VETERANS AND

ACTIVE SERVICE

PACKET – MNPIP

6/1-12/31 2017

WELCOME You have identified yourself as a Veteran or

Active Military seeking enrollment into our

Traumatic Brain Injury program. This short packet contains the most important documents

needed to start your evaluation. In the future, you may be asked to complete additional

documents. Once you have completed this packet please email it back to ClientLiaison@millenniumhealthcenters.com

Mark Gordon, M.D. Millennium Health Centers TBI Program

Instructions for the Military New Patient Information Packet

The NPIP consist of those documents that we need initially to establish a knowledge base of your medical history which will also be used in the interpretation of your laboratory results and for providing a customized treatment protocol and a report. These documents can be filled out on screen and then saved to your computer before attaching to an email or faxing to our office. In the future, we may provide you with additional documents.

The first page following these instructions is an Out of State Disclosure form. This lets you know that we need to have a physician in your state to write any of the prescription medications we recommend. We are presently training physicians in other states to provide assessment for TBI. Please make sure that you put your name on each space that asks for it and fill out the NPIP to the best of your ability.

Another page is the credit card authorization form which needs to be completed for us to enroll you in the program and to arrange for your blood draw. We are a cash only facility and do not have an insurance department nor do we, at this time, accept cases on contingency.

The remaining documents are import medical history questionnaires. These will act as a record of your baseline which will be assessed repetitively throughout your treatment protocol. You will also fill out a” History of Injury” report. If there have been multiple traumas or injuries in the past please indicate them in the “Summation of Injuries”, and only fully report on the case(s) under litigation. Please be as concise as possible.

Finally, please use the www.TBIMedlegal.com website to obtain answers and information on the most commonly asked questions or requested information. If you cannot find the answers, please email the office in lieu of calling. Once you have submitted your completed New Patient Information Packet (NPIP2017), someone in the office will call you at which time you can clarify any issues. Please be advised that there is a waiting list and backlog of patients requesting services. We are trying to minimize waiting time so if your NPIPL is complete and we can accept you into the program you will be notified within 3 business days.

Email and Fax to use: ClientLiaison@millenniumhealthcenters.com or fax (818-990-2841) to us as indicated on subsequent pages.

I look forward to reviewing your results with you soon.

All the best

Mark L. Gordon

Mark L. Gordon, MD Millennium-TBI Project

Veteran Of Traumatic Brain Injury Survey(VOTBIS 2017)

www.waftbi.org

Please read the instructions page before filling out this form to avoid rejection of your case.

Exposure

to:

I, ______________________________, authorize the use of this information by The Millennium Health

Centers, Inc. and all authorized individuals as a means of better understanding my unique case of

Traumatic Brain Injury. Under HIPPA guidelines, I have given The Millennium Health Centers, Inc,

permission to share my TBI case information with colleagues who participate in the evaluation and

treatment of individuals such as me, as well as with Warrior Angels Foundation.

Printed Name - Signature - Date

Name: DOB: Branch: ☐A ☐ N ☐ AF ☐M

Outfit: 1st Deployed: Multiple:

Tag# 2nd Deployed: Location:

Present Symptoms: Use a ‘0’ for NO and a ‘1’ for YES.

PSYCHOLOGICAL PHYSICAL COGNITIVE

Fatigue Weakness Forgetful

Irritability Headaches Periods of Disoriented

Nervous Dizziness Mental Fogginess

Depressed Change in Vision Learning difficulty

Sudden bouts of Anger Unsteady gait Lack of Concentration

Mood swings Tiredness Decrease in Recent Memory

Recurrent Headaches Change in Vision Decrease in Remote Memory

Decrease in Intelligence Change in Smell Tremors of Arms

Lace of interest Sleeping more Physical Impairment

Lack of Confidence Joint pain I walk without assistance

Lack of competitiveness Muscle pain I walk with prosthetic device

Lack of Assertiveness Weight gain Wheelchair bound

Initial Medical Status ( check all that apply) LOC = Loss of Consciousness

No LOC Dazed/confused LOC Coma

LOC < 1 hr LOC 1-3hrs LOC 3-12hr LOC 12 – 24hrs

LOC 1-7 days LOC 2-4 weeks LOC 1 month LOC 2 – 3 mos

LOC 3-6 mos LOC 6 -12 months LOC > 12months LOC =

Glasgow < 8 Glasgow 9-12 Glasgow 13-15 Glasgow 15

Evaluation and Treatment ( check all that apply):

