TEXAS ASSOCIATION OF PEDIATRIC NEUROLOGY, P.A. Jerry J. Tomasovic, M.D.

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1 Jerry J. Tomasovic, M.D. PATIENT NAME D.O.B. Who referred you today? What are the concerns that brought you here today? What specific questions do you have today? Please list present medication and dosage: GENERAL HEALTH Please list any serious medical illnesses: Hospitalizations / surgeries (date & reason): Trauma / accidents: BIRTH HISTORY: Where you born early or on time? _ If early, how early? Birth weight: Any complications/difficulties with your birth? DEVELOPMENTAL HISTORY / ACADEMIC HISTORY As a child were you ever told you were slow to develop? YES / NO What specific difficulties, if any? When did you first: SIT WALK CRAWL SPEAK IN SENTENCES Are you performing in your career/job for your age? If not, what specific areas are you behind in? FAMILY HISTORY Any family members with: (Check any that apply) muscle disorder seizure disorders migraine/headache visual problems hearing problems attention/concentration difficulties learning disability mental retardation mental illness Other: Please list immediate family members, ages & any medical conditions:

2 REMINGTON OAKS BUILDING525 Oak Centre Drive, Suite 400San Antonio, TX Phone Fax Jerry J. Tomasovic, M.D. Board Certified in Adult & Child Neurology Epworth Sleepiness Scale (ESS) of Sleep Disorders Please answer the following questions as honestly as you can by circling one answer only Directions: How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these recently, try to work out how they would have affected you. Use the following scale to rate your chance of dozing in each situation. Circle the correct number to indicate your chance of dozing for each item below. 0 would never doze 1 slight chance of dozing 2 moderate chance of dozing 3 high chance of dozing CIRCLE BELOW: 1. Sitting and reading Watching television Sitting inactive in a public place for example, a theater or meeting 4. As a passenger in a car for an hour without a break Lying down to rest in the afternoon Sitting and talking to someone Sitting quietly after lunch (when you ve had no alcohol) In a car while stopped in traffic Patient Name: Total:

3 JERRY J. TOMASOVIC, M.D. PATIENT DEMOGRAPHICS NAME: DOB: / / LAST FIRST MIDDLE ADDRESS: MALE FEMALE SOCIAL SECURITY# STREET NUMBER AND NAME CITY & STATE ZIP CODE PHONE NUMBERS: HOME ( ) WORK: ( ) CELL: ( ) DRUG OR MEDICATION ALLERGIES: NAME OF SCHOOL: REFERRING PHYSICIAN: FIRST & LAST NAME CITY OFFICE PHONE NUMBER RESPONSIBLE PARTY/PARENT/GUARDIAN INFORMATION NAME: RELATIONSHIP SOCIAL SECURITY# - - DOB: / / PHONE: ( ) EMPLOYER: EMPLOYER ADDRESS: WORK: OCCUPATION: MARITAL STATUS: S M D W NAME: RELATIONSHIP SOCIAL SECURITY# - - DOB: / / PHONE: ( ) EMPLOYER: EMPLOYER ADDRESS: WORK: OCCUPATION: MARITAL STATUS: S M D W INSURANCE INFORMATION INSURANCE CARRIER: ID# GRP# POLICY HOLDER DOB: SECONDARY INS: ID# GRP# POLICY HOLDER EMERGENCY CONTACT OTHER THAN PARENT NAME: PHONE: PHONE: ( ) RELATIONSHIP I HEREBY RELEASE AND AUTHORIZE TAPN, P.A. TO RELEASE INFORMATION ACQUIRED IN THE COURSE OF TREATMENT TO THE INSURANCE CARRIER TO EXPEDITE PAYMENT. I UNDERSTAND THAT MEDICAL RECORDS MAY BE REQUESTED AND SENT. I ALSO ASSIGN BENEFITS TO BE PAID DIRECTLY TO TAPN, P.A. AND THAT I AM FINANCIALLY RESPONSIBLE FOR THE CHARGES THAT THE INSURANCE DOES NOT PAY. SIGNATURE: DATE: / / DOB:

