Medical Record umber - UK HealthCare · Medical Record Number: ... Visitor Pay Parking. Visitor...

Medical Record Number:

Top area is for office/online use ONLY! Date of Service

Patient Registration Demographical Information

(Last Name) (First Name / Middle Initial) (Male / Female)

(Address) (City / State / Zip Code) (Area Code / Phone #)

(Race) (Primary Language) (Country of Origin)

(Social Security Number) (Date of Birth) (Age) (Maiden Name)

(Area Code / Secondary Phone #) (Patient Email Address)

Married ( ) Single ( ) Widowed ( ) Separated ( ) Divorced ( ) Mother’s Maiden Name Fathers FIRST Name

Patient Current Employer Information

Employer Name Hire Date:

(Name and Department)

Address Job Title:

(Number, Street, Building, Suite #)

(City / State / Zip Code) (Area Code / Phone #)

Patient Nearest Relative / Emergency Contact Information

Relative


(Social Security Number) (Date of Birth) (Age)

(Address) (City / State / Zip Code) (Area Code / Phone #)

(Relationship to Patient) (Area Code / Phone #) (Area Code / Secondary Phone #)

Emergency Contact


(Relationship to Patient) (Area Code / Phone #) (Area Code / Secondary Phone #)

Accident or Injury Information (ie: Fall at home, work injury, auto injury)

What is the date when your problem started? Is your problem due to a motor vehicle accident, work injury,

or other type of accident/injury? YES or NO If “YES”, Please describe briefly:

What type of work do you do? What was the last day you worked?

Complete Family and Referring Physician Information (Please provide FULL First and Last name)

Family Physician FULL Name

Phone

Fax

(City, State, Zip Code)

Referring Physician FULL Name

Phone

Fax

(City, State, Zip Code)

Primary Insurance Subscriber Information (If same as patient write “SAME”)

Primary Subscriber / Insured


(Address) (City / State (Zip Code)

(Area Code / Phone Number) (Area Code / Secondary Phone Number) (Relation to Patient)

(Date of Birth) (Social Security Number) (Name of Employer)

(Area Code / Secondary Phone #) (Patient Email Address)

Secondary Insurance Subscriber Information

Secondary Subscriber / Insured


(Address) (City / State ) (Zip Code)


(Date of Birth) (Social Security Number)

(Name of Employer)

If you have a Third Insurance Plan, Who is the Sub

Third Subscriber / Insured




(Date of Birth)

(Social Security Number)

(Name of Employer)

If the patient is under 18 years of age, parents please complete ALL of the following information:

Parent / Guardian / Guarantor Responsible for Patient




(Date of Birth) (Social Security Number) (Age)

Parent / Guardian / Guarantor Employer

Employer Name (Company Name) (Department)

Address

(Number, Street, Building, Suite Number) (Area Code / Phone Number)

(City, State) (Zip Code)

(Addressograph)

PATIENT NAME

DATE OF BIRTH

Dr. Phillip Tibbs

Dr. Thomas Pittman

Dr. Byron Young

Dr. Karin Swartz

Who referred you to the Neurosurgery Clinic?

Doctor City Phone

Who is your family Physician?

Doctor City Phone

Briefly describe your problem:

What is the date when you problem started?

Is your problem due to a motor vehicle accident, work injury, or other type of accident / injury? Yes or No

If “Yes”, Please describe briefly:

What type of work do you do? Last day you worked?

PERSONAL MEDICAL HISTORY

Have you had any chronic / serious illness? Yes or No If “Yes”, Please Explain:

List any operations you have undergone:

Please list all your current medications, their dosage, and how often you take them in the columns below.

Medication mg Frequency Medication mg Frequency

List any medications you are allergic to:

Have you sustained any disabling / serious injuries? Yes or No If “Yes”, Please Explain:

Do you smoke? Yes or No

If so, how many years: How many packs per day?

How many children do you have?

FAMILY MEDICAL HISTORY

If anyone in your immediate family has ever had any of the following, please mark the box accordingly.

Mother Father Grandparent Brother / Sister

1. Heart Attack

2. Cancer

3. Hypertension

4. Stroke

5. Back Problems

Please indicate with an X if you have a new problem, prior existing condition, or if you never had the condition from the list below. NEW PRIOR NEVER

CONSTITUTIONAL

1. Weight Gain? 2. Weight Loss?

3. Hair Loss?

EYES

1. Double Vision?

2. Eye Pain? 3. Hair Loss?

EARS, NOSE, & THROAT 1. Hearing Loss?

2. Sore Throat?

CARDIOVASCULAR

1. Heart murmur?

2. High blood pressure? 3. Treatment for high blood pressure?

4. Chest pain after exertion?

5. Heart attack? 6. Abnormal electrocardiogram?

7. Rapid pulse / heart beat?

8. Irregular pulse? 9. Leg cramps after walking?

RESPIRATORY

1. Coughing up blood?

2. Chest pain? 3. Shortness of breath?

GASTROINTESTIONAL 1. Abdominal pain?

2. Black bowel movement?

GENITOURINARY

1. (Male) Prostate Problems?

2. (Male) Erectile problems?

3. (Male or Female) Blood in Urine?

4. (Male or Female) Bladder Infection?

MUSCULOSKELETAL 1. Sciatica?