Field Evaluation Only Emergency Evaluation Hospitalization Surgery

Bullet wound Bomb Fragments Head injury Face Injury

Neck & Spine Injury Superficial injury Burn Treatment Skull Fracture

Removal of upper limb Removal of lower limb Abdominal wound Chest Wound

CT Scan MRI Plain X-rays fMRI

Blood Transfusion Hormone Assessment Hormone Deficiency Progesterone

Testosterone Treatment Cortisol Thyroid Estrogens.

Anti-Depressant Med Anti-Seizure Med At VA Facility now? Ft Collins, VA?

☐ Automatic Weapons

☐ Blast Trauma

☐ Mortar

☐ Tank/Cannon fire

☐ Flash/Bang

☐ Jet Engine Noise

☐ Heavy Vibrations

☐ Sonic Blasts

☐ Chemical Exposure

☐ Kill House Training

☐ Bouncing

☒ Parachuting

Veteran Of Traumatic Brain Injury Survey(VOTBIS 2017)

www.waftbi.org

Instructions- VETERANS ONLY: If you are a veteran or active service please fill this form out

to the best of your ability. Clear printing will help us read the form. If we cannot read it we cannot

respond. If you need someone to help you please ask a family member. Once you have filled this

form out print it and fax it to our offices (818) 990.2841 or if you can email it to us*.

Name: First name followed by last name.

Date of Birth: example - 01/20/1953 (January 1, 1953)

Branch: of the military (Army, Navy, Air Force, Marines and so forth).

Outfit: Division or if in Special Forces or Green Berets…

1st Deployed: the date you were deployed (06/20/2009)

2nd Deployed: a second date of initial deployment.

Location: Where you were deployed (Iraq (I), Afghanistan (A), or Other (O)). If your deployment was

classified, please put other (O).

Multiple: if you were deployed more than once (1) how many times?

Dog Tag Number: This will be our reference number along with your name and date of birth.

Present Symptoms: Use the number ‘0’ for no and the number “1” for yes to indicate what problems

you are having now.

Exposure to: Any of these forms of percussive/percussion waves.

Initial Medical Status: Immediately after the injury what was your condition? If you were unconscious

or in a coma, how long?

Evaluation and Treatment: After your injury where were you treated? What were the injuries you

sustained and the medical care that was given? Special studies? Any medication?

If you have any questions you can send them to : clientliaison@millenniumhealthcenters.com

Once we have these documents we will arrange for your blood draw.

Leave no one behind:

Please return this by email: Clientliaison@millenniumhealthcenters.com or fax to: 818-990-2841

Disclosure of Limitations of Medical Care for Out-of-State Clients Name: _________________________________ Date: ______________

Please check one or more of the following to identify yourself: ☐ Civilian

☐ Veteran ☐ Active Military ☐ Lawman/Fireman ☐ Legal Case ☐ Medi-Care ☐ Under 18yrs. The services that you are requesting from the Millennium Health Centers consist of an initial laboratory evaluation of brain and body hormones, comprehensive bio-chemical and cell counts, a written report and personalized handbook, 45-60 minute consult to review the report, and any recommendations as to treatment based upon these results and your goals. ___ (Option 1) Have your blood drawn and then come to the office in Encino, California for a face-to-face consultation. Thereafter, you can be considered a California patient with the ability to have prescription medication provided directly to you. ___ (Option 2) If coming to the office in Encino is not feasible, then after the Millennium has arranged for your laboratory testing and provided you with a comprehensive report, including a treatment protocol, your physician would write prescriptions for your medication. The Millennium Health Centers will provide over-sight and the program supplements as indicated in your report. You may also, obtain these from any other source and not just from us. When talking with your physician please let them know that we will provide them with compensation for the initial office meeting to review your program with you. ___ (Option 3) We are in the process of training physicians in the science and application of our protocols for traumatic brain injury. As we add certified physicians to the roster you can find their names on our website (www.tbimedlegal.com). I_______________________ have read the above statements and have chosen the option listed above.

