Associates in Neurology, P.C

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.

Main Office Novi Office 27555 Middlebelt Road 26850 Providence Parkway, Suite 210 Farmington Hills, MI 48334 Novi, MI 48374 Phone: 248.478.5512 Fax: 248.478.5350 Phone: 248.735.0502 Fax: 248.735.0507

Southfield Office Brighton Office 22250 Providence Dr., Suite 602 10415 Grand River Ave., Suite 100 Southfield, MI 48075 Brighton, MI 48116 Phone: 248.443.1666 Fax: 248.443.0468 Phone: 810.534.0070 Fax: 810.227.4930

Milford Office 1435 N. Milford Road Milford, MI 48381 Phone: 248.685.8435 Fax: 248.685.2251

Date: Patient Name:

Date of Birth: FAMILY MEDICINE/INTERNAL MEDICINE DOCTOR REFERRING DOCTOR (If same as family doctor write same) Name: Name:

Address: Address:

Phone: Phone:

CURRENT MEDICATION(S) – PLEASE INCLUDE NAME OF MEDICATION, DOSAGE, PHARMACY AND AMOUNT TAKEN PER DAY. 1. 2. 3. 4. 5.

6. 7. 8. 9. 10.

11. 12. 13. 14. 15.

ALLERGY LIST

Updated 1.20.2017 ASSOCIATES IN NEUROLOGY, P.C.

PAST MEDICAL HISTORY Medical History:

Surgical History:

Transfusion History:

Childhood Diseases:

FAMILY HISTORY General History:

Father: Living or Deceased

Mother: Living or Deceased

SOCIAL HISTORY Alcohol Use: Yes or No How Much and How Often: Do you want to quit? Yes or No

Tobacco Use: Yes or No How Much and How Often: Do you consider this an issue? Yes or No

Exercise: Yes or No How Much and How Often:

Pets in the Home: Yes or No How many? What are they?

PHARMACY INFORMATION – LOCAL Pharmacy Name: Address: Phone Number:

PHARMACY INFORMATION - MAIL IN Pharmacy Name: Address: Phone Number:

Updated 1.20.2017 Please Check All That Apply To You

GENERAL HEENT HEENT (Continued) Anexoria _____ Headache _____ Drooling _____ Appetite Loss _____ Head Injury _____ Hoarseness _____ Chills _____ Facial Numbing/Tingling _____ Oral Ulcers _____ Dietary Changes _____ Blurred Vision _____ Sore Throat _____ Excessive Crying _____ Color Blindness _____ Voice Changes _____ Fatigue _____ Decreased Night Vision _____ None _____ Feeling Well _____ Diplopia NECK Fever _____ Double Vision _____ Neck Mass _____ Medication Changes _____ Excessive Tearing _____ Neck Pain _____ Night Sweats _____ Eye Pain _____ Neck Stiffness _____ Obesity _____ Eye Redness _____ Neck Swelling _____ Persistent Infections _____ Glaucoma _____ Swollen Glands _____ Shakiness _____ Periorbital Puffiness _____ None _____ Tiredness _____ Visual Disturbances _____ BREAST Unable to Sleep Lying Flat _____ Visual Loss _____ Breast Mass _____ Weight Gain 5-10 LBS _____ Wears Glass or Contacts _____ Breast Pain _____ Weight Gain +10 LBS _____ Hearing Loss _____ Breast Swelling _____ Weight Loss 5-10 LBS _____ Deafness _____ Nipple Discharge _____ Weight -10 LBS _____ Decreased Hearing _____ Nipple Pain _____ None _____ Ear Discharge _____ Recent Breast Size Change _____ Ear Infection _____ Inverted Nipple(s) _____ SKIN Ear Pain _____ None _____ Brittle Nails _____ Earache _____ RESPIRATORY Bruising _____ Ringing in the Ears _____ Bloody Sputum _____ Change in Wart or Mole _____ Tinnitus ____ Chronic Cough _____ Clamminess _____ Spinning Sensation _____ Cough _____ Coarse Hair _____ Vertigo _____ Decreased Exercise Tolerance _____ Coarse Skin _____ Coryza_____ Difficulty Breathing _____ Cold Skin _____ Dry Mucous Membranes _____ Difficulty Breathing Exertion _____ Cracked Lips _____ Runny Nose _____ Dyspnea _____ Dryness _____ Nose Bleed _____ Hemoptysis _____ Excessive Sweating _____ Epitaxis _____ Sputum Production _____ Hair Growth _____ Decreased Sense of Smell _____ Waking Up Wheezing/SOB _____ Hair Loss _____ Frequent Colds _____ None _____ Hives _____ Nasal Congestion _____ MUSCULOSKELETAL Itching _____ Sneezing _____ Back Pain _____ Nail Changes _____ Seasonal Allergies _____ Backache _____ New Lesions _____ Sleep Apnea _____ Calf Pain _____ Pruritus _____ Rhinitis _____ Claudication _____ Pallor _____ Sinus Pain _____ Decreased Range of Motion _____ Rash _____ Snoring _____ Fasciculations _____ Skin Color Changes _____ Bleeding Gums _____ Joint Pain _____ Ulcer _____ Choking Sensation _____ Joint Redness _____ None _____ Decreased Sense of Taste _____ Joint Stiffness ______Difficulty Chewing _____ Joint Swelling _____