2. Back / Neck Pain?

SKIN (INTEGUMENTARY)

1. New skin growths?

2. Growths that change in size?

NEUROLOGICAL

1. Frequent headaches? 2. Migraine headaches?

3. Loss of vision?

4. Weakness in arms / legs? 5. Pain in arms / legs?

6. Convulsions?

7. Stroke?

PSYCHOLOGICAL

1. Depression? 2. Mood swings?

ENDOCRINOLOGY 1. Diabetes?

2. Thyroid problems?

HEMATOLOGY

1. Anemia?

2. Clotting Factor?

ALLERGY

1. Food?

2. Drug?

3. Environmental?

5. (Female) Date of last Pap Smear: Results:

6. (Female) Date of last Mammogram: Results:

DATE: Patient Signature:

DATE: Physician Signature:

On the two figures shown Please indicate the areas

that are troubling you most.

Kentucky Neuroscience Institute • Department of Neurosurgery Kentucky Clinic • 740 South Limestone Street, Suite B-101 • Lexington, Kentucky 40536-0284

Phone: (859) 323-5661 • Fax: (859) 323-1127

Parking Structure #8 (UK HealthCare Garage)

Location: 110 Transcript Avenue (at the corner of S. Limestone and Tran-

script Avenue)

Height Clearance: 8' 6"

No. of Spaces: 245 reserved; 1,351 patient

User Group(s): Employee Reserved Permits, Construction Permits Level E

and above, High Frequency Commuters (HFC Permits), Vendors and Patient/

Visitor Pay Parking

Visitor Rates:

Patient rate: $0.75/hour | $6/exit maximum

Non-patient rate: $10/hour | $25/exit maximum

Vendor rate: $2/first hour | $2/second hour | $1/hour thereafter | $10/exit maximum

This facility is designed to accommodate many different types of users including employee reserved permits,

construction permits, HFC permits, patients/visitors that include employees and students with medical appointments, and

vendors. Parking fees are paid at manned cashier booths at the exit. Anyone with questions concerning parking may

contact us at (859) 323-8085. Information about purchasing weekly Patient/Visitor passes and discount out-patient pass-

es is also available at this number, or by going to the parking office located on level A inside this structure.

Vendors are charged the vendor hourly rate when exiting. Between the hours of 8:00 a.m. and 4:30 p.m., parking is re-

stricted to patient/visitor, HFC, construction permits, and vendors.

Parking & Payment Information

Parking in the Structure

How does a paying patron (visitor or guest) go about parking in the structure? A paying patron must accept a ticket from

the ticket dispenser at the entrance. After accepting the ticket, the gate arm will open and the patron can then proceed

into the structure to locate a parking spot.

Payment Methods

Parking fees are paid at cashier booths at the exit. Current forms of payment accepted are cash, or check (with driver's

license).

Shuttles offer free door-to-door service

Wheelchair-friendly (no steps) shuttle buses transport parkers safely to and from the hospital’s front loop and

Emergency entrances, 24 hours a day, every day.

A second shuttle route serves the Kentucky Clinic 6 a.m. – 8 p.m., Monday – Friday.

Shuttle buses for each route arrive every three to five minutes.

Patients or visitors may continue to be dropped off at the hospital’s front loop or Emergency entrances, or at the

Kentucky Clinic entrance on South Limestone, prior to the driver parking.

Ambassador assistance

An ambassador is available at the shuttle loading area 6 a.m. – 11 p.m. to answer questions and help patients

and visitors access the shuttles. An ambassador also provides assistance at the hospital’s main entrance.

People with Disabilities

Accessible parking is available on levels B, C and D of the structure. The elevator is located in the lobby.


Phone: (859) 323-5661 • Fax: (859) 323-1127

Parking Structure #3 (KY Clinic Garage)

Location: 140 Huguelet Drive (located behind the KY Clinic)

Height Clearance: 9' 0"

No. of Spaces: 354 reserved; 490 patient

User Group(s): Employee Reserved Permits, and KY Clinic Patient Pay

Parking

Visitor Rates:

Patient rate: $0.75/hour | $6/exit maximum

Vendor rate: $2/first hour | $2/second hour | $1/hour thereafter | $10/exit

maximum

This facility is designed to accommodate many different types of users including employee reserved permits, patients

that include employees and students with medical appointments, and vendors. Customers exiting with a Patient Parking

Rate Stamp are charged the patient rate of $0.75 cents per hour, while vendors are charged the vendor hourly rate when

exiting.

Between the hours of 8:00 a.m. and 4:30 p.m., a patient rate stamp is required when exiting or patrons will be charged

the higher non-patient rate of $10.00 for the first hour and $5.00 for each additional hour (to a maximum of $25.00).

Parking fees are paid at cashier booths at the exit. Anyone with questions concerning parking may contact us at (859)

323-8085.

Parking & Payment Information

Parking in the Structure

How does a paying patron (visitor or guest) go about parking in the structure? A paying patron must accept a ticket from

the ticket dispenser at the entrance. After accepting the ticket, the gate arm will open and the patron can then proceed

into the structure to locate a parking spot.

Payment Methods

Parking fees are paid at cashier booths at the exit. Current forms of payment accepted are cash or check (with driver's

license).

People with Disabilities

Accessible parking is available on all levels of the structure.

Hours of Operation

This facility is open 24 hours a day, seven days a week. Between the hours of 8:00 a.m. and 4:30 p.m. Monday-Friday,

patient only parking is allowed (See Hospital Policy HP-10). Vehicles parking in violation may be cited, towed or

charged the non-patient rate when exiting.

