Burr Ridge 16W300 83 rd St 100 Burr Ridge, Illinois 60527 Tinley Park 16750 S 80 th Ave A Tinley Park, Illinois 60477 Associates in Neuroscience Phone: (630) 230-3372 Fax: (630) 568-5050 Effective Date: January 1, 2015 Dear Patients of Associates in Neuroscience: Due to the high volume of no shows and last minute cancellations we have been experiencing, any office appointments that are cancelled less than 24 Hours before the scheduled appointment time will be subject to a $35.00 cancellation fee. Any EEG appointments that are cancelled less than 24 Hours before the scheduled appointment time will be subject to a $50.00 cancellation fee. This fee will not be reimbursed by the insurance company, but billed directly to the patient. Thank You, Vijay Singh, CEO Associates in Neuroscience, SC Patient Name: Birth Date: Name of Parent/Guardian: Signature (Patient/Parent/Guardian): Date:
Patient Name: Address: Phone Number: Date of Birth: Associates in Neuroscience 16W300 83 rd St Burr Ridge, IL 60527 Phone: (630) 230-3372 Fax: (630) 568-5050 AUTHORIZATION FOR RELEASE OF PATIENT HEALTH INFORMATION I hereby authorize that the protected health information regarding the above named be forwarded: From: To: Person/Institution Address City State Zip Person/Institution Address City State Zip Purpose or need for information: Disclosure will include: (Check all that apply) Face Sheet History & Physical Laboratory Report Operative Report Itemized Bill Discharge Summary Progress Notes Radiology Report Pathology Report Other Emergency Report Nurses Notes EKG/EMG/EEG Report Consultation Report Records for the period (dates) from to I must check one or more of the following types of health information that I do not want released to the above named Recipient. I understand that if I do not check any of the three (3) following lines, the health information released to the named recipient may include any of the following: Diagnosis, Evaluation and/or treatment for alcohol and/or drug abuse Records of HTLV-III or HIV testing (AIDS test) result, diagnosis and/ or treatment Psychiatric, psychological records or evaluation and/or treatment for mental, physical and/or emotional illness including narrative summary, tests, social work assessments, medications, psychiatric examination, progress notes, consultations, treatment plans, and/or evaluation. I also understand that this Authorization is subject to revocation/withdrawal by me at any time in writing to the medical record contact person at this site of care except to the extent that action has already been taken to release this information. This Authorization shall remain valid unless revoked but will expire in 1 year after signing. I have a right to inspect a copy of the health information to be released and if I do not sign this Authorization, the institution named above will not release my health information. The above named person/institution will not refuse to treat me based on whether I agree to allow my health information to be used and disclosed to others. Signature of Patient Signature of Parent/Legal Guardian Date Relationship to Patient Witness REDISCLOSURE: Notice is hereby given to the patient or legal representative signing this Authorization that Associates in Neuroscience, SC cannot guarantee that the Recipient receiving the health information will not redisclose any or all of it to others. Notice is hereby given to the Recipient that law prohibits the redisclosure of any health information regarding drug and/or alcohol abuse, HIV and mental health treatment.
Burr Ridge 16W300 83 rd St 100 Burr Ridge, Illinois 60527 Tinley Park 16750 S 80 th Ave A Tinley Park, Illinois 60477 Associates in Neuroscience Phone: (630) 230-3372 Fax: (630) 568-5050 PATIENT AGREEMENTS AND AUTHORIZATIONS CONSENT FOR TREATMENT: I hereby consent to the treatment provided by Associates in Neuroscience and its employees and designees (Referred to as the Practice ). I authorize the mental and physical health care services deemed necessary or advisable by my caregivers to address my needs. AUTHORIZATION FOR RELEASE OF PERSONAL HEALTH INFORMATION: I authorize the use and disclosure of my personal health information for the purposes of diagnosing or providing treatment to me, obtaining payment for my care, or for the purposes of conducting the healthcare operations of the practice. I authorize the Practice to release any information required in the process of applications for financial coverage for the services rendered. This authorization provides that the practice may release objective clinical information related to my diagnoses and treatment, which may be requested by my insurance company or its designated agent. ASSIGNMENT OF INSURANCE BENEFITS / PAYMENT GUARANTEE / COLLECTION FEE: I authorize payment to be made directly to the Practice for insurance benefits payable to me. I understand that I am financially responsible to the Practice for any covered or non-covered services (including EEGs and any other procedures), as defined by my insurer. I understand that if my account balance becomes overdue and the overdue account is referred to a collection agency, I will be responsible for the costs of collection including reasonable attorney s fees. PRIVACY POLICY: I acknowledge that I have received a copy of the Associates in Neuroscience, SC Notice of Privacy Practices. I understand that Associates in Neuroscience, SC has the right to change its Notice of Privacy Practices from time to time and that I may contact Associates in Neuroscience at any time to obtain a current copy of the Notice of Privacy Practices. Patient Name: DOB: Patient or Authorized Person Signature Relationship Date
Patient Name: Date of Birth: Sex: M F PATIENT PAST MEDICAL HISTORY AND INFORMATION FORM Please complete the form below in its entirety and to the best of your ability. Additional directions are provided section by section where applicable. Reason for Visit: PHYSICIANS Please list all of your child s physicians: Physician Specialty MEDICATIONS Please list all medications (both prescription and over the counter) that your child is on: Name of Prescription Reason ALLERGY HISTORY Medications Environmental Parent/Guardian Signature: Date: PLEASE BRING THE COMPLETED FORM WITH YOU TO YOUR SCHEDULED VISIT
PATIENT REGISTRATION FORM DATE: PATIENT INFORMATION Last Name: First Name: MI: Date of Birth: Sex: SS#: Phone: Address: E-Mail: _ Emergency Contact: Phone: Alt: REFERRING PHYSICIAN Name: _ Address: Phone Number: PARENT/GUARDIAN INFORMATION (IF PATIENT IS A MINOR) Relationship to Patient: Mother Father Guardian Other: Last Name: First Name: MI: Date of Birth: Sex: SS#: Phone: Address: Cell Phone: Employer: Work Phone: Employer Address: E-Mail: _ PRIMARY INSURANCE INFORMATION Ins Co. Name: Ins Co Phone: Ins Co. Address: Name of Policy Holder: DOB: SS#: Policy Holder Address: Relationship to Patient: Policy# Group # SECONDARY INSURANCE INFORMATION Ins Co. Name: Ins Co Phone: Ins Co. Address: Name of Policy Holder: DOB: SS#: Policy Holder Address: Relationship to Patient: Policy# Group # STATEMENTS Who will be responsible for this bill? Address: Phone: I have read and understand all of the above information and hereby state that the information is correct to the best of my knowledge. Name: Relationship to Patient: Signature: Date: