________________________ __________
Patient signature Printed Name Date
Opioid (Narcotic) Policy Agreement
Gulf Coast Brain and Spine Center has a primary goal of providing excellence in care to our patients.
The best practice in Neurosurgery recognizes that patients undergoing operative procedures may require narcotic pain
medications. Your physician may prescribe pain medication during your post-operative period with a limited supply and
in accordance with The Florida Medical Board regulations.
It is important to understand the providers of Gulf Coast Brain and Spine Center DO NOT prescribe pain medication
pre-operatively (before you have surgery).
The physicians at Gulf Coast Brain and Spine Center do not manage chronic pain, if you need chronic pain
management, we can provide you with a referral to a pain management specialist.
To ensure that, as the provider, and you as the patient, understand how our practice will ensure high quality and safety
in prescribing narcotics you will need to adhere and agree to the policy agreement outlined below.
I,____________________________ understand that I may receive narcotic medication from Gulf Coast Brain and Spine Center
to treat my post-operative pain.
● I understand that if I am receiving long term pain medicine from a pain management physician, I will make
arrangements for post operative pain medication with that physician. I will not receive pain medications post
operatively from a Gulf Coast Brain and Spine Center physician
● I will not take prescribed narcotics in large amounts or more frequently than prescribed.
● I will not buy or use additional narcotics or borrow/use narcotics prescribed to another individual.
● I will not use any illegal or street drugs (ex. Cocaine or Methamphetamines) while under the care of a Gulf
Coast Brain and Spine Center physician.
● I will not purchase or use narcotics which may be available in another country or through mail order.
● I understand that Gulf Coast Brain and Spine Center will not provide refills on narcotics. A new prescription
may be provided at the first post operative visit. Any ongoing need for narcotic pain medication beyond that
point will be referred to pain management specialist.
● I will not drink alcohol while on narcotics.
● If I have left over narcotic pain medication, I will dispose of it. I will not donate or sell extra narcotics to
another individual.
● I understand that if my pain acute post operative pain medication requirements are beyond a neurosurgeon’s
scope of practice to manage, I will be referred to a pain management physician. I understand it is my
responsibly to follow up and schedule an appointment.
____________________________ ______________________________ __________
Patient signature Printed Name Date
Financial Policy
Health Insurance: Gulf Coast Brain and Spine Center will bill your health insurance provider(s) for each visit unless you are
within the 90-day post-operative period. You are responsible for paying co-payments and outstanding balances due at the time
of your visit. We accept cash and credit card. We recommend that you familiarize yourself with your insurance plan so there are
no surprises when it come to your bill.
Non-Participating Insurance Accounts: A patient who is insured by an insurance carrier with which Gulf Coast Brain and
Spine Center do not participate, is considered a self-pay patient. It is the patient responsibility to inform the practice of any
insurance coverage changes, to confirm the practice’s participation and to verify their eligibility before each visit. If you are
covered by an insurance carrier that Gulf Coast Brain and Spine Center does not participate with you are responsible for full
charges at the time of service.
Self-Pay Patients: Self-pay patients are those who are covered by an insurance carrier with which the practice does not
participate or patients without insurance at the time of service. As a self-pay patient, you are individually responsible to pay the
full charges at the time of service.
HMO Referrals and Authorizations: If your insurance is an HMO (has a designated primary care physician), you are required
to inform the office of this at the time of scheduling your appointment so and authorization may be obtained. If this information
is not provided at the time of scheduling, you will be asked to reschedule your appointment.
Non-Covered Services: It’s important to understand that some items and services are not considered “covered benefits” under
your health insurance plan and as such, your insurance will not pay for these services. It is the patient’s responsibility to
understand what your plan covers and does not cover. You will be responsible for all non-covered charges/services.
Appointment No Show/ Cancellations: If it is necessary to cancel/reschedule your appointment, please do so 24 hours PRIOR
to the time of your scheduled appointment. If you do not cancel and appointment or no show, you will be responsible for a
$25.00 charge. This fee is the responsibility of the patient and is not billable to any insurance.
Surgery Cancellations: If you must cancel a scheduled surgery, please notify our office by 12:00PM THREE (3) BUSINESS
DAYS (Monday- Friday) prior to surgery to avoid a cancellation fee of $150.