After 4:30 p.m. and before 8:00 a.m. Monday-Friday, and all day Saturday and Sunday, anyone can park in the structure

unless spaces are otherwise restricted by signage. If a customer is exiting when the cashier booth is open, the appropriate

fee will be charged.


Phone: (859) 323-5661 • Fax: (859) 323-1127

Dear Patient:

Our clinic is located on the 1st Floor of the Kentucky Clinic in Wing “C” (across from Starbuck’s Coffee). Please plan your travel

accordingly in order to arrive at least 10 minutes prior to your appointment. For your convenience we have enclosed directions

which should help assist you in reaching our Clinic. The attached parking structure has been reserved for patient parking, and the

parking fee is very nominal. From there you can directly enter the Kentucky Clinic building. A wheelchair may be obtained at the

Central Registration/Information desks located on the first floor and third floor of the Kentucky Clinic (first floor main entrance, or

third floor by the pedestrian walkway that leads to UK Hospital). Phones are available in each corridor should you require assis-

tance.

To expedite your evaluation we ask that you do the following:

1. If you are unable to keep your appointment, please notify KNI within 24 hours of your scheduled appointment, if at all possi-

ble, at (859) 323-5661 so we may contact the appropriate Doctor’s office and inform them of your cancellation. We will be

happy to reschedule your visit for a more convenient time by Neurosurgeon availability. The Clinic hours are from 8:00am to

5:00pm on weekdays.

2. Complete the enclosed Medical History form, including the full first and last name of your family doctor, referring doctor,

and all current medications you are taking.

3. Bring any X-rays, CT Scans, Myelograms, or MRI Scans relevant to your current condition. Failure to bring your studies to

the clinic on the day of your appointment can result in your appointment being rescheduled to the next available opening. If

your films were taken at UK Hospital, Kentucky Clinic, or the Gill Radiological center we will obtain those films prior to your

appointment.

4. Bring any medical records and referrals from your family doctor and/or referring doctor that are directly related to your condi-

tion.

5. Please have your co-pay ready at the time of check-in as your insurance company expects us to collect all co-pay’s prior to

your visit.

6. If you are not insured please bring the required $100.00 deposit for your visit. ($40.00 is required on follow-up visits)

7. Financial assistance is available; if you are unable to pay a deposit please call (859) 257-8618 and ask to speak to a financial

counselor.

8. If your condition is covered through a Workers Compensation Carrier, you must accurately complete the attached Important

Notice form to include the date of your injury, the claim number assigned to your case, the address where we will submit your

bills, and the name and phone number of the adjuster assigned to your case. Failure to bring this information could result with

your appointment being rescheduled to the next available opening. If you have any secondary insurance or medical cards we

must copy that information in your medical record so please bring all insurance and/or medical cards with you to the appoint-

ment.

9. If your condition is due to an Automobile accident or other accident, please complete the Important Notice form to include the

date of your accident, the claim number assigned to your case, the address where we will submit your bills, and the name and

phone number of the adjuster assigned to your case. Failure to bring this information could result with your appointment be-

ing rescheduled to the next available opening. If you have any secondary insurance or medical cards we must copy that infor-

mation in your medical record so please bring all insurance and/or medical cards with you to the appointment.

10. Please review your insurance benefits packet in order to assure you are coming within your provider network. Some insuranc-

es require that only your family doctor refer you to a specialist otherwise you may be balance billed for the out of network

difference in cost. Please assure that you are bringing all appropriate written referrals from your family doctor. Failure to

bring your referral can result in your appointment being rescheduled to the next available opening. Medicaid recipients who

are “Kenpac” (assigned a specified family doctor) must receive approval from the Kenpac provider in order to be seen and

cannot be referred by any doctor other than the family doctor. We do not accept Medicaid Passport plans.

11. Some insurances which require written referral/prior-authorizations are Tricare, most HMO plans, Medicare replacement

plans, Medicaid Kenpac, Workers Care plans, and out of network plans. You may call your insurer and speak to Benefits if

you are unsure.

12. A set of directions have been included in your packet for your convenience. However, if you have internet access you may log

on to www.ukhealthcare.uky.edu and type “directions” into the search engine to find detailed maps and directions to our clinic.

It is best to allow at least one hour for your initial evaluation since new patients often require x-rays or lab tests in addition to their

Neurological exams. If needed, special tests will be scheduled for another day, and those appointments will normally be sent to

you by mail within two to three weeks after your consultation. Due to the large volume of patients we see on any given day your

wait time could vary between 20 minutes to one hour. We apologize in advance for any inconvenience this may cause you.

http://www.ukhealthcare.uky.edu


Phone: (859) 323-5661 • Fax: (859) 323-1127

WORKMAN’S COMP/MOTOR VEHICLE ACCIDENT

HEALTH INSURANCE COVERAGE

To ensure proper claim filing you must present your insurance card, the one that has YOUR complete name,

billing address, policy numbers, etc. All co-pays are expected up front at the time of your visit. Please have

cash, check, money order, or credit card ready at the time of check in. It is the Patient’s responsibility to

know if their insurance carrier provides coverage for our physicians and the University Hospital. You must

check with your primary care physician and bring any referral necessary to see our neurosurgeons. If the

University system or our physicians are not covered under your insurance group, or if you come in without the

necessary referral, You will be liable for all expenses at the time of service. Please take time to study your

insurance manual and be informed.

Please read this page very carefully and decide which category relates to your case. NOTE: If you are unable

to provide any of the following information at the time of your visit, you will need to reschedule. If you have

any questions, please call us at (859) 323-5661. All co-pays are expected up front at the time of your medical

services.