My Physician is

Name

Specialty

Address 1

Address 2

Phone #

Email

Contact: ClientLiaison@millenniumhealthcenters.com 818-990-1166 ext. 103

Your full name ( F M L)

Date of Birth

Street Address1

Street Address 2

City

State and Zip

Primary Contact Phone #

Primary Contact Email

Your Credit Card Type ___AMEX ___VISA ___MasterCard ___Discover

Credit Card Number #

Expiration Date

CVV or Code on back

Military Program ☐$1,500.00 Parasail Financial can provide low-cost medical loans for our services: parasail.com/x4zbw

I authorize the Millennium Health Centers, Inc., and or their representative to charge my credit card in the amount

indicated above based upon the program I have selected (marked).

Digital Signature:

Once your Wellness Enrollment Packet has been submitted to the office it will be reviewed for appropriateness for

acceptance in the program you have selected. Only after we contact you will the card be charged and the laboratory

services ordered for your initial evaluation. We do not accept any insurance programs since we do

not have an insurance department.

Labs: P1700 (or P1449) and P3426. PSA is indicated. Walk-in blood draw.

© MHC 2004-2017.6 RAP2017

Traumatic Brain Injury – History Summation

Please check off all the activities that you have been involved in since birth regardless of perceived

injuries.

_________________________________________________________________________________ Name Date of exam

YRS = How many years did you participate in the activities or when the exposure happened?

Injures related to any of the above activities. (LOC = Loss of consciousness, unconscious)

Type of Injury Age Year LOC Home ER Hos Duration/Comment GCS

Relative to the head injures above have you experience any of the following?

√ Symptoms Intensity* √ Symptoms Intensity* Decrease in Short-term Memory Change in Menses (Periods)

Decrease in Long-term Memory Lack of sex drive (libido)

Lack of Concentration or Focus Lack of competitiveness

Periods of Disorientation Lack of confidence

Mood swings Sleeping more (hypersomnia)

Sudden out-bursts of Anger On-set of Insomnia.

Sudden Irritability Change in Sense of Smell

Depression Change in Vision

Anxiety (General) Increase in Tiredness or fatigued

Self-Isolation Lack of Interest in life/Bored

Recurrent Headaches/Migraines Decrease in intelligence

*Enter a number between 0 and 10.

Comments (please stay within the box)

Comments

√√ Activities YRS √ Activities YRS √ Activities YRS

Boxing Break dancing Soccer

Wrestling /Grappling Extreme Sports Rugby

Track and Field Water or Snow Skiing Basketball

Gymnastics Skate boarding Football

Martial Arts/MMA Dirt Bikes / Motocross Baseball

Snow Boarding Stock Car Racing Roller Coasters

Automobile Accident Motorcycle Accident Bicycle Accident

Slip and Fall Explosion (IED) Repetitive gun fire

Pneumatic Tools Parachutist Artillery

© MHC 2004-2017.6 RAP2017

TBI Primary Injury

Name Today’s Date

.

This event happened in (year) __________, when I was ______ years old.

