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New Patient Packet 2020

Patient Information: Annapolis Neurology Associates

First and Last
*If any other reason than illness, please notify the receptionist.
Please give dates and description of your injury
Insurance company name, Policy ID, Group number and medical claims address
Insurance company name, Policy ID, Group number and medical claims address
Insurance company name, Policy ID, Group number and medical claims address
Please print your name as acknowledgment: "I have completed this form entirely and certify that I am the patient or duly authorized agent of the patient to furnish the information requested. I understand that even though I may have insurance coverage, I am ultimately responsible for payment of services rendered

Reason for visit:

10 being the most severe?
Explain
Explain

Medical History:

Please list and explain:

Prior Hospitalizations and Surgeries:

When and What Hospital
When and What Hospital

Allergies to Medications:

Medications:

List pharmacy and telephone number

Social History:

Family Medical History:

Review of Symptoms:

Please indicate any personal history below

General Health:

Eyes

Ears/Nose/Throat

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

Musculoskeletal

Skin

Neurological

Psychiatric

Endocrine

Hematology/Lymphatic

Enlarged glands

Please list the names and complete mailing address of any medical providers that yo wish to receive a copy of your office visits and procedures. Please include your primary care provider

Headache Questionnaire:

Please fill this section out if you are coming in for headaches.

1. Please indicate to the best of your knowledge the year you tried and failed the medication

HIPAA and No Show Agreement:

Assignment and Release:

I authorize the disclosure of my protected health information to (friends, family members and or caregivers)

(Enter name)
(Enter name)

Cancellation Policy:

Each time a patient misses an appointment without providing proper notice, another patient is prevented from receiving treatment. Therefore, Annapolis Neurology Associates reserves the right to charge a fee for missed appointments ("no shows") that are not cancelled with a 24 hour advanced notice: $35.00 for missed office visits. $50.00 for missed procedures and $100.00 for missed Ambulatory EEGs. No show fees are subject to change without notice. "NoShow" fees will be billed to the patient. This fee is not covered by insurance, and must be paid prior to your next appointment. Multiple "no shows" in any 12 month period may result in termination from our practice. Thank you for your understanding and consideration as we strive to best serve the needs of all of our patients.

* Required field