Kevin R. Hargrave, M.D. Nurse Practitioners

Kevin R. Hargrave, M.D. Nurse Practitioners

Board certified in Neurology & Teddi P. Schneider, FNP

Sleep Medicine Angie Fontenot, FNP

New Patient Intake Form

Welcome to our office!

NAME______DATE of BIRTH______SEX______

STREET ADDRESS______CITY______STATE______ZIP______

MAILING ADDRESS ______CITY______STATE______ZIP______

(If different from above)

HOME PHONE______WORK PHONE______CELL______

SOCIAL SECURITY #______

EMERGENCY CONTACT

NAME______RELATIONSHIP______PHONE #______

INSURANCE INFORMATION

**Please provide ALL insurance cards at time of service. If your primary insurance plan is covered under your spouse,

please fill out the following information.

SPOUSE’S NAME______SS#______DOB______

EMPLOYER NAME______PHONE #______

Please list family members or other persons who we may inform about your general medical condition, appointment reminders, or lab and x-ray results, used primarily in urgent situations.

Name______Relationship______Phone #______

Name______Relationship______Phone #______

Do we have permission to photograph you and keep it in your medical records? Yes______No______

Who should we thank for referring you to our office? ______

PATIENT-DOCTOR AGREEMENT

Insurers and managed care companies occasionally review medical charts to insure compliance with company procedures. I understand that my chart may be selected for such review and that the confidentiality of the information in my chart will be preserved and I hereby consent to such review and release this physician and any such insurer or managed care company for liability for any reasonable review of my chart. Initial here______

I understand that personal health information may be transmitted by electronic transmission, by fax transmittal, by Internet, or by e-mail. I understand that the office personnel may call about health care information to my home or other numbers given. Office personnel may use telephone answering machines or cell phone voice mail to leave messages. I understand that cellular/cordless phones are not secure or private lines. Initial here______

I authorize treatment of the above named patient. I hereby assign all medical benefits to include major medical benefits to which I am entitled including Medicare and other governmental sponsored programs, private insurance, and any other health plans to Comprehensive Comprehensive Neurologics & Sleep, Kevin R. Hargrave, MD. This assignment will remain in effect until revoked by me in writing. I understand that I am financially responsible for all charges incurred by the doctors at Comprehensive Neurologics & Sleep. I understand that payment is due upon services rendered, unless credit arrangements have previously been made.

Patient Signature______Date______