Skip to content
Dr. Pasquale X. Montesano
  • Home
    • Bio: Dr. Pasquale X. Montesano
    • The Patient’s Role: Understanding Your Responsibilities
    • Media
  • Our Practice
    • Fly-In Treatment
  • Patient Resources
    • Conditions
      • Degenerative Disc Disease
      • Sciatica
      • Scoliosis
      • Spinal Stenosis
      • Accident Injuries & Trauma
      • Sports Injuries
    • Pain
      • Back Pain
      • Lower Back Pain
      • Diagnosis
    • Treatment
      • Laminectomy
      • Laminectomy with Fusion
      • Minimal Access Spinal Technologies
      • Minimally Invasive Spine Surgery
      • Alpha-2-Macroglobulin (A2M)
  • Portal
  • Health Tips
  • Contact Us
  • Facebook
  • Instagram
Menu Close
  • Home
  • About
    • Our Practice
    • Bio: Dr. Pasquale X. Montesano
    • The Patient’s Role: Understanding Your Responsibilities
    • Media
  • Fly-In Treatment
  • Conditions
    • Conditions & Injuries
    • Degenerative Disc Disease
    • Sciatica
    • Scoliosis
    • Spinal Stenosis
    • Sports Injuries
  • Pain
    • Chronic Neck or Back Pain
    • Back Pain
    • Lower Back Pain
    • Diagnosis
  • Treatment
  • Health Tips
  • Contact Us
  • Facebook
  • Instagram

Step 1 of 18

5%

Patient Information

Patient's Name(Required)
MM slash DD slash YYYY
Sex(Required)
Address(Required)
Mailing Address (If different from above)
Employer's Address
Marital Status(Required)
Name of Spouse(Required)

Emergency Contact

Name and address of relative or friend.
Name
Address

If Patient is a minor…

MM slash DD slash YYYY
Street Address
Mailing Address (If different from above)

INSURANCE INFORMATION

(If you have both primary and secondary health coverage, please complete the information for both)

Primary Private Insurance

Subscriber's Name(Required)
MM slash DD slash YYYY
Subscriber's Address(Required)
MM slash DD slash YYYY
Claims Address(Required)

Secondary Private Insurance

Subscriber's Name
MM slash DD slash YYYY
Subscriber's Address
MM slash DD slash YYYY
Claims Address

Auto Accidents

First Party (your insurance) Medical Payments/PIP – Personal Injury Protection
MM slash DD slash YYYY
Claim's Address

Worker's Compensation

MM slash DD slash YYYY
Claims Address

Authorization of Release

Has patient retained legal counsel?(Required)

If patient HAS retained legal counsel

Please fill out information below.
Address(Required)

Authorization to release information to above attorney:

I hereby authorize the release of medical information requested by my attorney.
Clear Signature
MM slash DD slash YYYY

If patient HAS NOT retained legal counsel

Please sign below.

I acknowledge that I currently DO NOT have an attorney who is representing me for the injury I am being treated for. If I do obtain legal counsel regarding this injury, I will notify the office immediately.

Clear Signature
MM slash DD slash YYYY

Release of Information

I hereby authorize the release of medical information requested by my Insurance Company or Worker’s Compensation carrier. I also authorize the release of information to any hospital or physician I may be referred to by this office. I authorize assignment of payment directly to Sarasota Laser & Spine Center. for the major medical benefits due to me.
Clear Signature
MM slash DD slash YYYY

Release of Information

I hereby authorize the release of medical information to the following private individuals (spouse, children, parents, etc.):
Name
Name
Name
Clear Signature
MM slash DD slash YYYY

Financial Policy

**All co-pays are due at the time of service. If you are cash/self-pay patient, payment is due at the time of service. We accept all cash, check, Visa, MasterCard, American Express, Discover and ATM/Debit Card.**

There is a $35.00 service charge for all returned checks. Returned checks and balances older than 30 days may be subject to additional collection fees and interest charges of 1.5% per month. If you have difficulty paying your balance in full, within this time frame, please contact the office at (941)350-6358 to discuss financial arrangements. For your convenience, you may setup auto-charge to your card for patient balances due. If you would like to have any patient balances due for co-pays, co-insurances or deductibles auto-charged to your credit card, please complete below:

Name on Card
Card Type
MM slash DD slash YYYY
Billing Address
Clear Signature
MM slash DD slash YYYY

Insurance Information

At each visit, all patients are responsible for providing proof of insurance and verifying with their insurance company our status as in or out of network providers. We are not contracted with insurance companies and therefore, we will file the primary insurance claim as a courtesy to our patients. We do not accept responsibility to file claims to secondary insurance companies. Upon payment from the insurance company, we will send you a statement for any patient balance due. We expect full payment within 30 days of receiving our statement. After this date, your account may be referred to a collection agency and you agree to pay for all the balance due our office, interest as allowable by law and the fees charged by the collection agency.

Due to changing insurance contracts, patients need to contact their insurance providers prior to medical treatment to verify rates. Our office is not responsible for out of network expenses because it is ultimately the patient’s responsibility to obtain authorizations for treatment.

Our office will not become involved in disputes between you and your insurance company regarding deductibles, co-payments, covered charges, secondary insurance, ‘usual and customary’ charges, non-authorized services, etc, other than to supply information as necessary.

I authorize assignment and payment directly to this office the major-medical benefits due to me. I hereby agree to pay the balance if my physician is not contracted with my insurance carrier and/or my insurance carrier does not pay my balance. I also agree to pay any items not covered by my insurance or any items deemed to be my portion and are due to my physician.

Clear Signature
MM slash DD slash YYYY

Medication Policy

Please read carefully.

Our physicians have a strict policy regarding the use of pain medications. Pain medications will only be prescribed in small quantities and for a short period of time.

For patients who have been scheduled for surgery, do not take anti-inflammatory medication two (2) weeks prior to surgery and try to reduce the pain medication two (2) weeks before surgery. If you do not have a surgery date scheduled continue taking your medication as prescribed.


REFILL REQUESTS MUST BE CALLED INTO YOUR PHARMACY. PLEASE HAVE YOUR PHARMACY FAX A REQUEST TO OUR OFFICE: (949) 382-6411. PLEASE ALLOW 3-4 WORKING DAYS FOR RESPONSE TO REQUESTS.


I understand the above medication policy:

Clear Signature
MM slash DD slash YYYY

Office Visit No-Show/Cancellation Policy


This office has a no-show policy. Patients who do not call at least 24 hours before their appointment will be charged $75 for the no-show appointment.

I understand that I will be charged for not showing to an appointment or not calling at least 24 hours in advance.

Clear Signature
MM slash DD slash YYYY

Surgery No-Show/Cancellation Policy


Scheduling surgery is a lengthy process, involving time and cost to the surgeon’s office as well as the surgical facility.

If a surgery is cancelled at the last moment these costs multiply significantly. Additionally, other patients who are awaiting surgery cannot be scheduled as we have blocked out time for your surgery. The facility cannot accommodate their numerous other patients as well as they too have scheduled time for your procedure.

Due to these factors we find it necessary to charge for cancelled surgeries. We must receive notice of cancellation more than two (2) weeks prior to the scheduled surgical date. The following charges will apply to any and all surgeries that are cancelled without adequate notice.

Anterior or posterior procedures with notice given two (2) weeks, you will be charged $1,500.00 for the surgical fee.

Anterior and posterior procedures with notice given two (2) weeks, you will be charged $3,000.00 for the surgical fee.

Anterior or posterior procedures with notice given one (1) week, you will be charged $3,000.00 for the surgical fee.

Anterior and posterior procedures with notice given one (1) week, you will be charged $6,000.00 for the surgical fee.

Occasionally surgeries may be cancelled at the last moment due to medical reasons that may not be under your control. In this case the cancellation fee may be waived at the surgeon’s discretion.

Please be sure that you want to proceed with the surgery on the date that you have been scheduled. If any situations, changes or emergencies arise please notify the office at once.