PAYMENT POLICIES:

In order to file your claim properly, we must have the complete name, address, phone number, contact person,

and claim number of your insurance carrier under workers compensation or auto. Without this COMPLETE

information, you will ultimately be responsible for your bill PRIOR to the time of service. Office visits range

from $170.00 to $415.00. It is required for you to also present with any secondary insurance cards, Medicare

card, or Medicaid card which must be copied for the chart. All billing will go to your Workers Comp or Auto

Insurance carrier. Please bring verification of Workers Comp approval for your visit.

FULL PAY

If you do not have Insurance coverage, you will be required to pay for your services PRIOR to the time of

service. Our office visits range from $160.00 to $440.00 and we accept cash, checks, and all major credit

cards. A “deposit” of $100.00 is required up front and any remaining balance due on the office visit will be

billed to you. Follow up visits require a $40.00 “deposit” up front and any remaining balance due on the

office visit will be billed to you.

Financial assistance is available to certain qualified individuals. Please call (859) 323-5661 if you know you

are unable to bring the deposit for your visit. We will be happy to have a Financial Counselor contact you

over the phone prior to your office visit to process an application for assistance or make an alternative payment

arrangement for you.


Phone: (859) 323-5661 • Fax: (859) 323-1127

Traveling East on Mountain Parkway:

Take the Bert T Combs Mountain PKWY all the way to I-64 West and

follow I-64 West to Exit 113 Marked Paris/Lexington

Turn right onto North Broadway (US-68)

Follow North Broadway through downtown Lexington for about 3 ½

miles. When you reach Main Street, North Broadway becomes South

Broadway.

Follow South Broadway past the Hyatt Regency Hotel (on your right)

for about 2 miles. Remain in the left lane until you see Red Mile Race

Track on your right, then turn left at this light onto Virginia Avenue

When you cross the intersection at South Limestone and Virginia

Avenue, Virginia Avenue becomes Huguelet Avenue. Proceed to the

STOP sign and turn right to enter the Kentucky Clinic parking garage.

PATIENT DROP OFF AREA MAIN ENTRANCE OF CLINIC

At the corner of Virginia Avenue and South Limestone you will turn right

onto South Limestone and get over in the left hand lane. Turn left onto

Kentucky Clinic Drive and proceed to the patient drop off area at the main

entrance of the Clinic. After dropping off the patient proceed forward and

turn right to enter the parking garage or turn left to go to the Main UK

Healthcare parking garage on the corner of South Limestone and Transcript

Avenue.

MAIN UK HEALTHCARE PARKING WITH SHUTTLE SERVICES


onto South Limestone and proceed to the corner of South Limestone and

Transcript Avenue where you will see the parking garage on your right.

From this structure you can take the shuttle to either UK Hospital or the

Kentucky Clinic.

Traveling West from Owensboro:

Take US-60 East and follow it straight to US-231 North

Merge onto I-64 East

Take Exit 115 toward Bluegrass Parkway/Airport/Lexington

Merge onto Newtown Pike / KY-922 South towards Lexington/Airport/

Keeneland and follow Newtown Pike all the way to West Main Street.

Turn left onto West Main Street and follow as the road curves toward

the right in front of Lexington Center / Hyatt Regency Hotel (You are

now on Vine Street). Turn right onto South Broadway. Remain in the

left lane until you see Red Mile Race Track on your right, and then turn

left at this light onto Virginia Avenue.

When you cross the intersection at South Limestone and Virginia

Avenue, Virginia Avenue becomes Huguelet Avenue. Proceed to the

STOP sign and turn right to enter the parking garage.



onto South Limestone and get over in the left hand lane. Turn left onto

Kentucky Clinic Drive and proceed to the patient drop off area at the main

entrance of the Clinic. After dropping off the patient proceed forward and

turn right to enter the parking garage or turn left to go to the Main UK

Healthcare parking garage on the corner of South Limestone and Transcript

Avenue.



onto South Limestone and proceed to the corner of South Limestone and

Transcript Avenue where you will see the parking garage on your right.

From this structure you can take the shuttle to either UK Hospital or the

Kentucky Clinic.

Traveling West from Indiana:

Take IN-62 East to US-41 North

Turn right onto IN-57 / Swope Road and continue to follow IN-57

Merge onto I-164 North / IN-57 North

Merge onto I-64 East via Exit 21A towards Louisville

Take the KY-922 exit (Exit 115) towards Bluegrass Parkway/Airport/

Lexington

Merge onto Newtown Pike / KY-922 South towards Lexington/Airport/

Keeneland

Turn left onto West Main Street and follow as the road curves toward the

right in front of Lexington Center / Hyatt Regency Hotel (You are now on

Vine Street). Turn right onto South Broadway. Remain in the left lane until

you see Red Mile Race Track on your right, and then turn left at this light

onto Virginia Avenue.

When you cross the intersection at South Limestone and Virginia Avenue,

Virginia Avenue becomes Huguelet Avenue. Proceed to the STOP sign and turn right to enter the Kentucky Clinic parking garage.


At the corner of Virginia Avenue and South Limestone you will turn right onto South Limestone and get over in the left hand lane. Turn left onto Kentucky

Clinic Drive and proceed to the patient drop off area at the main entrance of the

Clinic. After dropping off the patient proceed forward and turn right to enter the parking garage or turn left to go to the Main UK Healthcare parking garage on

the corner of South Limestone and Transcript Avenue.


