ASSOCIATES IN NEUROLOGY, P.C. M. Elkiss, D.O., F.A.C.N. * B. Silverman, D.O., F.A.C.N. * M. Kachadurian * M. Silverman, D.O., F.A.C.N. N. Warra, D.O. * Yvonne Will-Murphy, D.O., PhD
Patient Name (Print): Social Security Number: Marital Status: Sex: Age: Date of Birth: S M W D P
Race: Ethnicity: Language(s) Spoken: American Indian or Alaska Native ______Native Hawaiian ______Hispanic ______Asian ______Other Pacific Islander ______Not Hispanic or Latino ______African American ______White ______Refuse ______More than One Race______Refuse______Street Address: City & State: Zip Code: Home Phone:
Employer: Occupation: How Long? Business Phone:
Employer Address: City & State: Zip Code: Mobile Phone:
Spouse or Parent’s Name: Spouse or Parent’s Date of Birth:
Spouse or Parent’s Employer: Spouse or Parent’s Occupation: How Long: Social Security Number:
Employer’s Address: City & State: Zip Code: Business Number:
Patient E-mail Address: ______PRIMARY CARE PHYSICIAN Dr. Name: Phone:
REFERRING PHYSICIAN Dr. Name: Phone:
EMERGENCY CONTACT OTHER THAN SPOUSE Name: Relationship: Phone:
MISCELLANEOUS INFORMATION Are You Retired: Date of Retirement: Is Your Spouse Retired: Date of Retirement: Yes ______No ______Yes ______No ______
Are You Working? How Long Have You Been Off Work: Yes ______No______
Is This a Worker’s Comp Case If Yes, Please Let Our Front Desk Know. You Will Need to Complete An Additional Yes ______No ______Form. We will also need a copy of your Worker’s Comp Letter before you can be seen.
Is This an Automobile Accident? If Yes, Please Let Our Front Desk Know. You Will Need to Complete An Additional Yes ______No ______Form.
Do You Have an Attorney? If Yes, Attorney Name: Yes______No ______Attorney Contact Information: Attorney Phone :
Updated 1.20.2017 CONSENT TO OUTPATIENT TREATMENT
I request, authorize and consent to my physician(s), students, residents, nurse practitioner, collectively called “Associates in Neurology, P.C.“ to medically care for me/treat me in their office(s). This care may include, but is not limited to, office visits, neurological testing, diagnostic radiology, laboratory procedures and other routine medical care. I also authorize and consent to my physician(s) to perform other extended services in an emergency situation.
I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees or promises have been made to me with respect to the results of such diagnostic procedures or treatment.
I authorize my physician(s) or staff to contact healthcare providers, from whom I have received treatment, to obtain medical information and/or records including, but not limited to, commercial pharmacies, alcohol or drug treatment records.
I consent to having Associates in Neurology, P.C. place calls to my cellular or residential phone using an artificial or pre-recorded voice or auto dialer technologies for any follow-up purposes, including billing and collections.
ASSIGNMENT OF INSURANCE BENEFITS I authorize Associates in Neurology, P.C. to provide me with neurological services and to furnish my insurance company regarding my neurologic treatment, worker’s compensation, or auto carrier concerning my injury and treatment. I certify that the information provided by me in applying for payment under Title XVII of the Social Security Act is correct and request payment on my behalf of all authorized benefits.
All professional services will be billed to your insurance carrier. We do accept assignment of the insurance of the insurance carriers with which Associates in Neurology, P.C. participate; however, all copays, deductible and/or coinsurances MUST be paid at the time of service, at check-in. I authorize and instruct my insurance carrier to make payment directly to Associates in Neurology, P.C. otherwise payable by me. I agree to personally pay for any charges that are not covered by or collected from any applicable insurance program.
RELEASE OF INFORMATION I authorize Associates in Neurology, P.C. to release all medical and financial information to the following individual(s). They are:
Name Relationship
X______Signature of Patient Date
X______Patient Name (Please Print)
X______Name of Patient’s Representative Description of Personal Representative’s Authority
X______Name of Patient’s Representative (Please Print) Date
Updated 1.20.2017 ASSOCIATES IN NEUROLOGY, P.C. The Government has mandated that we obtain the following information. Do you smoke? Yes ______No ______If yes, how long? ______If yes, how much? ______
If you answered no, have you ever smoked? Yes ______No ______How much did you smoke? ______
If you answered yes, when did you quit? ______How much did you smoke? ______
Refuse to answer______PLEASE CHECK ALL THAT APPLY
General Symptoms Musculoskeletal Weight Gain _____ Muscle Pain _____ Weight Loss _____ Joint Pain _____ None _____ Weakness _____ Swelling _____ Eyes Restriction of Motion _____ Loss of Vision _____ Backache _____ Change of Vision_____ None _____ None _____ Ears/Nose/Throat/Mouth Skin/Chest Wall Hearing Changes _____ Rash _____ Hoarseness _____ None _____ Swallowing Difficulties _____ None _____ Psychiatric Recent Mood Changes _____ Respiratory Changes in Behavior _____ Shortness of Breath _____ None _____ Cough _____ Coughing Up Blood _____ Endocrine Wheezing _____ Heat Intolerance _____ None _____ Cold Intolerance _____ Excessive Thirst _____ Cardiac Change in Energy Level _____ Chest Pain _____ None _____ Palpitations _____ Swelling _____ Hematological None _____ Abnormal Bleeding/Bruising _____ None _____ Gastrointestinal Abdominal Pain _____ Genitourinary Change in Bowels _____ Change in Frequency _____ Heartburn _____ Urgency _____ None _____ Incontinence _____ Blood in Urine None _____
Updated 1.20.2017 ASSOCIATES IN NEUROLOGY, P.C. M. Elkiss, D.O., F.A.C.N. * B. Silverman, D.O., F.A.C.N. * M. Kachadurian * M. Silverman, D.O., F.A.C.N. * N. Warra, D.O. * Yvonne Will-Murphy, D.O., PhD
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS—THIS DOCUMENT WILL ONLY BE USED TO OBTAIN PREVIOUS MEDICAL RECORDS, LAB WORK, TEST RESULTS, ECT.