Clear Signature
MM slash DD slash YYYY

Chart Access and Transportation


I understand that my physician sees patients in multiple offices. I understand and give consent for all of my physician’s offices to have access to my medical records as deemed necessary by my physician, I understand that I may be seen at any of my physician’s offices, and that in order for me to have this convenience; I must give consent for my chart to be taken off premises.

I also give consent, in the event a surgical procedure is deemed necessary by my physician. for my physician to take my chart and films off premises, to wherever the procedure is being performed.

Clear Signature
MM slash DD slash YYYY

Provider:
Sarasota Laser & Spine Center
Pasquale X. Montesano, M.D.
Tax lD: 84-3117005

Mailing Addresses (For all Medical Records Requests, Correspondence, Payments):
Requests and Payments addressed to: Sarasota Laser & Spine Center
Office: 903 Osborne Drive, Sarasota, FL 34234
Phone: (941) 402-4003
Fax: (941) 346-6530

Clinic Locations (Treatment Only)
Sarasota Laser & Spine Center
903 Osborne Drive
Sarasota, FL 34234
Phone: (941) 402-4003
Fax: (941) 346-6530

Procedure Locations:
Hospital or Surgery Center to be determined per procedure.


*NOTICE TO ALL PATIENTS*

By entering this office, you agree to having a photograph of you taken at the time of your visit to be included in your medical record for documentation of your visit. This is a requirement for treatment in our office along with state issued identification. If you do not agree with the policies of this office, you will not be seen.

Clear Signature
MM slash DD slash YYYY

This document represents Sarasota Laser & Spine Center policy complying with the
HIPAA Privacy Rule

Patient information used for the purpose of treating healthcare problems, tracking improvement, and trending medical therapies. Patient information is described as health history, physical examinations, test results, diagnosis, pharmacy prescriptions, and laboratory results, obtained with the intention of providing treatment to the patient. Patient information also includes patient demographics (address, phone number, medical insurance, social security number, etc.)

We will disclose this information to referring physicians (whom the patient has a doctor/patient relationship), and to healthcare providers that our office wishes to refer for additional medical diagnosis or treatment (includes pharmacies for prescriptions). Patient’s verbal approval will be obtained prior to the release of the information to the healthcare providers. Medical insurance representatives will have access to patient information as per the patient’s contractual arrangement with their medical insurance policies. We will release patient information to insurance representatives necessary to obtain authorizations for medical procedures and office visits. All other requests for patient information will be released only with the patient’s written approval.

We will use patient information for the purpose of billing. All necessary information to satisfy the insurance provider’s request to support medical payments will be shared with the medical insurance company.

We will release patient information to any additional entity at the request of the patient after providing a written release of information. Sarason Laser & Spine Center, is the custodian for the patient’s information and will hold the records until one of the following occur:

  1. Sarasota Laser & Spine Center no longer exists as a treating entity in which the files will be placed in storage after notice is given in a local paper.
  2. Patient’s request their files be transferred to another physician and a written release is obtained.
  3. Patient information becomes inactive as defined by Florida Statues.

If questions or disputes occur concerning patient information Medical Director will resolve all disputes. The office manager, office personnel, or the Medical Director can answer the questions concerning this policy.

I authorize the office to contact me at my home, cell, or work phone numbers provided as mailing correspondence to my home address or email.

I have reviewed this document and I understand its context.

Clear Signature
MM slash DD slash YYYY

Initial Pain Assessment

Name(Required)
MM slash DD slash YYYY
MM slash DD slash YYYY
Do you have more pain in:(Required)
Have you had previous spine surgery?(Required)
MM slash DD slash YYYY

The following questions are only an approximate assessment of your pain problem. We understand that exact descriptions are impossible. Please choose the responses that most closely approximate your pain presently (over the last few weeks or months, or longer)

How often are you having pain now?(Required)
When having pain, is it generally…(Required)
How is the pain now limiting your job/housework(Required)
How is the pain now limiting your social, recreational, and other leisure activities?(Required)
Have you had back symptoms before your current episode?(Required)

Enter a number 1 through 10 for each question that most closely describes your pain at its least bother some and most bother some (1 being the least, and 10 being the most bother some)

If you have not had surgery for this complaint, please complete ONLY the before surgery section. If your pain fluctuates too much to estimate an average circle a range of numbers.

