Please describe the main reason you are being seen and any known or suspected diagnosis (e.g., seizures / epilepsy, headache, etc.).

Complete this section if insurance is being billed. Please present your current insurance card(s) at check-in.

Assignment of Benefits & Release of Information. I authorize the release of any medical information necessary to process this claim. I authorize payment of medical benefits to Comprehensive Neurology Clinic.

To the Patient — Consent for Care and Treatment: You have the right, as a patient, to be informed about your condition and the recommended medical or diagnostic procedure to be used so that you may decide whether or not to undergo any suggested treatment or procedure. This consent form is an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s).

This consent gives us your permission to perform reasonable and necessary medical examinations, testing, and treatment. By signing below, you indicate that (1) this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at this office or any other satellite office under common ownership. This consent remains fully effective until revoked in writing. You have the right at any time to discontinue services, and to discuss the purpose, potential risks, and benefits of any test ordered for you. If you have concerns about any test or treatment recommended, we encourage you to ask questions.

I voluntarily request a physician and/or mid-level provider (Nurse Practitioner), and other health care providers or designees as deemed necessary, to perform a reasonable and necessary medical examination, testing, and treatment for the condition which has brought me to seek care at this practice. I understand that if additional testing or invasive/interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s).

I certify that I have read and fully understand the above statements and consent fully and voluntarily to their contents.

Thank you for choosing Comprehensive Neurology Clinic as your healthcare provider. We are committed to your treatment being successful and we appreciate your trust in us. The following is our Financial Policy, which you are required to read, agree to, and sign prior to treatment being rendered.

Patients with Insurance: We will file your claim for you, but we must have complete and CURRENT information, a copy of your insurance card, and your signature on file.

Authorization: By signing below, you authorize Comprehensive Neurology Clinic to bill your insurance carrier. It is your responsibility to know your insurance benefits. Please contact your insurance company with any coverage questions.

Co-pays, Co-insurance & Deductibles: All patient balances are due at the time of service. We accept cash, check, and credit cards (Visa, MasterCard, American Express, Discover, and CareCredit).

Non-Covered Charges: Some services may be considered non-covered or excluded by your policy; you will be responsible for these charges.

Denied Claims: Failure to present CURRENT insurance information before services are rendered may result in denial of your claim and billing to you. You are responsible for any charges denied by your insurance company.

Medicare: We are participating Medicare providers and will bill Medicare and any secondary insurance. Not all services are covered; you are responsible for co-payments (usually 20% of the allowed amount) and any unmet annual deductible.

Medical Records Requests: Please allow 7-10 business days for processing. A Records Release Authorization form is required for each request.

Payment Arrangements: We offer monthly payment plans (balance paid over four consecutive payments) and financial hardship discounts (requires a completed Financial Evaluation Form with supporting documentation).

Past-Due Accounts: Past-due accounts are subject to collection proceedings. All fees allowable by law, including a 35% collection-agency fee and awarded court fees, become your responsibility in addition to the balance.

Forms Fees: $35 for completion of patient-requested forms or detailed work letters (work restrictions) — both types; $0 for a same-day work/school note. Please allow 7-14 business days.

By supplying phone numbers (including my mobile number), email address, and any other personal contact information, I authorize Comprehensive Neurology Clinic, or any business-associate vendor of Comprehensive Neurology Clinic (including billing and collection agencies), to contact me at any of the numbers or email addresses I provide using email, text messages, an automatic telephone dialing system, pre-recorded voice, or other automated outreach and messaging systems, and to use my protected health information or other identifying information during such contact for any administrative or healthcare matter, including billing and collection.

I consent to Comprehensive Neurology Clinic, or any of its business-associate vendors, contacting me via unencrypted email and text messages. I agree they may leave detailed messages on my voicemail or answering system, or with another individual, if I am unavailable at the number I provide. Any email address I provide is my personal address, not an employer-provided address. To opt out of or modify any of these communications, I may contact Comprehensive Neurology Clinic at any time.

Your Protected Health Information (PHI) will be used by Comprehensive Neurology Clinic, or may be disclosed to others, for the purposes of treatment, obtaining payment, or supporting the day-to-day healthcare operations of this office. You should review the Notice of Privacy Practices for a complete description of how your PHI may be used or disclosed and of your rights. A copy is available at the front desk on request. You may revoke this consent in writing at any time; any use or disclosure that already occurred prior to receipt of your revocation is not affected.

Use this form to have records sent to Comprehensive Neurology Clinic from another office, or to release your records to a third party.

I authorize Comprehensive Neurology Clinic to request / release my health information to / from the physician or practice below:

I understand I may revoke this authorization at any time by giving written notice to Comprehensive Neurology Clinic (except to the extent action has already been taken in reliance on it). If a recipient of this information is not a healthcare provider or health plan covered by federal privacy regulations, the information may be re-disclosed and no longer protected by those regulations.

Please read each policy below and enter your initials in the box beside it to acknowledge that you understand and accept it.

Please allow 7-10 business days for processing of ALL medical records requests. A signed Medical Release form is required for each request.

There is a $25.00 fee for any missed / cancelled Established or New Patient office visit with less than 24-hour notice. This is an internal charge and cannot be billed to your insurance company.

There is a $35.00 fee for completion of patient-requested forms and detailed work letters (work restrictions) — both types, no exceptions. A same-day work/school note is $0. Please allow up to 10 business days for completion of any forms.

All prescription refills require 24-48 hours' notice to our staff. Please allow 24-48 hours to process a medication request.

, acknowledge receipt and acceptance of these policies.

New Patient Registration

Reason for Referral / Diagnosis

Emergency Contact

Referral & Primary Care

Our Locations

Insurance & Guarantor Information

Policy Holder (Guarantor) if different from patient

Primary Insurance

Secondary Insurance

Consent for Care & Treatment

Financial Policy

Consent to Communications

Notice of Privacy Practices — Acknowledgement & Consent

Medical Records Request / Release

Information to be Released Check all that apply

Representative's Authority

Office Policy Acknowledgement

Thank You!