Neurology Center of Wichita
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- Laurel Curtis
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1 Neurology Center of Wichita Dr. Subhash Shah, M.D and Kathryn Welch, PA-C 220 S. Hillside Wichita, KS Phone: Fax: website: In order for the doctor to better provide you with a complete and thorough evaluation, the enclosed forms should be completely filled out prior to your appointment. If something does not apply to the patient or you do not know the answer please state so by writing unknown or n/a. Do not leave any questions or requested information blank. If you have any questions or need clarification on any of these forms please call our office at and we will be happy to help you. We are committed to providing you with the best possible care. Your clear understanding of our office and financial policy is important. Please ask if you have any questions about our fees, financial policy, or your responsibility. Check list of what we will need prior to or at time of appointments and Financial policy Please initial the spaces provided on 1-11 that you agree and understand. 1. You MUST bring your child/patient to all appointments. Most insurance companies will not pay for the visit if the patient is not present for the appointment. If the patient is under the age of 18 they must have a parent or legal guardian with them at every appointment. 2. Please bring all insurance cards or a clear copy of the front and back of cards. 3. If your insurance policy requires a referral it must come from the PCP you are locked in with. Please request a referral from your physician BEFORE your appointment. If we do not have the referral at the time of check in, you must sign a waiver accepting financial responsibility for the appointment or choose to reschedule. 4. Has the patient had an EEG, Video EEG, MRI or CT, Head ultrasound? If so, the doctor will need a CD of actual films, not just the report. If EMG/NCT, lab work or genetic testing done; if you have seen a specialist such as another neurologist, psychologist, geneticist or developmental pediatrician; if you have had any hospitalizations or ER visits related to this visit PLEASE INFORM US BEFORE THE DAY OF YOUR APPOINTMENT SO WE CAN GET THOSE RECORDS BEFORE YOU ARE SEEN. 5. Please bring a list of all current medications from all providers. 6. Bring any legal documentation regarding custody situations and/or legal guardianship. We will not get involved in divorce situations. If one parent is legally not to have information regarding a patient, we must have documentation supporting that. 7. CO-PAY, CO-INSURANCE & DEDUCTIBALE are due at the time of service unless payment arrangements are made prior to appointment. Patients without insurance will be expected to pay half of the cost at the time of the appointment. We accept cash, check, MasterCard, Visa. 8. Financial arrangements/ payment plan options are available if needed. Please call and speak with billing department at X216 to make arrangements prior to appointment. Services must be paid promptly in accordance with terms and agreements. In the event of default to pay, by insurance or myself, I agree to pay collection charges, and/or attorney fees. I hereby assign payment directly to Neurology Center of Wichita for the medical benefits, if any, for services as described. 9. Patients with Kancare/Medicaid must keep our office informed of ALL insurance coverage. You must inform KS Medicaid and managed care plan (Sunflower, Amerigroup, United Health Community Plan) of all insurance policies that cover the patient. Failure to do so will result in responsible party owing the full balance. All claims legally must be filed with primary coverage before it can be filed to secondary Kancare/Medicaid. 10. You will be charged a $25 fee if you do not show up for your appointment or the appointment is not cancelled/rescheduled 24 hours PRIOR to appointment time 11. All concerns/questions need to be directed to the office by phone. Please do not communicate by as it is not always reliable and your concerns may not be addressed in a timely manner. 1