At the corner of Virginia Avenue and South Limestone you will turn right onto

South Limestone and proceed to the corner of South Limestone and Transcript

Avenue where you will see the parking garage on your right. From this structure you can take the shuttle to either UK Hospital or the Kentucky Clinic.

Traveling West from Paducah:

Take I-24 TO Western KY Parkway East Exit 42 toward Princeton/Elizabethtown

Merge onto Wendell H Ford Western Kentucky PKWY East

Merge onto I-65 North via Exit 137B towards Bluegrass Parkway/Lexington/

Louisville

Merge onto Bluegrass Parkway East via Exit 93 toward Bardstown/Lexington

Merge onto US-60 (Versailles Rd) East toward I-64 East

Follow Versailles Road to the traffic light at the large intersection at Bluegrass

Airport and Man O’War Boulevard. Counting this traffic light, proceed down

Versailles road through four more traffic lights, and then turn right at the fifth traffic

light. This is Mason Headley Road. (Cardinal Hill Rehabilitation Hospital will be

on your left as you turn)

Proceed forward on Mason Headley, at the second traffic light Mason Headley

becomes Waller Avenue. Proceed forward on Waller Avenue to Nicholasville

Road. You should be in the left lane at this light.

Turn left onto Nicholasville Road.

Nicholasville Road becomes South Limestone. Get into the right lane.

TO ENTER KENTUCKY CLINIC PARKING GARAGE

Proceed forward through two traffic lights, you will pass beneath a pedestrian skywalk

with large blue letters that show UK, and then turn right onto Huguelet Avenue at the

third light. Turn right again at the STOP sign to enter the Kentucky Clinic parking

garage.


Turn right at the second light instead of proceeding to the third light and you will enter a

special drop off area at the main entrance of the Clinic. After dropping off the patient

proceed forward and turn right to enter the parking garage or turn left to go to the Main

UK Healthcare parking garage on the corner of South Limestone and Transcript Avenue.


After you turn off Waller Avenue you will see the parking garage on your left, it is on

the corner of South Limestone and Transcript Avenue. From this structure you can take

the shuttle to either UK Hospital or the Kentucky Clinic.


Phone: (859) 323-5661 • Fax: (859) 323-1127

Taking I-75 North to Lexington:

Take I-75 North to exit 104

Turn left onto Athens-Boonesboro Road, which becomes Richmond Road

Follow Richmond Road approximately 4 miles to the traffic light at Man O’War

Boulevard.

Turn left onto Man O’War.

Follow Man O’War about 1 mile to Alumni Drive. Turn right onto Alumni Drive.

Follow Alumni Drive straight through the large intersection at Tates Creek Road

and begin watching for the Commonwealth Football Stadium on the right.

Pass the Stadium and go to the 4-way STOP sign. Turn right onto

University Drive.

Follow University Drive to next traffic light at Cooper Drive.

Turn left onto Cooper Drive. Get in the right lane.

Follow Cooper Drive to the next traffic light, turn right onto South

Limestone.

TO FIND THE KENTUCKY CLINIC PARKING GARAGE

After turning right onto Limestone, proceed through two traffic lights, you will pass

beneath a pedestrian skywalk with large blue letters that show UK, and then turn right

onto Huguelet Avenue at the third light. Turn right again at the STOP sign to enter the

Kentucky Clinic parking garage.


Turn right at the second light instead of proceeding to the third light and you will enter a

special drop off area at the main entrance of the Clinic. After dropping off the patient

proceed forward and turn right to enter the parking garage or turn left to go to the Main

UK Healthcare parking garage on the corner of South Limestone and Transcript Avenue.

MAIN UK HEALTHCARE PARKING WITH SHUTTLE SERVICE

After turning onto Limestone you will see the parking garage on your left, it is on the

corner of South Limestone and Transcript Avenue. From this structure you can take the

shuttle to either UK Hospital or the Kentucky Clinic.

Taking I-75 South to Lexington:

Follow I-64 or I-75 to Exit 113 (marked Paris/Lexington). Turn right onto

North Broadway (US 68)

Follow North Broadway through downtown Lexington for about 3 ½ miles.

When you reach Main Street, North Broadway becomes South Broadway.

Follow South Broadway past the Hyatt Regency Hotel (on your right) for

about 2 miles. Remain in the left lane until you see Red Mile Race Track

on your right, then turn left at this light onto Virginia Avenue

When you cross the intersection at North Limestone and Virginia Avenue,

Virginia Avenue becomes Huguelet Avenue. Proceed to STOP sign and turn right to enter the Kentucky Clinic parking garage.



South Limestone and get over in the left hand lane. Turn left onto Kentucky Clinic Drive and proceed to the patient drop off area at the main entrance of the

Clinic. After dropping off the patient proceed forward and turn right to enter the

parking garage or turn left to go to the Main UK Healthcare parking garage on the corner of South Limestone and Transcript Avenue.



South Limestone and proceed to the corner of South Limestone and Transcript

Avenue where you will see the parking garage on your right. From this structure you can take the shuttle to either UK Hospital or the Kentucky Clinic.

US 27 North to Lexington:

Follow US 27 (which is Nicholasville Road) through the south part of

Lexington for approximately 4.2 miles.

Go straight at the large intersection at Waller Avenue, Nicholasville

Road, and Cooper Drive. Nicholasville Road becomes South

Limestone.


