* = Required Information
PATIENT INFORMATION
Name: First * Middle Last *  SSN: *  Gender: * MaleFemale
Birthdate: * Marital Status: SingleMarriedWidowedSeparatedDivorced
Language:
Race: AsianAmerican IndianWhiteBlackUnknown Ethnicity: HispanicNon-HispanicUnknown
Address: City: Zipcode:
Phone: (Home): * (Work): (Cell): *
Email:
Emergency Contact Name/Ph:
Referring Physician's Name + Phone:
Pharmacy Name: Address
Pharmacy Phone:
Do you want to enroll in Online Access for Health Records? YesNo
PRIMARY INSURANCE
Are you Self Pay? YesNo         If Yes, Skip this box.
Insurance Company: * Phone:
Policy #: * Group #: *
Medicare #: Medicaid #:
SECONDARY INSURANCE
Do you have additional Secondary Insurance?: YesNo If Yes, Secondary Insurance Company:
Policy #: Group #:
Payment Policy: I understand that I am responsible for payment of professional services at the time they are rendered. I understand that I am responsible for any amount not covered by insurance including, without limitation, deductible, co-payment, co-insurance, or other amounts unpaid by my insurance, if benefits assigned. Neurology & Sleep Clinic LLC files claims for only Medicare assignment and the contracted insurance carriers. Claims will not be filed with other insurance carriers including Workman’s Compensation. If you plan to pay by check and it is dishonored, a processing fee of $25 will be assessed. I hereby assign all medical benefits including major benefits to which I am entitled for medical services rendered to myself or my dependent to Kiran P Shah, MDPA and Neurology & Sleep Clinic LLC. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I hereby authorize said assignee to release all information necessary to secure payment on my behalf.
Initial: Date:
Phone Call Message Consent: I authorize that messages may be left for the patient about appointment reminders and/or medical information regarding patient care on the phone numbers provided in this form.
Initial: Date:
Prescription Information for new or refills: Please note that we require at least 24 hours to complete a prescription refill request. Please have your pharmacy fax your refill request to 972-306-6500 or via e-script. Refill requests received on Friday, will be processed on the following Monday. If patient is not evaluated in last 3 months or if patient has missed a follow up appointment, a medication refill request may be denied.
Initial: Date:
For Medicare Patients Only: I authorize the treating physician of Neurology and Sleep Clinic to release medical information about me to the Social Security Administration and the Health Care Financing Administration (HCFA) or its intermediaries, or carriers, any information needed for this or a related Medicare claim. I permit a copy of this authorization to be used in place of the original and request payment of medical insurance benefits to Neurology and Sleep Clinic, LLP. Regulations pertaining to Medicare assignment of benefits apply. I also authorize the same release of information to any Medicare supplemental insurance entities (i.e. Medigap) and further request payment of medical insurance benefits to the party who accepts assignment.
Initial: Date:
Appointment and Cancellation Policy: Please provide our office with 48 hours’ notice if you must cancel appointment or testing ordered or you may be subject to a $ 50.00 cancellation fee which is not covered by your insurance. If there is a change in your address, phone number and insurance information, please provide before or on the day of appointment. If insurance requires a referral for the appointment, it is patient’s responsibility to obtain it from the referring physician before the appointment. If you are covered by an insurance company that requires pre-certification and authorizations for procedures (e.g.: Sleep study, EEG, EMG), please inform our office immediately. Please show your valid insurance card at every appointment.
Initial: Date:
Notice of Privacy Practices: I understand that as part of my healthcare, Neurology & Sleep Clinic originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment and any plans for future care or treatment. I understand that this information is utilized to plan my care and treatment, to bill for services provided to me, to communicate with other healthcare providers and other routine healthcare operations such as assessing quality and reviewing competence of healthcare professionals. Neurology & Sleep Clinic's Notice of Privacy Policies provides specific information and a complete description of how my personal health information may be used and disclosed. I have been provided a copy of or access to the Notice of Privacy Practices and understand that Neurology & Sleep Clinic reserves the right to change the Notice of Privacy Practices. If changes are made to the Notice of Privacy Practices, they will be posted in the office where they can be seen, and I will have the opportunity to review the changes. I understand that I have the right to restrict the use/or disclosure of my personal health information for treatment, payment or healthcare operations and that Neurology & Sleep Clinic is not required to agree to the restriction requested. I may revoke this consent at any time in writing except to the extent that Neurology & Sleep Clinic has taken action in reliance on my prior consent. This consent is valid until revoked by me in writing. I further understand that any and all records, whether written, oral or in electronic format, are confidential and cannot be disclosed without my prior written authorization, except as otherwise provided by law. I have been provided access and have reviewed Neurology & Sleep Clinic Notice of Privacy.
Initial: Date:
I hereby assign all medical benefits including major benefits to which I am entitled for medical services rendered to myself or my dependent to Kiran P Shah, MDPA and Neurology & Sleep Clinic. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance company. I hereby authorize said assignee to release all information necessary to secure payment on my behalf.
Signature of Patient or Parent if Minor * Date *