4 REMINGTON OAKS BUILDING525 Oak Centre Drive, Suite 400 San Antonio, TX Phone Fax Jerry J. Tomasovic, M.D. Board Certified in Adult & Child Neurology PATIENT INFORMATION 1. APPOINTMENTS: There are two classifications of appointments; a New Patient and an Established Patient. We ask that you arrive 10 to 15 minutes early to complete necessary paperwork, if you have not received it by mail prior to your appointment we will do our utmost to minimize the waiting time. If you have moved, changed your phone number, or insurance please notify the receptionist, so that your file can be updated appropriately. If a referral is required from your primary care physician, it is your responsibility to obtain that referral; otherwise the specialist cannot treat you. *IF YOU ARE MORE THAN 15 MINUTES LATE, WE MAY REQUIRE YOU TO RESCHEDULE YOUR APPOINTMENT. 2. CANCELLATIONS: Due to a high demand for Pediatric Neurologist, we ask that you notify us at least 24 hours in advance so we may use that time slot for another patient. PATIENTS WHO DO NOT NOTIFY THE OFFICE THAT THEY ARE UNABLE TO KEEP THEIR APPOINTMENT AT LEAST 24 HOURS IN ADVANCE WILL BE CHARGED A FEE OF $ PAYMENTS: Regardless of your insurance coverage, YOU ARE ULTIMATELY RESPONSIBLE FOR PAYMENT IN FULL. We ask that you keep your balance current. ALL DEDUCTIBLES, CO-PAYS, OR CO-INSURANCE are due and payable at the time of each visit. 4. GUARDIAN OF A MINOR: In the case of guardianship, the parent who brings in the minor child is responsible for payment. We dot negotiate through a Third Party. It will be your responsibility to seek reimbursement. 5. RETURNED CHECKS (NSF): Pursuant to SB-921, you will have 10 days to tender payment, plus a $30.00 bank service charge, on all returned checks. If payment is not received within that period, the check will be forwarded to the District Attorney s Office.

5 6. DELINQUENT ACCOUNT: We know that this can be an uncomfortable subject, but we feel that being clear on this issue now will avoid misunderstandings. To maintain our facilities and continue to provide quality healthcare service, we must keep our reimbursements current. If your account becomes ninety (90) days delinquent it will be placed in collections and there will be an additional $30.00 processing fee. It is important to remember that the relationship for payment is between you and your insurance carrier. We simply, as a courtesy, file the claim for the services that are provided. It is your responsibility to understand your benefits. If you have questions regarding the coverage, please contact your insurance carrier. 7. FORM COMPLETION: All forms that need to be completed by Dr. Tomasovic will be filled out during the office visit at no charge. Any form, which Dr. Tomasovic is asked to complete outside of an office visit, needs to be faxed, mailed, or brought to the office accompanied by a payment of $25.00 before it is completed. We can then fax or mail the form according to your request. Before Dr. Tomasovic completes the form, it needs to already have the parent s or guardian s signature on it or a signed consent form for release of the medical information and needs to be in the medical record. If it is a medication form, the medication name, dose and time of administration must be indicated clearly. Due to the high volume of forms that Dr. Tomasovic has to fill out on a daily basis your forms will take up to 10 days for processing. 8. PRESCRIPTIONS: In order to process prescription refill requests, please notify the office at least 24 hours in advance. Less than 24 hours may result in a delay in getting your prescription filled. Same day triplicate prescriptions (controlled substance) will cost $25.00 as well as for expired triplicates that require the prescription to be re-written there is also a $25.00 charge. All triplicate prescriptions (controlled substance) will cost $5.00 to pick up, with the exception of Medicaid patients. The $5.00 service charge is for the review of the medical chart and approval of the dosage to fill the prescription. 9. MEDICAL RECORDS: Your medical record is the property of Texas Association of Pediatric Neurology, P.A. If another physician who is treating your child requests a copy of your medical record, this will be provided to them at no charge, with a signed medical release authorization. If you choose to obtain a copy for yourself, then a $25.00 charge will be applied. This fee will be in accordance with the guidelines established by the Texas State Board of Medical Examiners. The key to a good health care relationship is communication. Please let us know how we can better service you and meet your needs to make your visit as beneficial as possible. Thank you, TAPN Management Patient/Parent/Guardian Signature Date Revised 07/15/2009

6 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICE I, have received a copy of this office s Notice of Privacy Practices. Please Print Name Signature Date For Office Use Only We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but could not be obtained because: Individual refused to sign Communication barriers prohibited obtaining the acknowledgment An emergency situation prevented us from obtaining acknowledgment Other (please specify)