Car Accident (MVA) Assault Soccer Martial Arts IED

Motorcycle (MCA) Fall from object Rugby Parachute Gun Fire

Bicycle (BCA) Surgery Wrestling Jet engines Shot Gun

Slip n Fall (SnF) Stroke Grappling Cannon Noise

Blunt Head Trauma (BHT) Football Lacrosse Blast Trauma

1. With this injury, I DID NOT or I DID have loss of consciousness lasting ________________ sec/min/hrs/days/weeks.

2. With this injury, I WAS NOT or I WAS in a Coma for _________hrs./days/weeks/mons.

3. With this injury, I DID NOT or I DID have loss of memory immediately before or after the incident.

4. With this injury, I DID NOT or I DID have altered mental state at the time of the incident.

5. With this injury, I DID NOT or I DID have post-traumatic amnesia lasting LESS (<) than 24 hours.

6. With this injury, I DID NOT or I DID have post-traumatic amnesia lasting MORE (>) than 24 hours.

7. I was taken to: Home Medical Clinic ER Hospitalized for ____hours/days/weeks. Glasgow Scale ____

8. Radiologic Procedures: CT-Scan MRI fMRI SPECT PET Scan DTI-MRI

These are my present symptoms: (any adverse changes):

Angry Anger bouts Irritable Short temper Intolerant Aggressive

Impatient Tense Excitable Hostile Defensive Demanding

Mood swings Depression Sad Grumpy Mean/hateful Withdrawn

Memory loss Anxiety Nausea Insomnia Lonely Worrying

Sleepy Bored Apathetic Unloved Muscle pain Body pain

Disoriented Dizziness I’m spinning world spinning Headaches Stomach pain

Paranoid Alcohol use Drug use Narcotics Marijuana Low libido

Physician’s Notes:

© MHC 2004-2017.6 RAP2017

Notice of HIPAA Guidelines.

In general, the HIPPA privacy rule is intended to give further protection for the patient’s privacy

of medical records and information. This federal rule is now a law as of April 14, 2003. It restricts the

dissemination of your personal information to any entity other than those that you specifically indicate by

an in-person information release form. Additionally, we are restricted in the means by which your own

information is provided to YOU. Therefore, please indicate by checking all the applicable, those means by

which we can continue to provide you with your periodical medical results/reports.

I wish to be contacted in the following manner(s):

√ Home Phone: √ Mobile Phone: Leave message with detailed

information here.

Leave message with detailed

information here.

Leave message with callback

number only.

Leave message with callback

number only.

Email Report Written Communications Leave message with detailed

information here.

Please continue to send to my

home

Send all reports by email when

they are available.

I also authorize you to be able to speak with my Attorney or other physician as listed here:

Patient’s Signature and Date

Printed Name and Date of Birth

© MHC 2004-2017.6 RAP2017

Medical Services Agreement (MediCare)

__________________________________(PATIENT) and The Millennium Health Group (PHYSICIAN) hereby enter into this

agreement for provision of medical services specified herein ("Services"). Wherefore, in exchange for consideration, the receipt

and sufficiency of which the parties hereby acknowledge, the, PATIENT and PHYSICIAN agree as follows:

1. The PATIENT acknowledges and agrees that this agreement has been entered into before the PHYSICIAN has provided the

services specified herein to the PATIENT.

2. The Millennium Health Group and its PHYSICIANS are only responsible for the evaluation and prescription of hormone

replacement therapy when indicated by appropriate laboratory testing. All laboratory tests can be billed separately by the

laboratory performing those services or else the patient May request to pay a discounted fee.

3. The PATIENT acknowledges and agrees that this agreement has not been entered into at a time when the PATIENT is facing

an emergency or an urgent health care situation.

4. The services to be provided to the PATIENT consist of performing diagnostic tests and providing assessment of their chemical

and hormonal status. All laboratory tests have an interpretation fee and report fee added to their cost.

5. [ ]* The PATIENT agrees not to request that a health insurance claim form be submitted in their behalf under the

Social Security Act (MEDICARE) for the services, even if such services are otherwise covered under health insurance

or MEDICARE.

