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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
(Last Name) (First Name / Middle Initial) (Male / Female)
(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
(Last Name) (First Name / Middle Initial) (Male / Female)
(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
(Last Name) (First Name / Middle Initial) (Male / Female)
(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
(Last Name) (First Name / Middle Initial) (Male / Female)
(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)
If you have a Third Insurance Plan, Who is the Sub
Third Subscriber / Insured
(Last Name) (First Name / Middle Initial) (Male / Female)
(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)
If the patient is under 18 years of age, parents please complete ALL of the following information:
Parent / Guardian / Guarantor Responsible for Patient
(Last Name) (First Name / Middle Initial) (Male / Female)
(Address) (City / State ) (Zip Code)
(Area Code / Phone Number) (Area Code / Secondary Phone Number) (Relation to 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.
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 #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.
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
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.
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
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.
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
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
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 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.
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
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 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.
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
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.
PATIENT DROP OFF AREA MAIN ENTRANCE OF CLINIC
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 SERVICES
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.
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
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.
PATIENT DROP OFF AREA MAIN ENTRANCE OF CLINIC
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.
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
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.
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.
TO ENTER KENTUCKY CLINIC PARKING GARAGE
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.
PATIENT DROP OFF AREA MAIN ENTRANCE OF CLINIC
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 SERVICES
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.
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 Ken-tucky Clinic parking garage.
PATIENT DROP OFF AREA MAIN ENTRANCE OF CLINIC
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 SERVICES
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.
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
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
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
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
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
Extended Stay America
2750 Gribbin Drive
859-266-4800
$54.00
and up
Extended Stay America
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
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
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.
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
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
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
Name:
Date of Birth:
Home Phone:
Employer:
Martial Status:
New Patient Information
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
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
Date Signature of Patient or Designee and Relationship to Patient Signature of Witness
Date Signature of Patient or Designee and Relationship to Patient Signature of Witness
Date Signature of Patient or Designee and Relationship to Patient Signature of Witness
Date Signature of Patient or Designee and Relationship to Patient Signature of Witness
Date Signature of Patient or Designee and Relationship to Patient Signature of Witness
Date Signature of Patient or Designee and Relationship to Patient Signature of Witness
Date Signature of Patient or Designee and Relationship to Patient Signature of Witness
Administration
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
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):
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
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
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
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.