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PATIENT INFORMATION Yevgeniy Khavkin, MD Hayley Washinsky, PA-C

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Today’s Date:
PATIENT INFORMATION
Name:
First Middle Last
Mailing Address:
Street Address/P.O. Box City/State/Zip Code
Home Phone: Cell Phone: Work Phone:
Social Security #: Marital Status: Single Married Divorced Widowed
How did you hear about us? Insurance Co. Internet Magazine ER Family/Friend Radio/TV Other:
Referred by: Primary Care Physician:
Employment Status: Full-time Part-time Retired Unemployed Student
Occupation: Employer:
Employer Address:
Is today’s visit a work related issue? YES NO Is there legal litigation? YES NO
Pharmacy Name: Pharmacy Address:
Pharmacy Phone: Pharmacy Fax:
BILLING INFORMATION
Primary Plan
Name
Insured Name
Relation To Patient
Insured DOB/Insured Social Security #
ID Number/Group Number
WORKER’S COMPENSATION / ATTORNEY
Insurance Company / Attorney
Employer/Group Name
Adjuster Name
Claim Number/ Date Of Injury
Adjuster Phone Number
Do you have secondary insurance coverage? YES NO If so, please provide copy with your insurance card
CONSENT TO TREAT
I consent to necessary medical treatment as recommended by my physician. I understand that insurance may not cover all
recommended medical services, such as preventative health exams, immunizations, screening tests, detailed phone consultations,
copies of medical records, preparations of reports and forms or summaries.
I have read and fully understand the above consent for treatment, nancial responsibility, release of medical information, and
insurance authorization. These authorizations shall remain valid until written notice is given by my revoking said authorization.
Patient Signature: Date:
Yevgeniy Khavkin, MD
Board Certif ied Neurosurgeon
Fellowship Trained Spine Surgeon
Ippei Takagi, MD
Board Eligible Neurosurgeon
Fellowship Trained Spine Surgeon
Sherif Al-Hawarey, MD
Board Certified Pain Management Physician
Arlyn Valencia, MD
Physician Assistant
Gavin Pope, PA-C
Physician Assistant
Hayley Washinsky, PA-C
Physician Assistant
Kimbrelle Pascua, APN
Nurse Practitioner
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04/17/2019
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signature
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PRIVACY NOTIFICATION
As permitted by the Health Insurance Portability and Accountability Act (HIPAA), I understand that my protected health information
may be used and disclosed by my physician, oce sta, and others outside of this oce who is involved in my care and treatment for
the purpose of providing health care services.
I acknowledge that I have been provided an opportunity to review the Notice of Privacy Practices which explains how my medical
information will be used and disclosed. I understand that I am entitled to a copy of this document.
Patient Signature: Date:
RELEASE OF INFORMATION
I authorized Khavkin Clinic to discuss information with the following:
Family Members Coaching/Training sta at my school
Name: Relation:
Name: Relation:
Name: Relation:
Patient Signature: Date:
EMERGENCY CONTACT INFORMATION
Name: Phone:
Relation:
THANK YOU FOR CHOOSING KHAVKIN CLINIC.
Khavkin Clinic is centered on compassionate, conservative and evidenced-based care with patient education being one of our highest
priorities. We have organized our practice to include services that complement our treatment philosophy so that you can feel condent
that you are receiving the best care possible:
• Electronic medical records
• Durable Medical Equipment (DME) to include lumbar and cervical braces.
If surgery is the treatment option recommended for you, our physicians are aliated with Medical and Dental Center of Nevada.
This facility is staed with experienced nurses and support sta who work closely with our physicians to provide the highest quality
specialized care in an ecient and personal manner. This facility is equipped with state of the art equipment specic for spine patients
who are having an outpatient procedure as well as those who require an overnight stay.
FINANCIAL DISCLOSURE
We feel it is your right to know that our physicians have ownership in some of the surgical facilities listed above as permitted by both
state and federal law.
If you have questions or concerns please let us know, we would be happy to discuss this further with you.
We appreciate the opportunity to serve you and your family and look forward to helping you feel better and get your life back!
