Neurology Center of Wichita

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Neurology Center of Wichita Dr. Subhash Shah, M.D and Kathryn Welch, PA-C 220 S. Hillside Wichita, KS 67211 Phone: 316-686-6866 Fax: 316-686-9797-website: www.pedsbrain.com 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 316-686-6866 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 316-686-6866X216 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 email as it is not always reliable and your concerns may not be addressed in a timely manner. 1

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 316-686- 6866 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

Neurology Center of Wichita Dr. Subhash Shah, M.D and Kathryn Welch, PA-C 220 S. Hillside Wichita, KS 67211 Phone: 316-686-6866 Fax: 316-686-9797 www.pedsbrain.com 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

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 1. 2. 3. 4. 5. Miscarriages: Still Births: SOCIAL HISTORY Parents: Natural Adoptive Foster Guardian Fathers Education: Type of Work: Mothers Education: Type of Work: 4

PATIENT INFORMATION RECORD Patient s Name Pt DOB SS # Primary Phone# - - Alternate Phone # - - Email 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

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