6. The PATIENT agrees to be responsible for the SERVICES. Although hormone replacement therapy is medically beneficial,

insurance companies have not yet accepted this position. At this point in time, neither insurance companies nor MEDICARE

will reimburse for preventive care or anti-aging/hormone-balancing replacement therapy. As a result of this, medical records

will not be provided to any insurance company or MEDICARE. The United States Department of Health and Human Services,

Office of Inspector General take the position that a PHYSICIAN who orders "medically unnecessary" tests may be subject to

civil penalties. Because of this, it is the policy of this office not to fill out any insurance benefit claim forms or provide a letter

of medical necessity. The Health Insurance and Reform Act of 1997 allows the Federal Government to investigate what they

may determine is "health insurance fraud" or any medical treatment not deemed "medically necessary" by the Federal

Government. Even though the use of human growth hormone in adults has been approved by the Food and Drug

Administration, it has not been recognized by the Federal Government as "medically necessary" and therefore, could, be

interpreted as fraudulent.

7. The PATIENT acknowledges that health insurance companies or "Medigap plans" (42 U.S.C., section 1882) will not provided

reimbursement, for the SERVICES and that no fee limits (including those specified in 42 U.S.C., Section 1395a-1848g) will

apply to the amounts PHYSICIANS charge for their SERVICES.

8. The PATIENT acknowledges that PATIENT has the right to have services provided by other PHYSICIANS for whom payment

may be made under health insurance plans or MEDICARE.

9. [ ]* By signing this agreement, the PATIENT understands that they are foregoing their rights to receive

insurance/MEDICARE benefits for the SERVICES, but that PATIENT is not forfeiting all health insurance benefits

for other services from other health insurance/MEDICARE providers.

Patient’s Signature Date:

Physician Signature Date:

Witness Signature Date:

*** An additional MediCare Contract will be needed for any person who is receiving any financial

assistance from MediCare or is of age to receive benefits from MediCare.

11

Hormonal Imbalances in the brain can cause symptoms that can present in one or more of the following manners; Please check off accordingly with 0 = Never, 1 = 25%, 2= 50%, 3= 75% and 4 = 100% of the time. Name: Date:

How often do you feel : 0 1 2 3 4 Comments 1. Angry 2. Fatigued 3. Impatient 4. Blaming 5. Dissatisfied 6. Moody/Grumpy 7. Fearful 8. Discontented 9. Hypersensitive/Easily Annoyed 10. Mentally exhausted 11. Bored 12. Aggressive 13. Unloved 14. Unappreciated 15. Tense (anxious) 16. Touchy 17. Unloving 18. Lonely 19. Hostile 20. Overwhelmed 21. Destructive 22. Demanding 23. Frustrated 24. Withdrawn/detached 25. Mean 26. Sad (depressed feeling) 27. Scared 28. Numb/insensitive 29. Explosive 30. Defensive 31. Denies Problems 32. Self-Critical 33. Troubled 34. Desire to Over-eat 35. Drug or Alcohol Use. 36. Excitable 37. Withdrawn into TV 38. Overworked 39. Sleep more 40. Impulsive 41. Worried 42. Argumentative 43. Sarcastic 44. Jealous 45. Uncommunicative

INFORMEDCONSENTFORTELEMEDICINESERVICESPatientName: DateofBirth: MedicalRecord:

PatientAddress:City:State:Zip: DateConsentDiscussed:

PhysicianName: Location:

ConsultantName: Location:

ConsultantName: Location:

INTRODUCTIONTelemedicineinvolvestheuseofelectroniccommunicationstoenablehealthcareprovidersatdifferentlocationstoshareindividualpatientmedicalinformationforthepurposeofimprovingpatientcare.Providersmayincludeprimarycarepractitioners,specialists,and/orsubspecialists.Theinformationmaybeusedfordiagnosis,therapy,follow‐upand/oreducation,andmayincludeanyofthefollowing:

Patientmedicalrecords Medicalimages Livetwo‐wayaudioandvideo Outputdatafrommedicaldevicesandsoundandvideofiles

Electronicsystemsusedwillincorporatenetworkandsoftwaresecurityprotocolstoprotecttheconfidentialityofpatientidentificationandimagingdataandwillincludemeasurestosafeguardthedataandtoensureitsintegrityagainstintentionalorunintentionalcorruption.

