Annapolis Neurology Associates

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Available Forms

Copy of Copy of New Patient Packet 2022 Medical Record Release Form New Patient Packet 2022 Welcome Letter

Copy of Copy of New Patient Packet 2022

Patient Information: Annapolis Neurology Associates

First and Last Name *

Date of Birth *

Home Address

Gender

What is your preferred method of contact? *

May we leave a detailed message with medical information? If so, which phone number?

Home

Work

Cell

Email address

Home Phone

Cell Phone Number

Work Phone Number

Employer and Occupation

Referring Provider

Primary Care Provider *

Race

Ethnicity

Primary Language

Responsible Party

Name of Responsible Party

First and Last

Responsible Party Phone Number

Responsible Party Address

Responsible Party Date of Birth

Relationship to Responsible Party

Reason for Visit *

*If any other reason than illness, please notify the receptionist.

If MVA or WC

Please give dates and description of your injury

Primary Insurance

Insurance company name, Policy ID, Group number and medical claims address

Secondary Coverage

Insurance company name, Policy ID, Group number and medical claims address

Tertiary Coverage

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:

Please give a detailed description for the reason for your visit *

Your current Height *

Your current Weight *

When did the pain or problem start

Medical History:

Diabetes

High Blood Pressure

Stroke

Heart Disease

Irregular heart rate

Cancer

Arthritis

Headaches

Multiple Sclerosis

Seizure/Epilepsy

Parkinson's Disease

Other Medical Conditions

Please list and explain:

Prior Hospitalizations and Surgeries:

Hospitalizations

When and What Hospital

Surgeries

When and What Hospital

Allergies to Medications:

Do you have any allergies to medications? *

Please list medications you have allergies to and what the reaction is or state "NKDA": *

Medications:

What pharmacy would you like any prescriptions to be sent to?

List pharmacy and telephone number

Please list all medications you take currently, including vitamins, over the counter medications, and supplements or state "None". *

Social History:

Marital Status

Caffeinated beverages:

Coffee

Tea

Sodas

Other

Alcohol Use *

Number of drinks and frequency (ie. 1 per day or 2 per week)

Tobacco Use *

If you are a current smoker, how many packs per day?

Illicit Drug Use *

If you use illicit drugs, what type and frequency?

Family Medical History:

Father's medical condition and if deceased, cause of death and age at death

Mother's medical condition and if deceased, cause of death and age at death

Sibling 1 medical condition and if deceased, cause of death and age at death

Sibling 2 medical condition and if deceased, cause of death and age at death

Child 1 medical condition and if deceased, cause of death and age at death

Child 2 medical condition and if deceased, cause of death and age at death

Child 3 medical condition and if deceased, cause of death and age at death

Please print your name to confirm you have completed the Review of Systems to the best of your knowledge. *

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

Physician Name:

Address:

Telephone number

Fax number

Email address

Physician name

Address

Telephone number

Fax number

Email address

Headache Questionnaire:

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

How long have you had headaches?

How often do they occur?

Severity of headaches on a scale of 0-10 (if it varies, please give a range)

How long do the headaches typically last?

What does the headache feel like? Choose up to 3.

Where are the headaches?

Left side

Right side

Around the eyes

Temples

Top of head

Back of head

Neck

Other

Do you have any associated symptoms?

Do any of the following trigger your headaches?

What makes the headache better?

Sleep

Moving around

Dark room

Massage

Heat

Ice

Time/waiting

Medication

Have you taken any of the following medications to reduce the frequency of your headaches (ie. prevent headaches)?

Have you used any of the following treatments/meds to get rid of a headache?

Please indicate to the best of your knowledge the reason you stopped any of the above medications.

Extra space provided to list any additional information you would like the provider to know about your condition:

HIPAA and No Show Agreement:

Assignment and Release: *

I hereby assign my insurance benefits to be paid directly to Daniel Hexter MD PA dba Annapolis Neurology Associates

I understand that I am financially responsible for all non-covered "denied" services, copays, deductables. coinsurance, MVA/WC cases and after hours calls to the provider on call

I authorize and give consent for my provider to bill me directly for recommended services performed that are not covered under the terms of my health plan

I am responsible for payment in full within 30 days of receipt of a bill for services provided. If I am unable to pay in full within 30 days, it is my responsibility to contact the office to arrange a payment plan with the management and or the billing department

I authorize the provider or designated representative to contact me by telephone, e-mail or text message about appointments, billing and medical care. (A personal message may be left on our voicemail)

I authorize the physician to release any medical information required to process this claim and continuity of care.

I acknowledge that I have viewed and been given a copy of the "Notice of Privacy Practices" which includes the mega HIPAA Revisions 2013.

I will keep all my scheduled appointments. I am aware this office has a non-compliance policy for missed appointments (see the Cancellation Policy Agreement)

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

PHI released to

(Enter name and phone number)

PHI released to

(Enter name and phone number)

Print your name to confirm that you have reviewed this document

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. 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.

Please read the Cancellation Policy and print your name in acknowledgement of this policy. *

* Required field