2 Insurance is a contract between you and your insurance company. We WLL NOT become involved in disputes between you and your insurance regarding deductible, co-payments, covered charges, coordination of benefits or other matters regarding reimbursement. IF YOUR INSURANCE HAS NOT PAID IN 120 DAYS, THE AMOUNT DUE WILL BECOME YOUR RESPONSIBILITY. Primary Insurance: Card holders name as shown on card Policy ID # Group # Insurance requires referral YES or NO Locked in provider name Effective date / / Date of Birth of card holder / / Relationship to patient SS # - - Employer Secondary Insurance Card holders name as shown on card Policy ID # Group # Insurance requires referral YES or NO Locked in provider name Effective date / / Date of Birth of card holder / / Relationship to patient SS # - - Employer **Tips to help your claims process smoothly** *Always respond to information requested from your insurance company even if you are sure it is information they already have. *Most insurance companies will request that you update COB-coordination of benefits one or more times per year. Most insurance companies will not process your claims without this information. *All insurance companies have their own Timely Filing Limit in which claims must be submitted. If we don t have all the needed information to submit your claim with in their specific time limit the insurance company will not pay the claim. *Always bring the most current copy of insurance card to all appointments even if nothing has changed. Sometimes there are minor changes that don t affect you but it affects the way medical offices have to process your claims. *Know your policy. We do not decide what or how much your policy pays for or covers. Please call us at X 216 if you receive a statement and feel that your claims were not processed or paid correctly. Thank you! *By signing below, I acknowledge that I have read the above information on page 1 and 2 and agree to the terms/conditions. I understand I am responsible for all costs of medical treatment regardless of what my insurance carrier may or may not pay. This signature will also serve as signature on file for assignment of insurance benefits. I hereby authorize the Neurology Center of Wichita to release any information acquired in the course of my child s examination or treatment to insurance companies as required for claims processing. *By signing below, I also acknowledge that I have the right to a copy of the Neurology Center of Wichita s Notice of Privacy Practices. This handout states how we will always protect you/your child s personal health information and will not release any information without your consent. I was offered but declined a copy of the Privacy Policy I would like a copy of the Privacy Policy Guardian Printed name Parent/Guardian Signature Relationship to patient **Please be specific about relationship to patient, i.e. biological/step/foster/adoptive parent, aunt/uncle, legal guardian, etc.** 2
3 Neurology Center of Wichita Dr. Subhash Shah, M.D and Kathryn Welch, PA-C 220 S. Hillside Wichita, KS Phone: Fax: NEW PATIENT EVALUATION Patient Name: Today s Date: / / DOB: / / Sex: Referred by: Mothers name Age Fathers name Age Parents are (please circle) Married Divorced Single Widowed Other Chief Complaint: BIRTH HISTORY Birth Weight: LBS. Oz. Gestational Age (weeks in Womb): Delivery: Normal C-Section Forceps Anesthesia Left Hospital on Day # of life. Major Problems during the newborn period: Maternal History: Use of drugs during pregnancy: Y / N if yes explain Use of alcohol during pregnancy: Y / N if yes explain Use of tobacco during pregnancy: Y / N if yes explain Use of medication during pregnancy: Y/N if yes explain Complications: Excessive Morning sickness YES or NO Dehydration: YES or NO Bleeding: YES or NO Diabetes: YES or NO DEVELOPMENTAL HISTORY (if you are unsure of exact date, please put delayed, normal or advanced) Social Smile: Sat without Support : Rolled Over: Walked: Spoke 1 st words other than Mama or Dada : Spoke short sentence: 3
4 PAST MEDICAL HISTORY Immunizations current: yes no Hospitalizations or surgeries: Serious Illnesses or Head Injury: Seizures Onset: Characteristics: Known Triggers: Medical Allergies: Medications: Testing and previous medical visits--please circle all that apply: EEG Video EEG MRI CT Head ultrasound EMG/NCT Lab work Neurologist Psychologist Geneticist Developmental pediatrician FAMILY HISTORY Seizures Mental Retardation Migraines Cerebral Palsy Muscular Dystrophy Depression Other Psychiatric Disorders Name of Siblings Age of Siblings Miscarriages: Still Births: SOCIAL HISTORY Parents: Natural Adoptive Foster Guardian Fathers Education: Type of Work: Mothers Education: Type of Work: 4