EXPECTEDBENEFITS Improvedaccesstomedicalcarebyenablingapatienttoremaininhis/heroffice(orataremotesite)while

thephysicianobtainstestresultsandconsultsfromhealthcarepractitionersatdistant/othersites. Moreefficientmedicalevaluationandmanagement. Obtainingexpertiseofadistantspecialist.

POSSIBLERISKSAswithanymedicalprocedure,therearepotentialrisksassociatedwiththeuseoftelemedicine.Theserisksinclude,butmaynotbelimitedto:

Inrarecases,informationtransmittedmaynotbesufficient(e.g.poorresolutionofimages)toallowforappropriatemedicaldecisionmakingbythephysicianandconsultant(s);

Delaysinmedicalevaluationandtreatmentcouldoccurduetodeficienciesorfailuresoftheequipment; Inveryrareinstances,securityprotocolscouldfail,causingabreachofprivacyofpersonalmedical

information; Inrarecases,alackofaccesstocompletemedicalrecordsmayresultinadversedruginteractionsor

allergicreactionorotherjudgmenterror;

Pleaseinitialafterreadingthispage:

INFORMEDCONSENTFORTELEMEDICINE PAGE2

BYSIGNINGTHISFORM,IATTESTTOANDUNDERSTANDTHEFOLLOWING:1. Iunderstandthatthelawsthatprotectprivacyandtheconfidentialityofmedicalinformationalsoapplyto

telemedicine,andthatnoinformationobtainedintheuseoftelemedicinewhichidentifiesmewillbedisclosedtoresearchersorotherentitieswithoutmyconsent,

2. IunderstandthatIhavetherighttowithholdorwithdrawmyconsenttotheuseoftelemedicineinthecourseofmycareatanytime,withoutaffectingmyrighttofuturecareortreatment,

3. IunderstandthatIhavetherighttoinspectallinformationobtainedandrecordedinthecourseoftelemedicineinteraction,andmayreceivecopiesofthisinformationforareasonablefee,

4. Iunderstandthatavarietyofalternativemethodsofmedicalcaremaybeavailabletome,andthatImaychooseoneormoreoftheseatanytime. (nameofPhysician)hasexplainedthealternativestomysatisfaction,

5. Iunderstandthattelemedicinemayinvolveelectroniccommunicationofmypersonalmedicalinformationtoothermedicalpractitionerswhomaybelocatedinotherareas,includingoutofstate.

6. Iunderstandthatitismydutytoinform (nameofPhysician)ofelectronicinteractionsregardingmycarethatImayhavewithotherhealthcareproviders.

7. IunderstandthatImayexpecttheanticipatedbenefitsfromtheuseoftelemedicineinmycare,butthatnoresultscanbeguaranteedorassured.

8. IattestthatIamlocatedinthestateofCaliforniaandwillbepresentinthestateofCaliforniaduringalltelehealthencounterswith (nameofPhysician).

PATIENTCONSENTTOTHEUSEOFTELEMEDICINEIhavereadandunderstandtheinformationprovidedaboveregardingtelemedicine,havediscusseditwithmyphysicianorsuchassistantsasmaybedesignated,andallofmyquestionshavebeenansweredtomysatisfaction.Iherebygivemyinformedconsentfortheuseoftelemedicineinmymedicalcare.

Iherebyauthorize (nameofPhysician)tousetelemedicineinthecourseofmydiagnosisandtreatment.

PATIENT’SSIGNATURE DATE(ORAUTHORIZEDPERSONTOSIGNFORPATIENT) IFAUTHORIZEDSIGNER,RELATIONSHIPTOPATIENT WITNESS DATE PHYSICIAN’SSIGNATURE DATE

Ihavebeenofferedacopyofthisconsentform. (Patient’sInitials)