Patient Signature: Date:
Yevgeniy Khavkin, MD
Board Certif ied Neurosurgeon
Fellowship Trained Spine Surgeon
Ippei Takagi, MD
Board Eligible Neurosurgeon
Fellowship Trained Spine Surgeon
Sherif Al-Hawarey, MD
Board Certified Pain Management Physician
Arlyn Valencia, MD
Physician Assistant
Gavin Pope, PA-C
Physician Assistant
Hayley Washinsky, PA-C
Physician Assistant
Kimbrelle Pascua, APN
Nurse Practitioner
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New Patient Established Patient (New Problem) Today’s Date:
Name:
DOB: Age: Sex: M F Height: _____’ _____” Weight: __________ Lbs
Primary Care Physician: Phone:
How did you hear about us? Doctor Referral Family/Friend Internet Insurance Other:
HISTORY OF COMPLAINT
Is this a work related injury? Yes No
Is this a result of a motor vehicle accident or a slip and fall? Yes No
Date of Injury:
Describe how you were injured:
If this is not an injury, when did your pain start?
Location of pain:
Does pain radiate into extremities? Right Arm Left Arm Left Leg Right Leg Buttocks
Intensity: 0 1 2 3 4 5 6 7 8 9 10
What helps with pain? What makes pain worse?
DRUG ALLERGIES
Drug: Reaction:
Drug: Reaction:
Drug: Reaction:
Yevgeniy Khavkin, MD
Board Certif ied Neurosurgeon
Fellowship Trained Spine Surgeon
Ippei Takagi, MD
Board Eligible Neurosurgeon
Fellowship Trained Spine Surgeon
Sherif Al-Hawarey, MD
Board Certified Pain Management Physician
Arlyn Valencia, MD
Physician Assistant
Gavin Pope, PA-C
Physician Assistant
Hayley Washinsky, PA-C
Physician Assistant
Kimbrelle Pascua, APN
Nurse Practitioner
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FAMILY HISTORY & SOCIAL HISTORY
Mother Father Grandmother Grandfather Sibling
Cancer
Diabetes
Heart Disease
Arthritis
Ra
Stroke
Kidney Disease
Liver Disease
Other
Do you smoke? Yes No If yes, how many packs a day? _______ Number of years smoked: _______
Do you drink alcohol? Yes No If yes, how many drinks a day/week? ______ / ____________ Number of years drinking: ______
Do you exercise regularly? Yes No If yes, how many days per week? ______ Number of years exercising: ______
REVIEW OF SYSTEMS
When was your last physical examination? More than 5 years ago
Have you ever had any of the following conditions? (Circle all that apply)
Cancer
Heart Disease
Stroke
Diabetes
Seizures
Constipation
Other:
High Blood Pressure
Migraine Headaches
Hepatitis ( A B C )
Asthma
Psoriasis
Depression
Other:
Blood Clots In Legs
Excessive Fatigue
Irregular Heartbeat
Previous Blood Transfusion
Headaches (Not Relieved By Medication)
Diculty Breathing
Other:
PRIOR EVALUATION
Please list the name of any physicians/facilities you have been seen for your current condition:
Yevgeniy Khavkin, MD
Board Certif ied Neurosurgeon
Fellowship Trained Spine Surgeon
Ippei Takagi, MD
Board Eligible Neurosurgeon
Fellowship Trained Spine Surgeon
Sherif Al-Hawarey, MD
Board Certified Pain Management Physician
Arlyn Valencia, MD
Physician Assistant
Gavin Pope, PA-C
Physician Assistant
Hayley Washinsky, PA-C
Physician Assistant
Kimbrelle Pascua, APN
Nurse Practitioner
Please list any prior surgeries you have had:
PROCEDURE LEVELS DATE
Lumbar Disc Surgery
Lumbar Fusion
Cervical Fusion
Other:
Other:
On the body diagram below, please indicate where your pain is located at the present time.
Please do not indicate areas of pain that are not related to your present injury or condition.