5 PATIENT INFORMATION RECORD Patient s Name Pt DOB SS # Primary Phone# - - Alternate Phone # - - address for Patient Portal Sex Age Student YES / NO Mailing Address City State Zip Primary care physician Referring physician Parents are (please circle) Married Divorced Single Widowed Other- Patient lives with (circle all that apply) Mother Father Step-mother Step-father Foster mother Foster father Legal guardian(s) Other - please specify Legal Guardian Name Please SPECIFY RELATIONSHIP to patient (i.e. biological/step/foster/adoptive) SS# - - DOB / / Home # - - Cell # - - Work # - - Do you give permission to leave messages with appointment info and test results to above numbers? YES NO Mailing Address City State Zip Secondary Contact Name Please SPECIFY RELATIONSHIP to patient (i.e. biological/step/foster/adoptive) SSN# - - DOB / / Home # - - Cell # - - Work # - - Do you give permission to leave messages with appointment info and test results to above numbers? YES NO Mailing Address City State Zip Emergency Contact (please list contact other than mom or dad) Relationship to patient Phone number Emergency Contact (please list contact other than mom or dad) Relationship to patient Phone number Patient s race--please check all that apply American Indian or Alaska Native Asian Black or African American Hispanic White Other (please specify) Unreported/Refused to Report Ethnicity please check all that apply Hispanic or Latino Not Hispanic or Latino Unreported/Refused to report 5
Pediatric & Adolescent Center of NW Houston, PA & Northwest Houston Neurology, PA
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Patient Name: DOB: Sex: Male/Female. Primary Address: Home Phone: Mobile Phone: Address: Emergency Contact Name and Phone Number:
Patient Registration Patient Name: DOB: Sex: Male/Female Primary Address: Home Phone: Mobile Phone: Email Address: Emergency Contact Name and Phone Number: Primary Language: Race(s): (Circle all that applies)
Bucci Lancer Pediatrics Patient Registration
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C.A.I. A Cardiovascular & Arrhythmia Institute
Acknowledgement of Receipt of Notice of Privacy Practices By signing below I acknowledge that I have received the Notice of Privacy Practices of Cardiac Arrhythmia Institute, LLC, which explains its legal
Referring Physician: Primary Care Physician: Other Physician(s)/Specialty: EMERGENCY CONTACT INFORMATION INSURANCE INFORMATION
PATIENT INFORMATION Name: Date of Birth: Sex: Male Status: Single Married Divorced Widowed Other 502 Elm Street NE Language: Female Race: American Indian or Alaska Native Native Hawaiian or Or Pacific
WELCOME TO OUR OFFICE PLEASE PRINT THE FOLLOWING INFORMATION THANK YOU
DATE: / / WELCOME TO OUR OFFICE PLEASE PRINT THE FOLLOWING INFORMATION THANK YOU Richard L. Corbin, DPM, FACFAS PATIENT NAME: LAST FIRST MIDDLE SOCIAL SECURITY NUMBER: / / D.O.B: / / STREET ADDRESS: CITY:
PATIENT DEMOGRAPHICS. Primary Insurance: Policy #: Group #: Secondary Insurance: Policy #: Group #:
TEXAS DIABETES & ENDOCRINOLOGY, P.A. 6500 North Mopac*Bldg. 3, Ste. 200*Austin, TX 78731 5000 Davis Ln*Ste 200*Austin, TX 78749 170 Deep Wood Dr*Ste. 104*Round Rock, Tx 78681 Phone: (512) 458 8400*Fax:
WELCOME Thank you for selecting our healthcare team! To help us meet your healthcare needs, please fill out this form completely.
Page 1 of 4 WELCOME Thank you for selecting our healthcare team! To help us meet your healthcare needs, please fill out this form completely. Date: Dr: Chart #: Patient s Name: First MI Last Patient s
NORTH TEXAS ARRHYTHMIA ASSOCIATES, PA
Demographic Information Name of Birth Sex Male / Female Social Security Number Email Marital Status Single / Married / Widowed / Divorced / Other Mailing Address City/State Zip Code Primary Phone Secondary
Phoenix Neurology and Sleep Medicine Phone: (623) Fax: (623)
Patient Information Date: Name: SSN (Last) (First) (MI) Address City State Zip Code Home # Cell # Work Sex Male Age DOB Married Single Divorced Female Widowed Other Email Address Employed? No Yes Employer
HAMILTON FOOT AND ANKLE CARE, LLC 9865 E. 116 th St. #300 Fishers, IN (317)
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PATIENT INFORMATION Patient First Name Middle Name Last Name Age Birth Date. Mailing Address City State Zip. Street Address City State Zip