Cervical (neck) pain (average)

Before Surgery(Required)
After Surgery

Arm pain (average)

Before Surgery(Required)
After Surgery

Back Pain (average)

Before Surgery(Required)
After Surgery

Leg Pain

Before Surgery(Required)
After Surgery

Thoracic (midback) pain (average)

Before Surgery(Required)
After Surgery
Do you feel better now compared to before surgery?
Would you have decided to have surgery knowing the present outcome?
What makes the pain worse? (you may choose more than one)(Required)

Spine Baseline Patient Evaluation

During the past 6 months, did you consult a phsyician or other health care professionals about your neck and/or back condition.(Required)
If yes, which one:(Required)
During the past 6 months, have you had any non-surgical treatment (like physical therapy, chiropractic manipulation, brace, massage, nerve blocks, etc.) for your neck and/or back condition?(Required)
During the past 12 months, have you had any surgical treatments for your condition?(Required)
During the past month, how often have you felt jittery restless?(Required)
During the past month, how often have you felt anxious or tense?(Required)
During the past month, how often have you felt worried or concerned about your physical health?(Required)
During the past month, how often have you felt sickly or unwell?(Required)
During the past month, how often have you felt sad, discouraged, or hopeless?(Required)

Section Break

Section 1 – Pain Intensity (check only one)(Required)
Section 2 – Personal Care (check only one)(Required)
Section 3 – Lifting (check only one)(Required)
Section 4 – Walking (check only one)(Required)
Section 5 – Sitting (check only one)(Required)
Section 6 – Standing (check only one)(Required)
Section 7 – Sleeping (check only one)(Required)
Section 8 – Social life (check only one)(Required)
Section 9 – Travelling (check only one)(Required)
Section 10 – Changing degree of pain(Required)

HEALTH SURVEY

This survey asks for your views about your health. This information will help you keep track of how you feel and how well you are able to do your usual activities. Answer every question by marking the answers as indicated. If you are unsure about how to answer a question, please give the best answer you can.

In general, would you say your health is (check one)(Required)
Compared to a year ago, how would you rate your health in general now (check one)?(Required)

Past Medical History

Have you ever had or do you now have problems with any of the following?(Required)
Disease of your(Required)
Have you ever had a blood transfusion?(Required)
MM slash DD slash YYYY
MM slash DD slash YYYY
Have you ever sought treatment for stress or have you ever been treated for a psychological disorder?(Required)
Have your blood relatives had any of the following? (Check all that apply)(Required)
Please list all surgeries you have had, doctor and the dates – All Spine Surgeries and Oher Surgeries:

Sarasota Laser & Spine Center
Sarasota, FL 34234
941-402-4003

Diplomate, American Board of Spine Surgery
Diplomate, American Academy of Orthopedic Surgeons

Patient's Name(Required)
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
Were you at work when you were injured?(Required)
Was this an automobile accident?(Required)
Was this a slip/fall injury?(Required)
MM slash DD slash YYYY
Name(Required)
MM slash DD slash YYYY
Chief complaint:(Required)
MM slash DD slash YYYY
MM slash DD slash YYYY
Any known drug allergies?(Required)

Social History Report

Caffeine Dependency(Required)
Smoke Tobacco?(Required)
Drink Alchol?(Required)
Recreational Drug Use?(Required)
Lived Outside USA?(Required)
Military Service?(Required)
Highest Education Completed?(Required)

Family History Report

Please complete below or adopted and unknown.

lf Already Completed and no further changes Initial Verified No Changes and stop here

Mother
Father
Child
Child
Child
Child
Child
Brother
Brother
Brother
Brother
Sister
Sister
Sister
Sister
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Maternal Grandmother
Other

Pasquale x. Montesano, M.D.