Indicate which of the following you have tried for your pain and if it helped:
TRIED HELPED TRIED HELPED
Pain Management
Yes No Yes No
Anti-inammatory/NSAID
Yes No Yes No
Epidural Steroid Injection
Yes No Yes No
Chiropractic Therapy
Yes No Yes No
Trigger Point Injections
Yes No Yes No
Physical Therapy
Yes No Yes No
How long are you able to sit/stand comfortably?
How far are you able to walk?
Yevgeniy Khavkin, MD
Board Certif ied Neurosurgeon
Fellowship Trained Spine Surgeon
Ippei Takagi, MD
Board Eligible Neurosurgeon
Fellowship Trained Spine Surgeon
Sherif Al-Hawarey, MD
Board Certified Pain Management Physician
Arlyn Valencia, MD
Physician Assistant
Gavin Pope, PA-C
Physician Assistant
Hayley Washinsky, PA-C
Physician Assistant
Kimbrelle Pascua, APN
Nurse Practitioner
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Patient Name: D.O.B.: Date:
Please include all prescribed medications, over the counter medications, vitamins, herbals, and supplements taken.
This list will be updated at each visit.
DATE MEDICATION DOSE FREQUENCY TAKEN DISCONTINUED
Pharmacy Name:
Location:
Phone: Fax:
Yevgeniy Khavkin, MD
Board Certif ied Neurosurgeon
Fellowship Trained Spine Surgeon
Ippei Takagi, MD
Board Eligible Neurosurgeon
Fellowship Trained Spine Surgeon
Sherif Al-Hawarey, MD
Board Certified Pain Management Physician
Arlyn Valencia, MD
Physician Assistant
Gavin Pope, PA-C
Physician Assistant
Hayley Washinsky, PA-C
Physician Assistant
Kimbrelle Pascua, APN
Nurse Practitioner
AGREEMENT FOR NARCOTIC MAINTENANCE THERAPY
The purpose of this Agreement is to prevent misunderstandings about certain medications you will be taking for pain management.
This Agreement is to help you and your physician to comply with the law and CDC guidelines regarding controlled pharmaceuticals.
The long-term use of pain medication is somewhat controversial as there is a risk of developing dependency and abuse. It is necessary
that the use of these narcotic pain medicines be accurately monitored and regulated. Please read and initial each of our policies:
_
All narcotic medication must always come from one physician as required by law. It is inappropriate as illegal for multiple
physicians to be prescribing pain medications.
_
No rells will be allowed after 3:00 PM on weekdays and after 1:00 PM on Fridays. No rells provided on weekends. DO NOT
CALL ANSWERING SERVICE REQUESTING REFILL(S).
_
Rells will not be given if you have not been seen in the oce within the last 90-days.
_
Narcotic medications must all be obtained from same pharmacy. Filling prescriptions at multiple pharmacies in not
acceptable. The prescribing physician is authorized to discuss all diagnostic and treatment details with the pharmacist at the
dispensing pharmacy at any time.
_
Rells should be requested via your pharmacy not our oce unless a change of medication needs to be discussed.
_
Medications will not be replaced if they are lost, fall in the toilet, eaten by pets, left on airplane, etc. If medications are stolen a
police report must be led in order to get a rell. Otherwise, early rells will not be authorized.
_
If it appears that narcotic medications are being used inappropriately and against medical advice the responsible legal
authorities may be notied. All condentiality is waived and consent is given by patient to provide the appropriate authorities
with full access to the patient’s records.
_
I understand that failure to adhere to these policies will result in permanent cessation of all narcotic medication by our
physicians.
_
If you are under the care and/or being treated by a pain management physician you must obtain a release of care sent to our
oce before narcotic medication will be prescribed.
_
I understand that there is a risk of psychological and/or physical dependence and addiction associated with chronic use of
controlled substances.
_
I understand that this Agreement is essential to the trust and condence necessary in a provider/patient relationship and that
my provider undertakes to treat me based on this Agreement.
_
I understand that if I break this Agreement, my provider will stop prescribing these pain control medicines.