PATIENT INFORMATION Patient First Name Middle Name Last Name Age Birth Date Mailing Address City State Zip Street Address City State Zip Home Phone Cell Phone Employer Name (for work comp only) Employer
PATIENT REGISTRATION FORM
Today s Date / / PATIENT REGISTRATION FORM PATIENT INFORMATION Patient Name Last First Middle Is this your legal name? If not, what is your legal name? Birthdate Age Sex q YES q NO / / q M q F q T Street
Namaste Health Care. New Patient Registration, Age 14 and Under. Father s Name Father s Mailing Address Work Phone (Father) Cell Phone (Father)
Namaste Health Care Bridget P. Early, M.D. Kate Branham, F.N.P. New Patient Registration, Age 14 and Under Date: Patient Name Date of Birth Age Sex M F Social Security # Race American Indian/Alaskan Native
(Please Print using Black or Blue Ink) SEX: GENDER IDENTITY: MARITAL STATUS: SINGLE MARRIED OTHER
PATIENT INFORMATION (Please Print using Black or Blue Ink) LAST NAME: FIRST NAME: MIDDLE INITIAL: ADDRESS: CITY: STATE: ZIP: SEX: GENDER IDENTITY: MARITAL STATUS: SINGLE MARRIED OTHER RACE (OPTIONAL):
Primary Care Physician Cardiologist Referring Physician PROTECTED HEALTH INFORMATION AUTHORIZATION
DEMOGRAPHIC INFORMATION Name Sex Male / Female Social Security Number Email Marital Status Single / Married / Widowed / Divorced / Other Mailing Address City/State Zip Code Primary Phone Secondary Phone
ADULT PATIENT REGISTRATION
PATIENT NAME: (LAST) (FIRST) (M) CELL: ( ) HOME: ( ) PERSONAL E-MAIL: (FOR PATIENT PORTAL) DATE OF BIRTH: / / AGE: GENDER: MALE FEMALE SOCIAL SECURITY: - - MARITIAL STATUS: SINGLE MARRIED WIDOW(ER) OTHER
PATIENT PROFILE. Marital Status: Please Check One [ ] Single [ ] Married [ ] Divorced [ ] Widowed. Address: City: Zip: Address: City: Zip:
![PATIENT PROFILE. Marital Status: Please Check One [ ] Single [ ] Married [ ] Divorced [ ] Widowed. Address: City: Zip: Address: City: Zip:](/thumbs/82/85694847.jpg "PATIENT PROFILE. Marital Status: Please Check One [ ] Single [ ] Married [ ] Divorced [ ] Widowed. Address: City: Zip: Address: City: Zip:")
PATIENT PROFILE PATIENT INFORMATION: Name: Date of Birth: Marital Status: Please Check One [ ] Single [ ] Married [ ] Divorced [ ] Widowed Address: City: Zip: Home#: Message#: Name of Primary Physician,
West Cary Family Physicians 256 Towne Village Dr Cary, NC
New Patient Registration Form - page 1 PATIENT INFORMATION Patient s first name: Patient s middle name: Patient s last name: Patient date of birth: Patient sex: Marital status: single married Patient s
Patient Registration Form. Patient Name: Date of Birth: Address: City: State: Zip Code: Primary Number: Secondary Number:
George Skarpathiotis, M.D., S.C. 7110 West 127 th Street, Suite 130 Palos Heights, IL 60463 (708)923-6300 Fax (708) 923-6303 8537 South Cicero Ave Chicago, IL 60652 (708) 923-6300 Fax (708) 923-6303 420
REGISTRATION FORM. Physician (PCP): PATIENT INFORMATION. Last Name: First Name: MI: Billing Address: City: ST Zip Code:
: REGISTRATION FORM Physician (PCP): PATIENT INFORMATION Last Name: First Name: MI: Social Security #: DOB: Sex: M F Billing Address: City: ST Zip Code: Home Phone#:( ) Cell Phone#:( ) Work Phone#:( )
Welcome to Our Practice
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NEW PATIENT INFORMATION
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TEXAS ASSOCIATION OF PEDIATRIC NEUROLOGY, P.A. Jerry J. Tomasovic, M.D.
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NORTH TEXAS DIABETES & ENDOCRINOLOGY OF PLANO
Demographic Information Name Sex Male / Female Social Security Number Email Marital Status Single / Married / Widowed / Divorced / Other Mailing Address City/State Zip Code Primary Phone Secondary Phone
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Champions Pediatric Associates Compassionate Care for Kidz Patient Registration Form ID#: Patient Last Name First Name Int. Birthdate Sex Primary Address City State Zip Code Primary Phone Number ( ) -
Family address preferred for patient portal access:
: Patient Relationship to Guarantor: of Birth: Sex: M F Social Security Number: Home Address: City: State: Zip Code: Pharmacy of Choice: Pharmacy Address: Pharmacy Phone Number: Siblings: Name Sex DOB
Please plan to arrive 15 minutes prior to your scheduled appointment time.
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HOME ADDRESS APT. NO CITY STATE ZIP CODE S M D W PRIMARY INSURANCE INFORMATION SUBCRIBER S FIRST NAME LAST NAME RELATIONSHIP TO PATIENT DATE OF BIRTH
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