Review of Systems Each Visit – Do you have any of the following TODAY?
Patient
MM slash DD slash YYYY
MM slash DD slash YYYY
Constitutional (Check all that apply)
Skin (Check all that apply)
Head (Check all that apply)
Eyes/Vision (Check all that apply)
Ear/Nose/Throat/Mouth (Check all that apply)
Cardiovascular (Check all that apply)
Respiratory (Check all that apply)
Gastrointestinal (Check all that apply)
Neurologic (Check all that apply)
Endocrine (Check all that apply)
Hematologic (Check all that apply)

ASSIGNMENT OF RIGHTS AND BENEFITS

I, the below named patient/insured, in consideration for being treated by Montesano Spine and Sport without payment in full at the time of treatment (or in advance of treatment), hereby fully and completely assign over to Montesano Spine and Sport any and all MedPay benefits and Personal Injury Protection (PIP) rights and benefits (including but not limited to the right to sue and the right to compromise claims) to which l am entitled by virtue of Florida Statute 627.736 and/or any policy of insurance providing Personal injury Protection benefits and/or MedPay benefits. This assignment also includes and is not limited to the right to reimbursement of transportation costs, my right to bad faith claims and any and all rights I may have to notice of attendance of counsel to, and copies or transcripts or reports of, any EUO (Examination Under Oath), any lME (independent Medical Examination) scheduled or taken by any insurance carrier regarding treatment provided by Montesano Spine and Sport peer review reports, copies of insurance policies, declaration pages and PIP logs.

If any portion of this document is deemed to be inconsistent with an assignment of rights and benefits within the meaning of 627.736, Florida Statutes, or said policy of insurance said portion shall be rewritten in order to conform with Florida law to give full effect to the intended purpose of this agreement, said intended purpose being to create an assignment of rights and benefits from the below named patient/insured to Montesano Spine and Sport.

INFORMED CONSENT TO TREAT: I fully understand that Montesano Spine and Sport is a multidisciplinary organization and that I may be seen by an M.D., P.A., N.P. or a combination of them. I understand that the practice of medicine is not an exact science, and that diagnosis and treatment may involve risks of injury or even death. I also understand that no guarantee or promise has been made as to the results that may be obtained.

LIVING WILL/ADVANCE DIRECTIVE: Montesano Spine and Sport does not honor living wills/advance directives. In the event of a life threating emergency, 911 will be called. If you would like more information, please contact our front desk and they will direct you to the proper person in our organization to speak with.

APPLICANT’S AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS: I hereby authorized in accordance to the Health Insurance Portability and Accountability Act of 1996 (HIPAA)-privacy and security requirements that any licensed physician, medical practitioner, hospital, clinic or other medical or medically related facility, insurance company, or other organization, institution or person, that has any records or knowledge of me or my health, to release such information to

I also give my permission for Montesano Spine and Sport to RELEASE ANY of my records to a medical provider or facility, or to my attorney requesting such information from Montesano Spine and Sport and to any insurance company responsible for payment. This release specifically includes but is not limited to authorization to release any and all medical records and information associated with (or in reference to) the following conditions: Positive exposure to my infection, ARC, AIDS, alcohol or drug dependency, mental and nervous disorders. A photographic copy of this authorization shall be valid as the original. This authorization shall be valid for five years from the date of signature. I give permission to my current attorney or any attorney in the future representing me to access my medical record electronically.

GUARANTEE OF PAYMENT: I agree to be fully responsible for all costs and services provided to me, including transportation charges. I understand that I am responsible for any costs incurred in the collection of my account(s) in case of default, including reasonable attorney’s fees and costs. I also grant Montesano Spine and Sport a lien against any recovery that I may have now or in the future against any tortfeasor or any responsible insurance carrier.

STATEMENT OF TRUTHFULNESS: l state that any and all of the information I provided concerning my financial information, insurance information, accident and automobile information and any information concerning coverage under any type of health care plan is true and correct. I further understand and acknowledges that if any of the information I provided is in any way incorrect or untrue, that I may be liable for damages and penalties of violating this agreement and Florida law, including by not limited to Florida Statue 817.50 which prohibits a person from fraudulently obtaining services from a medical facility.