_
In this case, my provider will NOT taper o the medicine over a period of several days, and you may experience withdrawal
symptoms. Also, a drug-dependence treatment program may be recommended.
_
I would also be amendable to seek psychiatric treatment, psychotherapy, and/or psychological treatment if my provider
deems necessary.
_
I will communicate fully with my provider about the character and intensity of my pain, the eect of the pain on my daily life,
and how well the medicine is helping to relieve the pain.
_
I will not use any illegal controlled substances, including marijuana, cocaine, etc., nor will I misuse or self-prescribe/medicate
with legal controlled substances.
_
I will not use alcohol while being prescribed this medications. I will be monitored for alcohol metabolites during random drug
testing.
Yevgeniy Khavkin, MD
Board Certif ied Neurosurgeon
Fellowship Trained Spine Surgeon
Ippei Takagi, MD
Board Eligible Neurosurgeon
Fellowship Trained Spine Surgeon
Sherif Al-Hawarey, MD
Board Certified Pain Management Physician
Arlyn Valencia, MD
Physician Assistant
Gavin Pope, PA-C
Physician Assistant
Hayley Washinsky, PA-C
Physician Assistant
Kimbrelle Pascua, APN
Nurse Practitioner
_
I will not share my medication with anyone.
_
I will not attempt to obtain any controlled medication, including opioid pain medications, controlled stimulants, or anti-
anxiety medications from any other provider.
_
I will safeguard my pain medication from loss, theft, or unintentional use by others, including youth. Lost or stolen medications
will not be replaced under NO CIRCUMSTANCES.
_
I agree that rells of my prescriptions for pain medications will be made only at the time of an oce visit or during regular
oce hours. NO rells will be available during evenings or on weekends.
_
I agree to use only one pharmacy to ll all of my medications.
_
I authorize the provider and my pharmacy to cooperate fully with any city, state or federal law enforcement agency, including
this state’s Board of Pharmacy, in the investigation of any possible misuse, sale, or other diversion of my pain medication. I
authorize my provider to provide a copy of this Agreement to my pharmacy, primary care provider and local emergency room.
I agree to waive any applicable privilege or right of privacy or condentiality with respect to these authorizations.
_
I agree that I will submit to a blood or urine test if requested by my provider to determine my compliance with my program of
pain control medications.
_
I understand that my provider will be verifying that I am receiving controlled substances from only one prescriber and only
one pharmacy by checking the Prescription Monitoring Program website periodically throughout my treatment period.
_
I agree that I will use my medicine at a rate no greater than the prescribed rate and that use of my medicine at a greater rate
will constitute a breach of this agreement.
_
I will bring unused pain medicine to every oce visit.
_
I agree to follow these guidelines that have been fully explained to me.
I HAVE READ AND AGREED TO THE ABOVE MENTIONED TERMS:
Patient Signature: Date:
I obtain my pain medication from my primary physician/pain management doctor:
Dr. and will continue to do so until I discuss these changes with one of our physicians.
Physician Signature: Date:
Patient Signature: Date:
PATIENT REFUSED TO SIGN
Yevgeniy Khavkin, MD
Board Certif ied Neurosurgeon
Fellowship Trained Spine Surgeon
Ippei Takagi, MD
Board Eligible Neurosurgeon
Fellowship Trained Spine Surgeon
Sherif Al-Hawarey, MD
Board Certified Pain Management Physician
Arlyn Valencia, MD
Physician Assistant
Gavin Pope, PA-C
Physician Assistant
Hayley
Washinsky, PA-C
Physician Assistant
Kimbrelle Pascua, APN
Nurse Practitioner
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Patient Name: D.O.B.: Date:
OFFICE POLICIES
We are dedicated to providing you with the best possible care and service, and we regard your understanding of our oce and
nancial policies as an essential element of your care and treatment. Please read the following carefully. If you have questions about
your account, charges, insurance, or payments, please speak with one of our representatives.
Oce hours are 9 :00am to 5:00pm Monday through Friday. All routine telephone calls to the oce should be made during these hours.