Proceed forward through two traffic lights, you will pass beneath a pedestri-

an skywalk with large blue letters that show UK, and then turn right onto

Huguelet Avenue at the third light. Turn right again at the STOP sign to

enter the Kentucky Clinic parking garage.


Turn right at the second light instead of proceeding to the third light and you

will enter a special drop off area at the main entrance of the Clinic. After

dropping off the patient proceed forward and turn right to enter the parking

garage or turn left to go to the Main UK Healthcare parking garage on the

corner of South Limestone and Transcript Avenue.


After you pass Waller Avenue you will see the parking garage on your left,

it is on the corner of South Limestone and Transcript Avenue. From this

structure you can take the shuttle to either UK Hospital or the Kentucky

Clinic.

Bluegrass Parkway or Frankfort to Lexington:

Follow Bluegrass Parkway to Lexington and exit right onto Route 60 (Versailles Road). From Frankfort, Take US 60 to Versailles and continue to Lexington.

TO REACH THE KENTUCKY CLINIC:

Follow Versailles Road to the traffic light at the large intersection at

Bluegrass Airport and Man O’War Boulevard. Counting this traffic light, proceed down Versailles road through four more traffic lights, and then

turn right at the fifth traffic light. This is Mason Headley Road. (Cardinal

Hill Rehabilitation Hospital will be on your left as you turn)

Proceed forward on Mason Headley, at the second traffic light Mason

Headley becomes Waller Avenue. Proceed forward on Waller Avenue to

Nicholasville Road. You should be in the left lane at this light.

Turn left onto Nicholasville Road.

Nicholasville Road becomes South Limestone. Get into the right lane.


Proceed forward through two traffic lights, you will pass beneath a pedestrian

skywalk with large blue letters that show UK, and then turn right onto Huguelet

Avenue at the third light. Turn right again at the STOP sign to enter the Ken-tucky Clinic parking garage.


Turn right at the second light instead of proceeding to the third light and you will enter a special drop off area at the main entrance of the Clinic. After dropping

off the patient proceed forward and turn right to enter the parking garage or turn

left to go to the Main UK Healthcare parking garage on the corner of South Limestone and Transcript Avenue.


After you turn off Waller Avenue you will see the parking garage on your left, it

is on the corner of South Limestone and Transcript Avenue. From this structure

you can take the shuttle to either UK Hospital or the Kentucky Clinic.


Phone: (859) 323-5661 • Fax: (859) 323-1127


Phone: (859) 323-5661 • Fax: (859) 323-1127


Phone: (859) 323-5661 • Fax: (859) 323-1127


Phone: (859) 323-5661 • Fax: (859) 323-1127

Local Hotels in Lexington, Kentucky

$119.00

To

$1,200.00

Campbell House-Crowne Place

1375 Harrodsburg Road

859-255-4281

Comfort Suites

3060 Fieldstone Way

859-296-4446

$125.00

Singe Rate

Embassy Suites

1801 Newtown Pike

859-455-5000

$135.00

and up

Extended Stay America

2650 Wilhite Drive

859-278-9600

$54.00

and up

Fairfield Inn

3050 Lakecrest Circle

859-228-2800

$80.00

Hampton Inn

3060 Lakecrest Circle

859-223-0088

$89.00

and up

Hilton Garden Inn

1973 Plaudit Place

859-543-8300

$98.00

and up

Holiday Inn

1950 Newtown Pike

859-233-0512

$109.00

to

$134.00

Holiday Inn Express

2221 Elkhorn Drive

859-293-0047

$83.00

to

$114.00

Hyatt

401 W. High Street

859-2533-1234

$165.00

and up

La Quinta Inn

1919 Stanton Way

859-231-7551

$72.00

to

$74.00

Microtel

2240 Buena Visa Road

859-299-9600

$39.95

Quality Inn

750 Newtown Court

859-233-0561

$50.00

to

$55.00

Comfort Inn

2381 Buena Vista Drive

859-299-0302

$69.00

to

$129.00

Courtyard Marriot

775 Newtown Court

859-253-4646

$139.00

to

$245.00


2750 Gribbin Drive

859-266-4800

$54.00

and up


3575 Tates Creek Road

859-271-6160

$69.00

and up

Gratz Park Inn

120 W. 2nd Street

859-231-1777

$149.00

Hampton Inn

2251 Elkhorn Road

859-299-2613

$75.00

and up

Hilton Suites

245 Lexington Green Circle

859-271-4000

$132.00

and up

Holiday Inn Express

1000 Export Street

859-389-6800

$89.00

to

$129.00

Homewood Suites

249 Ruccio Way

859-223-0800

$89.00

And up

Kentucky Inn

525 Waller Avenue

859-254-1177

$55.00

to

$61.00

Marriot Griffin Gate

1800 Newtown Pike

859-231-5100

$189.00

to

$249.00

Motel 6

2260 Elkhorn Road

859-293-1431

$36.00

Radisson

369 W. Vine Street

859-231-9000

$164.00

and up


Phone: (859) 323-5661 • Fax: (859) 323-1127

Red Roof Inn

2651 Wilhite Drive

859-277-9400

$50.00

To

$55.00

Rodeway Inn

5556 Versailles Road

859-254-6699

$70.00

to

$99.00

Springhill Suites

863 S. Broadway

859-225-1500

$119.00

Super 8

2351 Buena Vista Road

859-299-6241

$44.00

to

$54.00

Red Roof Inn

1980 Haggard Court

859-293-2626

$39.00

to

$45.00

Sheraton Four Points

1920 Plaudit Place

859-543-8400

$84.00

Springs Inn

2020 Harrodsburg Road

859-277-5751

$66.00

to

$145.00

University Inn

1229 S. Limestone Street

866-881-9676

$55.00

to

$68.00

The Hospitality House and the Ronald McDonald House are additional options that do exist. Since referrals

are required for both of these options, Hospital staff must be contacted. If you are interested in either of these

options, please contact either Hospital Services at 859-323-5501 or Pastoral Care at 859-323-1214 for more

information

St Agnes House is an additional option for those who are being treated for infectious disease in Lexington.

