DOB (Fecha de Nacimiento)             SS# (Seguro Social)          

 Address (Direccion)               Apt#  

 City    State(Estado)     Zip Code (Zona Postal)  

 Home Phone (Telefono de Casa)     Work/Mobile Phone(Telefono Secundario)  

 Patient’s Employer (Lugar de Empleo)     

 City (Ciudad)     State(Estado)     Zip Code (Zona Postal)  

 Marital Status (Estado Civil)         Single (Soltero/a)          Married(Casado/a)           Widow(Viudo/a)           Divorced(Divorciado/a)

 Spouse’s Name (Nombre de Esposo/a)     Student (Estudiante)  

 Emergency Contact (Contacto de Emergencia)    Relation(Relacion)

  Allergies to Medications

  Pharmacy Name (Nombre de Farmacia):    Telephone (Telefono)  

 

 Patient Name:

     As a service to our patients, our office accepts assignments of most medical plans. However, in an increased managed care environment, reimbursement for certain services has become increasingly difficult to obtain. In addition, most in-office procedures now require some sort of pre-certification or referral. In an effort to continue to give our patients excellent, yet affordable care, we ask that you take time to read and sign the following agreement. This will enable us to continue to submit insurance claims on behalf of our patients.

1.  I understand that I must have a current referral for every office visit, and that it is my responsibility to obtain referral forms from my Primary Care Physician (PCP), according to the guidelines of my plan.
2. I understand that co-payments must be paid at the time of service
3. I understand that Dr.   has agreed to accept assignment from my insurance carrier for services rendered in the office. However, payment for services is ultimately my responsibility
4. I understand that some services performed by the physician may not be covered under Medicare and/or my insurance carrier(s). If it is not covered, I agree to remit payment(s) in full. I also understand that disability and similar forms that I request a physician to complete on my behalf will incur a charge of at least $50.00 that is not payable by nor reimbursable by my insurance.
5. I understand that in the event that I am unable to keep my scheduled appointment, I will notify the office to cancel or reschedule at least 24 hours before my scheduled appointment. Failure to do so will be subject to a $30 no show fee for follow up visits ($100 for Dr. Berliner in Manhattan) or a $50 no show fee for EMG/NCV testing. I also understand that a rescheduling of my appointment will be subject to the next available appointment date at my physician’s discretion.

Assignment & Release of Information Statement

Authorization for release of information by:

Dr. Berliner, Dr. Gulati, Dr. Elyaderani & Dr. Kazmi

 I hereby authorize and direct the above named physicians, having treated me, to release to governmental agencies, insurance carriers, or others who are financially liable for my medical/hospital care, all information needed to substantiate payment for such services rendered during medical/hospital care, and to permit representative thereof to examine and make copies of all records relating to such care and treatment. I also transfer and set over to the above named physicians sufficient monies and/or benefits to which I may be entitled from governmental agencies, insurance carriers, or others who are financially liable for my medical/hospital care to cover the cost of the care and treatment rendered to my dependant or myself by the above mentioned physicians. A photostatic copy of this signature may be used as a substitute.

  Patient Name:

 My injuries are not a result of a car accident or work related accident. I have not reported any accidents to my insurance company or to my employer. At no time in the future will a no-fault or worker’s compensation case be opened pertaining to this injury or illness.

 

REGIONAL NEUROLOGICAL ASSOCIATES reserves the right to modify the privacy practices outlined in the notice
  I have received a copy of the Notice of Privacy Practices for Regional Neurological Associates, P.C.
      Signature of Patient Representative
(Required if the patient is a minor or an adult who is unable to sign this form)
 

 Reason for visit: (Describe symptoms and complaints)Reason for visit: (Describe symptoms and complaints)

 OTHER:

  Allergies to Medications  

 Tobacco Use  

Alcohol Use