INSURANCE PLANS
If you are insured, we will bill those insurance plans with which we have an agreement. However, it is ultimately your responsibility to
become familiar with the details of your insurance plan coverage. To nd out what your insurance plan covers and what your nancial
obligation may be, we strongly recommended that you call the customer service or member services department of your insurance
company (the phone numbers are on your insurance card) prior to your rst visit. Your deductible that is due at the time of the visit.
In the event that your health plan determines a service to be “non-covered,” we will bill you, and payment is due upon receipt of that
statement. Any amount not paid by your insurance company within 30 days will be billed to you. If your insurance coverage is with a
plan that we do not have an agreement, payment is expected, in full, at the time of service. As a courtesy, we will submit a claim to your
insurance company on your behalf.
You are responsible to notify us of your insurance, any changes to your insurance, and to provide the necessary information about
your insurance plan (or plans if you have more than one coverage); therefore, please have your current insurance card(s) with you at all
times, as well as your prescription card (if dierent).
MEDICARE
Khavkin Clinic is a participating Medicare provider. Not all Medicare patients have traditional Medicare. If you have signed up for a
Medicare Advantage Plan, it Is your responsibility to verify if our doctors are participating providers with your specic plan. Most
Medicare Advantage Plans require prior authorization or referrals from your primary care provider or IPA. If you have a Medicare
Advantage Plan, you are responsible for obtaining prior authorization and/or referral for your initial visit. We will request authorization
for follow up visits and surgeries. If you have traditional Medicare we will collect the estimated coinsurance at the time of service. If you
have a Medicare Advantage Plan, we will collect your specialist co-pay at the time of service. Any amount not paid by your insurance
company within 30 days will be billed to you. If your insurance coverage is with a plan that we do not have an agreement or if you do
not have the required prior authorization, payment is expected, in full, at the time of service. As a courtesy, we will submit a claim to
your insurance company on your behalf.
MEDICAID
Khavkin Clinic is a participating Medicaid provider for Nevada Medicaid and Arizona Medicaid. Not all patients have traditional
Medicaid. If you have signed up for a Medicaid HMO, it is your responsibility to verify if our doctors are participating providers with
your specic plan. Most Medicaid HMO Plans require prior authorization or referrals from your primary care provider or IPA. If you have
a Medicaid HMO, you are responsible for obtaining prior authorization and/or referral for your initial visit. We will request authorization
for follow up visits and surgeries. If your insurance coverage is with a plan that we do not have an agreement with or if you do not have
the required prior authorization, payment is expected, in full, at the time of service.
SELF-PAY ACCOUNTS
If you do not have a valid insurance plan to cover the cost of our services, you will be required to make full payment at the time of service.
I HAVE READ AND AGREED TO THE ABOVE MENTIONED TERMS:
Patient Signature: Date:
Yevgeniy Khavkin, MD
Board Certif ied Neurosurgeon
Fellowship Trained Spine Surgeon
Ippei Takagi, MD
Board Eligible Neurosurgeon
Fellowship Trained Spine Surgeon
Sherif Al-Hawarey, MD
Board Certified Pain Management Physician
Arlyn Valencia, MD
Physician Assistant
Gavin Pope, PA-C
Physician Assistant
Hayley Washinsky, PA-C
Physician Assistant
Kimbrelle Pascua, APN
Nurse Practitioner
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HIPAA COMPLIANT AUTHORIZATION FOR THE USE
AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
Date:
Patient’s Name:
Eective Date:
Expiration of authorization of release of information:
I, hereby authorize the use or disclosure of my protected health
information as described below. I understand that the information I authorize a person or entity to receive may be redisclosed and no
longer protected by federal privacy regulations.
Specic Information that may be used/disclosed: All Medical Records, Radiology Reports, Oce Visit/Consultation Notes, Progress
Reports, Lab Results, Testing Results.