____________________________ ______________________________ __________
Patient signature Printed Name Date
HIPAA Notice of Privacy Practices:
Consent to Use or Disclose Information for Treatment,
Payment or Health Care Operations
The Patient hereby consents to the use or disclosure of his/her individually identifiable health information (“protected health
information”) and patients medical record information by Gulf Coast Brain and Spine Center (the “Practice”) in order to carry
out treatment, payment or health care operations. The patient should review the Practice’s Notice of Privacy Practices for more
complete description of the potential uses and disclosures of such information, and the patient has the right to review such
Notice prior to signing this consent form.
The Practice reserves for itself the right to change the terms of its Notice of Privacy Practices at any time. If the Practice does
change the terms of its Notice of Practices, Patient may obtain a copy of the revised notice.
Patient retains the right to request that the Practice further restrict how his/her protected health information is used or disclosed
to carry out treatment, payment, or health care operations. The Practice is not required to agree to such requested restrictions;
however, if the practice does agree to Patient’s requested restriction(s), such restrictions are then binding on the practice as it
pertains to the patient only.
Patient acknowledges and agrees that the Practice may disclose Patient’s protected health information and patient medical
record information to the following individuals who are either the Patients Family members, legal representative, guardians,
health care surrogates, or have power of attorney on behalf of the Patient (list names below):
The patient agrees that the Practice may disclose the following types of information contained in the Patient’s medical records
below, unless otherwise indicated (Please initial on IF YOU DO NOT WISH to disclose):
_____ HIV/ AIDS Information
_____ Mental Health Information
_____ Substance Abuse Information
_____ Sexually Transmitted Disease Information
_____ Pregnancy Information (if patient is under 18 years of age)
At all times, Patient retains the right to revoke this consent. Such revocation must be submitted to the practice in writing. The
revocation shall be effective except to the extent that the practice has already take action in reliance on the consent.
I HAVE READ AND UNDERSTAND THE INFORMATION IN THIS CONSENT. I HAVE RECEIVED A COPY OF THIS
CONSENT, AND I AM THE PATIENT OR I AM AUTHORIZED TO ACT ON BEHALF OF THE PATIENT TO SIGN THIS
DOCUMENT VERIFYING CONSENT TO THE ABOVE STATED TERMS.
____________________________ ______________________________ __________
Patient signature or Authorized Printed Name Date
Representative
_____________________________
Authorized Representatives Relationship
to patient
HIPAA NOTICE OF PRIVACY PRACTICES
Gulf Coast Brain and Spine Center is 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. We are also required to abide by the terms of the
notice currently in effect.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION
This Notice of Privacy Practices is NOT an authorization. This Notice of Privacy Practices describes how we, our Business
Associates and their subcontractors, may use and disclose your protected health information (PHI) to carry out treatment,
payment or health care operations 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
condition and related health care services.
USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
Your protected health information may be used and disclosed by your physician, 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 operation of the physician’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, your protected health information may be provided to a physician to whom you have been referred
to ensure that the physician has the necessary information to diagnose or treat you. We will abide by the patient’s
request not to disclose PHI to a health plan for services which the patient has paid out of pocket and requests the
restriction
● 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.
● HEALTHCARE OPERATIONS We may use or disclose, as needed your protected health information to support the
business activities of your physician’s practice. These activities include, but are not limited to, quality assessment,
employee review, and 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 physician. We may also call you by name in the waiting room when your physician 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, and inform you about treatment alternatives or other health-related benefits and services that may be of
interest to you. 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, immunizations to schools, abuse or neglect, food and drug administration requirements,
legal proceedings, law enforcement, coroners, funeral directors, organ donation, research, criminal activity, military
activity and national security, workers’ compensation, inmates, and other required uses and disclosures.
Under the law, we must make disclosures to you upon your request. Under the law, we must also disclose your protected health
information when required by the Secretary of the Department of Health and Human Services to investigate or determine our
compliance with the requirements under Section 164.500.