Updated 1.20.2017 MUSCULOSKELETAL (Continued) GASTROINTESTINAL (Continued) NEUROLOGICAL (Continued) Leg Cramps _____ Dysphagia _____ Spinning Sensation _____ Muscle Atrophy _____ Excessive Gas _____ Stroke _____ Muscle Cramps ______Food Intolerance _____ Syncope _____ Muscle Pain _____ Fills Up Quickly at Meals _____ Tingling_____ Muscle Weakness _____ Hematemesis _____ Tremor _____ Myalgia _____ Hemorrhoids _____ Trouble Walking _____ Physical Disability _____ Heartburn _____ Unusual Sensation _____ Swelling of Extremities _____ Hyperdefecation _____ Unsteadiness _____ None _____ Hyperphagia _____ Vertigo _____ CARDIOVASCULAR Incontinence of Stool_____ Visual Changes _____ Abnormal Blood Pressure _____ Indigestion _____ Weakness _____ Bradycardia _____ Jaundice _____ Weakness in Extremities _____ Calf Cramps _____ Laxative Use _____ None _____ Chest Pain _____ Melena _____ PSYCHIATRIC Claudications _____ Nausea _____ Anxiety _____ Difficulty Breathing Lying Down ___ Painful Swallowing _____ Change in Sleep Pattern _____ Edema _____ Pain with Bowel Movements Delirium _____ Elevated Blood Pressure _____ Rectal Bleeding _____ Depression _____ Fainting _____ Stool Has Tested Positive for Blood Disorientation _____ in the Past 6 Months _____ Fainting/Blacking Out _____ Stool Has Not Tested Positive for Early Awakening _____ Blood in the Past 6 Months _____ Heart Stent _____ Vomiting_____ Easily Irritated _____ Hypertension _____ Vomiting Blood _____ Fearful _____ Irregular Heart Beat _____ None _____ Feels Safe at Home _____ Leg Cramps _____ NEUROLOGICAL Frequent Crying _____ Orthopnea _____ Attention Deficit _____ Hallucinations _____ Palpitations _____ Auras _____ Hypersomnia _____ Paroxysmal Nocturnal Dyspnea ___ Decreased Memory _____ Impaired Cognitive Function _____ Phlebitis _____ Difficulty Speaking _____ Inability to Concentrate _____ Rapid Heart Rate _____ Dizziness _____ Insomnia _____ Shortness of Breath _____ Dysarthria _____ Memory Loss _____ Slow Heart Rate _____ Easily Distracted _____ Mood Changes _____ Swelling of Extremities _____ Fasiculations _____ Nervousness _____ None _____ Fainting _____ Panic Attacks _____ GASTROINTESTINAL Focal Neurological Symptoms _____ Personality Changes _____ Abdominal Mass _____ Headaches _____ Suicidal Ideation _____ Abdominal Pain _____ Hyperactivity _____ Suicidal Planning _____ Abdominal Swelling _____ Incontinence Stool _____ Trouble Falling Asleep ____ Belching _____ Incontinence Urine _____ None _____ Black, Tarry Stool _____ Incoordination _____ ENDOCRINE Change in Bowel Habits _____ Loss of Consciousness _____ Appetite Changes _____ Chronic Diarrhea _____ Muscle Twitching _____ Cold Intolerance _____ Constipation _____ Numbness _____ Decreased Sweating _____ Diarrhea _____ Paresthesias _____ Excessive Sweating _____ Difficulty Swallowing _____ Seizures _____ Excessive Thirst _____ Slow Reflex Relax_____ Excessive Urination _____

Updated 1.20.2017 ENDOCRINE (Continued) Hair Changes _____ Heat Intolerance _____ Hot Flashes _____ Libido Change _____ Polydipsia _____ Polyuria _____ Sexual Dysfunction _____ Thyroid _____ None _____ HEMATOLOGY Abnormal Bleeding _____ Anemia _____ Blood Clots _____ Easy Bruising _____ Enlarged Lymph Nodes _____ Epistaxis _____ Excessive Bleeding _____ Gland Problems _____ Nose Bleeds _____ Painful Lymph Nodes _____ Petechiae _____ Pinpoint Hemorrhages _____ Spontaneous Bleeding _____

ARE YOU TAKING ASPIRIN DAILY YES ______NO ______IF YES, WHAT DOSE? ______

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 Phone: 248-478-5512 * Fax: 248-478-5350

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS—THIS DOCUMENT WILL ONLY BE USED TO OBTAIN PREVIOUS MEDICAL RECORDS, LAB WORK, TEST RESULTS, etc.

I, ______, birthdate ______authorize ______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

Updated 1.20.2017 X______Witness Date

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 * 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