They can be contacted directly at 859-254-1214 for additional information.

Disclaimer: Although every effort has been made to provide up to date prices, the listed prices are subject to

change based upon inflation and demand. Some hotels offer discounts to patients of the University Hospital

and Kentucky Clinic and their family members. It is in your best interest to call the hotel of which you are

interested in staying to inquire about patient care unit. Clinic appointments can be verified through the clinic

providing care.


Phone: (859) 323-5661 • Fax: (859) 323-1127

NEW PATIENT EVALUATIONS / CONSULTATIONS

Have you had any bleeding problems or anesthesia problems with any operation?

If yes please explain:

Have you had any blood transfusions?

Any history of HIV, Hepatitis (A, B, or C)?

Any tattoos or other needle stick possible exposure?

Yes No

Yes No

If yes, when/why:

If yes, which:

Medications: Please list your current medications, dosage, and how often you take them. Include “over-the-counter” medications

as well. Attach a separate piece of paper with your list, if necessary.

Medication

mg Frequency

Allergies: List any medications to which you are allergic:

Family History: If anyone in your immediate family has ever had any of the following, please mark the box accordingly.

Date of Birth: Patient Name:

Personal Medical Information: Please list any chronic and/or serious illness, including any surgeries:

Yes No

Yes No

Mother Father Grandparent Your Sibling Your Child

Heart Attack / Heart Disease

Cancer

High Blood Pressure

Stroke

Back / Neck Problems


Phone: (859) 323-5661 • Fax: (859) 323-1127

Name:

Date of Birth:

Home Phone:

Employer:

Martial Status:

New Patient Information


Phone: (859) 323-5661 • Fax: (859) 323-1127

UNIVERSITY OF KENTUCKY KENTUCKY MEDICAL SERVICES FOUNDATION INC. AUTHORIZATION & AGREEMENTS ADDRESSOGRAPH

CONSENT TO TREATMENT Consent to Treatment: I/we voluntarily authorize the rendering of such care, including diagnostic procedures and medical treatment, by author-

ized agents and employees of the University of Kentucky, its medical staff and their designees, as may in their professional judgment be deemed

necessary or beneficial, and may include testing for HIV (the virus that causes AIDS) and other blood borne diseases. I/we acknowledge that no

guarantees have been made as to the effect of such examination or treatment on my condition or the condition of the person for whom I am duly

authorized to sign. I/we understand that I/we have the right to make decisions concerning my health care or the health care of the person for whom

I am duly authorized to make such decisions, including the right refuse medical and surgical procedures. *This consent to treatment may be revoked at any time, except to the extent that action has already been taken, by the patient/duly au-

thorized agent.

ADVANCE DIRECTIVES I have formulated Advance Directives (living will, health care surrogate declaration) and request that these directives govern my course of

care, in as much as is possible under the federal law. I understand that it is my responsibility to provide the Hospital with a copy of my Ad-

vance Directives and that those directives will not govern my course of care until they have been filed in my medical record. Advance Directives attached Advance Directives not attached

I have not formulated Advance Directives (living will, health care surrogate declaration), but I understand that it is my right to make deci-

sions regarding my course of treatment, including the executing of advanced directives.

FINANCIAL RESPONSIBILITY Guarantee of Payment: I/we agree to be responsible to the University of Kentucky and Kentucky Medical Services Foundation, Inc. (hereafter

referred to as KMSF) for charges resulting from services rendered at their prevailing rates. I/we agree all bills are due in full upon demand. Should

I/we fail to honor this agreement, I/we agree to pay any collection cost or attorney fees resulting from the collection of my accounts. No granting of extensions, indulgences or forbearances to the patient or any responsible party and no delays or lack of diligence on the part of the

University of Kentucky or KMSF in enforcing any rights shall in any manner release the undersigned liability. If the undersigned is more than one

person this obligation shall be joint and several. I/we agree the University of Kentucky or KMSF is not party to any disputed claim or peer-review decision which affects payment of any claim

filed on my behalf and that upon request for payment from the University of Kentucky or KMSF. I/we agree to pay any outstanding balance. Assignment of Benefits: I/we hereby assign all rights and privileges and authorize payment directly to the University of Kentucky and KMSF for

any claim filed on my behalf or on the behalf of the person for whom I am duly authorized to sign for insurance benefits. I/we agree this assign-

ment is primary to any assignment given after this date including any cost relative to attorney fees. I/we also understand that I/we am financially

responsible to the University of Kentucky and KMSF for charges not covered by this assignment or not paid on a timely basis by the insurance

company. Certification: I certify that I have read and understand the authorizations given above and I am the patient, or I am duly authorized by the patient

to execute the above and accept its terms.

Date Signature of Patient or Designee and Relationship to Patient Signature of Witness








Administration


Phone: (859) 323-5661 • Fax: (859) 323-1127

IMPORTANT NOTICE!