USES AND DISCLOSURES THAT REQUIRE YOUR AUTHORIZATION
Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization or opportunity to object
unless required by law. The same authorization/restrictions that were used while you are alive will remain in place for up to 50
years after your death. Without your authorization, we are expressly prohibited to use or disclose your protected health
information for marketing purposes. We may not sell your protected health information without your authorization. We may not
use or disclose most psychotherapy notes contained in your protected health information. We will not use or disclose any of
your protected health information that contains genetic information that will be used for underwriting purposes. You may
revoke the authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken
an action in reliance on the use or disclosure indicated in the authorization.
YOUR RIGHTS
The following are statements of your rights with respect to your protected health information:
You have the right to inspect and have a copy of your protected health information (fees may apply). Pursuant to your
written request you have the right to inspect or have a copy your protected health information whether in paper or electronic
format. The records will be provided within 30 days of request. Under federal law, however, you may not inspect or copy the
following records: Psychotherapy notes, information compiled in reasonable anticipation of, or used in, a civil, criminal, or
administrative action or proceeding, protected health information restricted by law, information that is related to medical
research in which you have agreed to participate, information whose disclosure may result in harm or injury to you or to another
person, or information that was obtained under a promise of confidentiality.
Patient Requesting Medical Record Copies. There may be fees associated with requesting copies of medical records, such as
copy fees, and/or shipping and handling fees. You have the right to request a restriction of your protected health information.
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.
You have the right to request to receive confidential communications. You may ask us to contact you in a specific way (for
example, home or office phone) or to send mail to a different address.
You have the right to request an amendment to your protected health information. You may ask us to correct health
information about you that you think is incorrect or incomplete. We may say “no” to your request, but we will tell you why in
writing within 60 days.
You have the right to receive an accounting of certain disclosures. You have the right to receive an accounting of
disclosures, paper or electronic, except for disclosures: pursuant to an authorization, for purposes of treatment, payment,
healthcare operations; required by law for up to six years prior to the date of the request.
You have the right to receive notice of a breach. We will notify you if your unsecured protected health information has been
breached.
You have the right to obtain a paper copy of this notice from us even if you have agreed to receive the notice electronically.
We reserve the right to change the terms of this notice and we will notify you of such changes on the following appointment.
We will also make available copies of our new notice if you wish to obtain one.
COMPLAINTS
If you believe that your privacy rights as described in this notice have been violated, you may file a complaint with the practice
at the following address or telephone number:
Gulf Coast Brain and Spine Center, LLC
Attn: HIPAA Officer
10201 Arcos Ave. STE 202
Estero, FL 33928
(239) 908-3938
To file a complaint, you may either call or send a written letter. The practice will not retaliate against any individual who files a
complaint. You may also file a complaint with the Secretary of the Department of Health and Human Services
Your Rights
Here at Gulf Coast Brain and Spine Center we recognize and respect your rights as a patient with unique healthcare needs. We
want you to know what your rights are as a patient. We encourage a partnership between you and your healthcare team. Your
role as a member of this team is to exercise your rights and to take responsibility for things you do not understand.
As a patient you have the right to…
● To be informed of your rights and responsibility as a patient of Gulf Coast Brain and Spine Center.
● To be informed of rules, regulations and services provided by each physician and clinic including days and hours of
service and what to do in an emergency, and clinic numbers.
● To receive care in a safe setting that is free from abuse, neglect and harassment by physicians and clinic employees
● To receive considerate and respectful care. We respect your right to:
o Expect quality treatment with the scope of our mission
o Be treated with dignity, free of discrimination. Your care will not be affected by race, religion, beliefs, cultural
values, sex or age.
o Choose your own physician.
o Ask all personnel involved in your care to introduce themselves, state their role in your care and explain what
they are doing for you.
● To be informed about your treatment and healthcare including
o A description of your condition and diagnosis
o Treatment plan
o Alternative treatments
o Prognosis and any problems related to treatment
o Recuperation
o Benefits and risks of each treatment option and alternatives
o Explanations of risks faced if treatment is not pursued
● The right to make an informed consent.
● The right to make treatment choices, including the right to refuse treatment.
● To receive a reasonable estimate of charges for medical care.
● To have privacy and confidentiality respected. Your health care team will:
o Respect your privacy related to your medical care.
o Provie confidential treatment of your condition, medical care, medical records, and financial information.
● To have access to your personal medical records and obtain copies upon written request.
____________________________ ______________________________ __________
Patient signature Printed Name Date
