Neurology Physicians, LLC

NEUROLOGY PHYSICIANS LLC

Columbia Medical Center

11055 Little Patuxent Parkway, Suite 209

Columbia, MD 21044

Phone: 410/884-0191

Fax: 410/997-2607

Patient’s

Last Name: ______First Name: ______MI: ______

Address: ______Email: ______

City: ______State: ____ZipCode: ______

Referral Doctor: ______Referral Doctor’s Phone#: ______

Sex: M/FBirthday: ___ / ___ / ____Social Security #: ______- ______- ______

Race: ______Spanish / Latino: Y / NPreferred Language: ______

Marital Status: S / M / D / W

PhoneHome: ______Work: ______Cell: ______

Primary Insurance CoverageSecondary Insurance Coverage

Company:______Company:______

Insured Name: ______Insured Name:______

Relationship: ______DOB: ______Relationship:______DOB: ______

Co-Pay Amount: ______Co-Pay Amount: ______

Policy Number: ______Policy Number: ______

Group Number: ______Group Number: ______

Employer: ______Employer: ______

Guarantor Information

Guarantor:______

Address:______

City:______State: ______Zip Code: ______

Phone #: ______Miscellaneous: ______

Patient’s Authorization

______

I authorize NEUROLOGY PHYSICIANS LLC to apply for benefits on my behalf for services rendered by NEUROLOGY PHYSICIANS LLC. I request payment from my insurance company be made directly to NEUROLOGY PHYSICIANS LLC. I certify information I have reported with regard to my insurance coverage is correct and further authorize the release of any necessary information, including medical information for this or any related claims. I permit a copy of this authorization to be used in place of the original. The authorization may be revoked by me at any time in writing. I understand that nothing herein relieves me of my primary responsibility and obligation to pay for medical services provided when a statement is rendered.

______

Signature of Subscriber of BeneficiaryDate

Neurology Physicians, LLC

Health Questionnaire

Date: ______

Patient name:______Date of Birth:______

Reason for visit: ______

______

______

Please circle all that apply:

ConstitutionalEars, Nose, Throat

FeverDecreased hearing

Weight lossEar pain

Tinnitus

EyesNasal discharge

Problem with visionInability to smell

Double visionDifficulty swallowing

Eye painPain with swallowing

CataractsSore throat

Glaucoma

Macular degenerationCardiovascular

Chest pain

RespiratoryChest pressure

Shortness of breath at restShortness of breath with activity

Chest pain with breathingSwelling in legs

CoughingHistory of heart attack

Coughing up sputumHigh cholesterol

Coughing up bloodHigh triglycerides

EmphysemaDo you have high blood pressure: Yes No

Chronic bronchitis

Lung cancerGastrointestinal

AsthmaNauseacolon cancer

Vomiting

GenitourinaryDiarrhea

Urinary incontinenceAbdominal pain

Unable to hold urine when feel need to urinateVomiting up blood

Urinating frequently at nightBlack bowel movements

Urinating frequently during the dayBlood in bowel movements

Weak urine streamAbdominal bloating

Enlarged prostateReflux

Prostate cancerUlcers

Bladder cancerIrritable bowel syndrome

Health QuestionnaireName______

Page 2

MusculoskeletalSkin and/or Breast

Muscle weaknessRashes

Muscle painSkin ulcers

Joint painSkin pain

Joint stiffnessMelanoma

Neck painBreast pain

Back painBreast lump

OsteoporosisDischarge from breast

Breast cancer

NeurologicalEndocrine

HeadachesWeight gain

SeizuresIntolerance to cold

DizzinessIntolerance to heat

Difficulty with speechHypothyroidism

Difficulty with balanceGraves disease

NumbnessHashimoto’s thyroiditis

TinglingHair loss

Hematological/LymphaticAllergic/Immunologic

AnemiaAllergies to environment

Fatigue Specify______

LeukemiaAllergies to medications

Lymphoma Specify______

PolycythemiaFrequent pneumonia

History of cancer

History of Lyme disease

Other

Falling asleep during the day

Difficulty sleeping at night

Depression

Schizophrenia

Lack of interest in hobbies or social activities

Bipolar disorder

Irritability

Health QuestionnairePatient name:______

Page 3

FAMILY HISTORY - please list any major illnesses and indicate family relationship

(parent/siblings/children):

______

______

______

______

PAST MEDICAL HISTORY

Please list medical conditions, hospitalizations and/or surgeries:

Condition/SurgeryYear

______

______

______

______

______

______

MEDICATIONS:

Please list medications, strength and dosage including non-prescription and “alternative” medications:

______

______

______

______

______

______

Have you or do you currently smoke?______

Have you or do you currently drink alcohol? If yes, how often?

______

Have you or do you currently use recreational drugs?

______

Do you have diabetes?______

Reviewed with patient ______

Signature of physician and date

New Patient Consent to the Use and Disclosure of Health Information for Treatment, Payment, or Healthcare Operations

I, ______, understand that as part of my health care, NEUROLOGY PHYSICIANS LLC originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as:

A basis for planning my care and treatment,

A means of communication among the many health professionals who contribute to my care,

A source of information for applying my diagnosis and surgical information to my bill

A means by which a third-party payer can verify that services billed were actually provided, and

A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals

I understand and have been provided access to a Notice of Privacy Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:

The right to review the notice prior to signing this Consent,

The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations

I understand that I may revoke this Consent in writing, except to the extent that the organization has already take action in reliance thereon. I also understand that by refusing to sign this Consent or revoking this Consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations.

I further understand that NEUROLOGY PHYSICIANS LLC reserves the right to change their notice and practices and prior to implementation, in accordance with Section 164.520 of the Code of Federal Regulations. Should NEUROLOGY PHYSICIANS LLC change their notice, they will send a copy of any revised notice to the address I’ve provided (whether U.S. mail or, if I agree, e-mail).

**I wish to have the following restrictions to the use or disclosure of my health information:

______
**I wish to allow NEUROLOGY PHYSICIANS LLC to discuss my medical care with the following family member or other designated person(s):
______

I understand that as part of this organization’s treatment, payment, or health care operations, it may become necessary to disclose my protected health information to another entity, and I Consent to such disclosure for these permitted uses, including disclosures via fax.

I fully understand and accept / decline the terms of this Consent.

______
Patient’s SignatureDate
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FOR INTERNAL OFFICE USE ONLY

[ ] Consent received by ______on ______.
[ ] Consent refused by patient, and treatment refused as permitted.
[ ] Consent added to the patient’s medical record on ______.