If your medical problem is due to an injury or an accident, either at Work, Auto, or ANY other accident/injury that you feel per-

tains to your visit today, PLEASE READ CAREFULLY and COMPLETELY:

We will be happy to submit your clinical billings to your Workers Compensation, Auto PIP claim, or your commercial insur-

ance or medical card should there be no 3rd party involvement; but in order to file your claim properly we MUST have the fol-

lowing information: Complete name, address, phone number, claims adjuster, and claim number of the insurance carrier. Without

this COMPLETE information, YOU will be responsible for your bill PRIOR to the time of service. Office visits range from

$160.00 to $440.00. Should your accident claim carrier deny payment, you will be responsible for payment of service. However, if

you happen to have a secondary insurance plan, please have your card with you when you register in the clinic, and your secondary

insurance will pick up any charges your workers comp/auto insurance carrier might deny. If there is no third party insurance in-

volved, please write “No claim filed, or no third party insurance involved” in the Name field of the claim information section.

IF YOU ARE A WORKERS COMP RECIPIENT: IN ORDER TO BE SEEN YOUR CASE WORKER MUST CONTACT

OUR OFFICE FIRST TO PROVIDE WORKER’S COMPENSATION AUTHORIZATION!! WITHOUT PROPER AU-

THORIZATION YOU CANNOT BE SEEN.

Workers Comp or Motor Vehicle Insurance covering your (NOT your Health Insurance Plan)

Name

(The insurance space below is where the bills regarding your claim will be sent)

Address

City State Zip Code

Claims Adjuster Phone Number

Claim Number (required in order for you to be seen)

I authorize and request that Dr.__________________ and the University of Kentucky Chandler Medical Center send my

medical bills and medical information to the insurer(s) listed above. This authorization will be valid unless revoke by me in

Patient Signature (REQUIRED)

Name

Address

City State Zip Code

Employer at time of injury (for work injuries ONLY)

Phone Supervisor

Date of accident/injury

Where did the accident/injury occur:

Time

Work: (See Below)

Specify: (example: fell, lifting, etc.)

Motor vehicle accident; location:

Specify: (example: Rear-ended, ran off road, side swiped, etc.)

Other: (Please describe):


Phone: (859) 323-5661 • Fax: (859) 323-1127

IMPORTANT QUESTIONS TO ASK YOUR DOCTOR

This sheet is provided to help you remember certain things to ask your doctor BEFORE you leave the EXAM

ROOM today since the front desk staff cannot provide some of these services.

DO YOU HAVE ANY PARTICULAR PROBLEMS YOU WISH TO DISCUSS TODAY?

DO YOU NEED ANY PRESCRIPTIONS REFILLED? PLEASE ASK THE DOCTOR BEFORE

YOU LEAVE, HE/SHE WILL BE HAPPY TO HELP YOU

(WILL THE REFILL BE ENOUGH TO LAST UNTIL YOUR NEXT VISIT?)

PLEASE ASK BEFORE LEAVING THE EXAM ROOM

WHEN IS MY NEXT SCHEDULED APPOINTMENT?

You will receive paperwork to leave with the Front desk staff who will schedule your follow-up ap-

pointments. Or ASK the NURSE, please. She may need to schedule a test such as a CT Scan or an

MRI in which case the appointment will be mailed to you at a later time. Please allow 4-6 weeks for

those appointments to arrive in your mail. Call (859) 323-5661 to inquire about appointment dates

and times already booked. If you have been referred to a Pain Clinic please allow 4-6 weeks for the

Pain Clinic to call you with your scheduled appointment. Pain clinic in Lexington can be reached

directly at (859) 323-7246.

How do I reach my doctor if I need further assistance at a later time?

Your doctor’s office may be reached by calling the numbers listed below.

Please keep in mind that the clinic cannot refill your prescriptions, you MUST call your doctor’s office.

Dr. Phillip Tibbs (859) 323-6597

Dr. Byron Young (859) 323-5861

Dr. Thomas Pittman (859) 323-8986

Dr. Karin Swartz (859) 323-5928

Dr. Robert Owen (859) 323-0616

Appointments or

Medical Records (859) 323-5661


Phone: (859) 323-5661 • Fax: (859) 323-1127

Fees for Forms The Kentucky Neuroscience Institute charges the following fees for completing

paperwork for your employer or insurance

Insurance Forms $20.00

Workers Comp/Disability Forms $20.00

All Other Forms (3 Pages or More) $20.00

Form Letters To Attorneys $20.00

Home Bound Forms $15.00

Family Medical Leave Forms $15.00

Handicap Parking Forms $15.00

Family Based Service Forms (Food Stamps, Child Support Forms, Etc.)

$15.00

Forms, along with payment, must be turned in to the Kentucky Neuroscience

Institute located in Suite B-101 on the 1st floor, Wing C, of the Kentucky Clinic.

(Across from Starbucks)

All forms that are mailed should be addressed as follows:

Kentucky Neuroscience Institute

740 S. Limestone Street, Suite B-101

Attn: Forms Enclosed

Lexington, KY 40536-0284

Forms cannot be completed before payment is received.

We accept all major credit cards, cash or checks.

(Please do not send cash in the mail)

Call (859) 218-5072 to make credit card payments by phone.

Please allow 10 business days for processing upon receipt of your forms.

Date post:	06-Sep-2018
Category:	Documents
Upload:	nguyencong
View:	220 times
Download:	0 times

Medical Record umber - UK HealthCare · Medical Record Number: ... Visitor Pay Parking. Visitor...

Documents