Patient Name(Required)
Clear Signature
MM slash DD slash YYYY
Clear Signature

Records Release Request

(Physician, hospital, etc.)
Address

I hereby authorize the release of my records and/or x-ray films to be mailed or faxed to:

SARASOTA LASER & SPINE CENTER


Pasquale X. Montesano, M.D.
903 Osborne Drive
Sarasota, FL 34234
Phone: (941) 402-4003
Fax: (941) 346-6530

– OR –


I request my records to be mailed to the following location:

Address

Dates of records requested

Any and all specific dates:
MM slash DD slash YYYY
MM slash DD slash YYYY
Patient Name:(Required)
MM slash DD slash YYYY

Your attention to this request is appreciated so Dr. Montesano may review these records as soon as possible. Thank you.

Clear Signature
MM slash DD slash YYYY

Standard Disclosure and Acknowledgement Form


Personal Injury Protection – Initial Treatment or Service Provided

The undersigned insured person (or guardian of such person) affirms:

  1. The services or treatment set forth below were actually rendered. This means that those services have already been provided.

    INITIAL ORTHOPEDIC-SPINE EVALUATION

  2. I have the right and the duty to confirm that the services have already been provided.
  3. I was not solicited by any person to seek any services from the medical provider of the services described above.
  4. The medical provider has explained the services to me for which payment is being claimed.
  5. If I notify the insurer in writing of a billing error, I may be entitled to a portion of any reduction in the amounts paid by my motor vehicle insurer. If entitled, my share would be at least 20% of the amount of the reduction, up to $500.

Insured Person (patient receiving treatment or services) or Guardian of Insured Person.

Name(Required)
Clear Signature
MM slash DD slash YYYY

The undersigned licensed medical professional or medical director, if applicable, affirms the statement numbered 1 above and also:

  • I have not solicited or caused the insured person, who was involved in a motor vehicle accident to be solicited to make a claim for Personal Injury Protection Benefits.
  • The treatment or services rendered were explained to the insured person, or his or her guardian, sufficiently for that person to sign this form with informed consent.
  • The accompanying statement or bill is properly completed in all material provisions and all relevant information has been provided therein. This means that each request for information has been responded to truthfully, accurately, and in a substantially completed manner.
  • The coding of procedures on the accompanying statement or bill is proper. This means that no service has been upcoded, unbundled, or constitutes an invalid or not medically necessary diagnostic test as defined by Section 627.732(14) and (15). Florida Statutes or Section 627.736(5)(b)(6). Florida Statutes.

Licensed Medical Professional Rendering Treatment Services of Medical Director. If applicable (Signature by his or her own hand):

MM slash DD slash YYYY

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of Claim or an application containing any false, incomplete, or misleading information is guilt of a felony of the third degree per Section 817.234(1)(b) Florida Statutes.

The original of this form must be furnished to the insurer pursuant to section 627.736(4)(b), Florida Statutes may not be electronically furnished. Failure to furnish this form may result in non-payment of the claim.

PASQUALE X. MONTESANO, MD

Orthopaedic Spine Surgeon

  • Facebook
  • Instagram

Privacy Policy

Sarasota Laser & Spine Center Office and Montesano Wellness Center
903 Osborne Drive
Sarasota, FL 34234

VG Primary Care
5285 Summerlin Rd #101
Fort Myers, FL 33919

Venice Office
1872 Tamiami Trail S, Suite C
Venice, FL 34293

EAST Phone/Fax Numbers:
(All Locations)
Scheduling: (941) 402-4003
Fax: (941) 214-9595

4362 Northlake Blvd
Suite 209
Palm Beach Gardens, FL 33410
Tel: (561) 345-2299

WEST Mailing Address:
468 N Camden Dr, FL 2
Beverly Hills, CA 90210

WEST Phone/Fax Numbers:
P: 310-858-5561
F: 310-858-5562

Copyright © Montesano Spine & Sport. Site by New York Marketing.