I, ______, Date of Birth ______authorize
AIN, P.C. to release the following medical information to ______
______.
I hereby authorize the use or disclosure of my individually identifiable health information as described below. I understand that this authorization is voluntary. I understand that if the organization authorized to receive the information is not a Health plan or health care provider, the release may no longer be protected by Federal Privacy Regulations.
Please check the appropriate line:
Specific description of information (including dates):
All medical records up to the date of signature on this form: ______
Specific medical records (as marked below): ______
Consultation and Office Notes: ______
Radiology Notes: ______
Laboratory Studies: ______
Other: ______
Any and all of my records except for the following: ______
This release also specifically allows the release of the following information (this information will not be released unless the line is initialed: ______Any record of drug and/or alcohol dependency or abuse. ______Any record of mental health treatment. ______Any record of testing, care, treatment, reporting or research pertaining to infection with HIV or related diseases.
The purpose of the use or disclosure of this information is: ______Continuity of Care ______Other The release is effective for one (1) year from the date of execution. I understand I may revoke this authorization at any time by notifying the providing organization in writing, but if I do, it will not have any affect taken before the revocation was received. I understand that my healthcare and the payment for the healthcare will not be affected if I do not sign this form.
X______Patient or Legal Guardian Signature Date
X______Witness Date
Updated 1.20.2017 Updated 1.20.2017 ASSOCIATES IN NEUROLOGY, P.C. M. Elkiss, D.O., F.A.C.N. * B. Silverman, D.O., F.A.C.N. * M. Kachadurian * M. Silverman, D.O., F.A.C.N. * N. Warra, D.O. * Yvonne Will-Murphy, D.O., PhD
CANCELLATION AND NO SHOW POLICY
Thank you for choosing Associates in Neurology, P.C. for your healthcare needs. We understand that emergencies arise and you may have to miss an appointment due to an emergency or obligation you may have forgotten. Our doctor’s time is valuable, they are in high demand, but more importantly they love taking care of their patients.
Please realize that it is extremely important for you to notify us as early as possible if you cannot keep your appointment. If you do not call to cancel a scheduled appointment you may be preventing another patient from getting their treatment. Conversely, the situation may arise were another patient fails to call and cancel their appointment, leaving us unable to schedule you for a visit, due to a seemingly “full” schedule.
With that said, we have implemented a new practice policy where we are now charging $25 for every appointment that is not cancelled 24 hours in advance.
Our phone system will call you at least 24 hours prior to your appointment to remind you of the time and day.
______Patient Name Date
X______Patient/Guardian Signature Date
Account Number ______
Updated 1.20.2017 ASSOCIATES IN NEUROLOGY, P.C. M. Elkiss, D.O., F.A.C.N. * B. Silverman, D.O., F.A.C.N. * M. Kachadurian, D.O. M. Silverman, D.O., F.A.C.N. * N. Warra, D.O., * Yvonne Will-Murphy, D.O., PhD Date: ______
Patient Name: ______
Date of Birth: ______PATIENT HISTORY Chief Complaint: Why are you here to see the doctor today? ______Past Medical History: ______Past Surgical History: ______Medication Allergies: ______Current Medication List: (please include dosing information) ______PATIENT HISTORY Name of Local Pharmacy: ______Address: ______Phone Number: ______Name of Mail-In Pharmacy: ______Address: ______Phone Number: ______SOCIAL HISTORY Alcohol Use (amount): ______Tobacco Use (amount): ______Caffeine Use (amount): ______Drug Use (amount): ______FAMILY HISTORY General Family History: ______Mother: Living _____ Deceased _____ Age _____ History: ______Father: Living _____ Deceased _____ Age _____ History: ______
ASSOCIATES IN NEUROLOGY, P.C.
Updated 1.20.2017 M. Elkiss, D.O., F.A.C.N. * B. Silverman, D.O., F.A.C.N. * M. Kachadurian * M. Silverman, D.O., F.A.C.N. N. Warra, D.O. * Yvonne Will-Murphy, D.O., PhD Acknowledgement of Receipt of Notice of Privacy Practices By signing this document below, I acknowledge that I have been notified and offered a copy of Associates in Neurology, P.C.’s Notice of Privacy Practices (HIPPA). (A patient under 18 years of age must have a parent(s) or legal guardian(s) sign this document on their behalf).
According to HIPPA guidelines, we cannot and will not give out any medical information (i.e. test results, diagnoses, treatment plans, etc.) to anyone but the patient, parent(s) or legal guardian(s). If there is another person (spouse, child, POA) you would like to have access to your medical records you must provide that information in writing (you can change this information at any time). With that said there is an area below for you to provide us information as to whom we can give information to regarding your health.
Name: Relationship: Name: Relationship: Name: Relationship: Name: Relationship:
______Patient Name Date
X______Patient/Guardian Signature Date
Account Number ______
Office Use Only Failure to Obtain Acknowledgement On this date ______, the patient named above was presented with the Acknowledgement of Receipt of Notice of Privacy Practices form for Associates of Neurology, P.C. The patient/parent/legal guardian refused to provide a signature of receipt for this documentation. Staff Member Print Name: ______
Staff Member Signature: ______
Updated 1.20.2017