Information will be used/disclosed for the following purpose(s): CONTINUITY OF CARE
Persons/organizations authorized to use or disclose the information:
Phone: Fax:
Persons/organizations authorized to receive the Information:
KHAVKIN CLINIC
653 N. TOWN CENTER DRIVE, SUITE# 602
LAS VEGAS, NEVADA 89144
PHONE: (702) 888-1188 FAX: (702) 673-1155
I understand that this authorization Is voluntary and that I may refuse to sign this authorization. My refusal to sign will not aect my
eligibility for benets or enrollment, payment for or coverage of services, or ability to obtain treatment I understand that I may inspect
or copy the information used or disclosed. I understand that I may revoke this authorization at any time by notifying KHAVKIN CLINIC in
writing, except to the extent that:
a) Action has already been taken as a result of this authorization; or
b) If this authorization is obtained as a condition of obtaining insurance coverage, other law provides the insurer with the right to
contest a claim under the policy or the policy itself.
I understand that I have a right to request and receive a Notice of Privacy Practices from KHAVKIN CLINIC.
Signature of Patient or Personal Representative Date
If not signed by patient, print name of Personal Representative Description of Personal Representative’s Authority
Yevgeniy Khavkin, MD
Board Certif ied Neurosurgeon
Fellowship Trained Spine Surgeon
Ippei Takagi, MD
Board Eligible Neurosurgeon
Fellowship Trained Spine Surgeon
Sherif Al-Hawarey, MD
Board Certified Pain Management Physician
Arlyn Valencia, MD
Physician Assistant
Gavin Pope, PA-C
Physician Assistant
Hayley
Washinsky, PA-C
Physician Assistant
Kimbrelle Pascua, APN
Nurse Practitioner
Patient Name: D.O.B.: Date:
PATIENT HIPAA ACKNOWLEDGMENT AND DESIGNATION DISCLOSURE FORM
Acknowledgment of Practice’s Notice of Privacy Practices:
By subscribing my name below, I acknowledge that I was provided a copy of the Notice of Privacy Practices (NPP), and that I have read
(or had the opportunity to read if I so chose) and understand the Notice of Privacy Practices {NPP) and agree to its terms.
Signature of Patient or Personal Representative Date
If not signed by patient, print name of Personal Representative Description of Personal Representative’s Authority
Above signature was not obtained because:
Patient is unable to sign and is unaccompanied by a representative. Patient left with all pertinent disclosures.
Patient refused to sign.
Patient refused forms.
DESIGNATION OF CERTAIN RELATIVES, CLOSE FRIENDS AND OTHER CAREGIVERS AS MY
PERSONAL REPRESENTATIVE:
I agree that the practice may disclose my health information to a Personal Representative of my choosing, since such person is involved
with my health care or payment relating to my healthcare. In that case, the Physician Practice will disclose only information that is
directly relevant to the person’s involvement with my health care or payment relating to my health care.
Print Name Relationship to You Telephone # What we may disclose
Any and all info
Pre/Post procedure instructions
Appointment info only
Any and all info
Pre/Post procedure instructions
Appointment info only
Any and all info
Pre/Post procedure instructions
Appointment info only
REQUEST TO RECEIVE CONFIDENTIAL COMMUNICATIONS BY ALTERNATIVE MEANS:
As provided by Privacy Rule Section 164.522(b), I hereby request that the Practice make all communications to me by the alternative
means that I have listed below.
Home Phone:
OK to leave message with detailed information
Leave message with callback number only
Cell Phone:
OK to leave message with detailed information
Leave message with callback number only
Email Address:
OK to leave message with detailed information
Leave message with callback number only
Patient or Personal Representative Date
Yevgeniy Khavkin, MD
Board Certif ied Neurosurgeon
Fellowship Trained Spine Surgeon
Ippei Takagi, MD
Board Eligible Neurosurgeon
Fellowship Trained Spine Surgeon
Sherif Al-Hawarey, MD
Board Certified Pain Management Physician
Arlyn Valencia, MD
Physician Assistant
Gavin Pope, PA-C
Physician Assistant
Hayley Washinsky, PA-C
Physician Assistant
Kimbrelle Pascua, APN
Nurse Practitioner
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PATIENT INFORMATION Yevgeniy Khavkin, MD Hayley Washinsky, PA-C

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Completed 18 August 2021

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