Welcome to Atlanta Southeast Center for Epilepsy & Neurodevelopment, PC

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Lenard Small
8 years ago
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1 Welcome to Atlanta Southeast Center for Epilepsy & Neurodevelopment, PC We are looking forward to meeting you and your child! To help you prepare for your visit, please use the checklist below of items we will need at your appointment. You may fax the completed Pre- Registration and Review of Systems & History form to prior to your appointment. If you have any questions, please do not hesitate to call us or you may visit our website at Locations: 5505 Peachtree Dunwoody Road, Suite 500, Atlanta, GA Old Milton Parkway, Suite 360, Alpharetta, GA Completed Pre-Registration Information and Review of Systems and History forms Current Insurance cards Referral or Prior Authorization (if required by your insurance) MRI or CT films/results (if done within past year) EEG tracing/report (if not performed at our office or Children s Healthcare of Atlanta) Pertinent medical records from other specialists or primary care physicians Co-pay, coinsurance and deductibles are due at time of appointment. We accept Visa, Master Card, Discover, Personal Check and Cash The maximum parking garage rate is $5.00 (only at Peachtree-Dunwoody location) Your initial appointment will consist of a comprehensive evaluation of your child s neurological problems, as well as a complete history and physical examination. This visit will last approximately 45 minutes. Subsequent follow-up appointments will last minutes, depending on the complexity of the evaluation. Our office hours are Monday thru Thursday 8:30am 5:00pm and Friday 8:30am 1:00pm. If you have an emergency after hours, please call our main number at and our answering service will contact the on-call physician for you. Please arrive 20 minutes prior to the appointment time to anticipate paperwork and traffic. To save time at check-in, please have all paperwork already completed. It is very important that you call our office at least 48 hours in advance if you need to change or reschedule this appointment and as a courtesy to our other patients. Please see our No Show-Cancellation Policy.

You may fax the completed Pre- Registration and Review of Systems & History form to 404-847-9596 prior to your appointment.

2 We participate with the following insurance plans. If we do not participate with your insurance plan, you will be responsible for payment in full at the time of your visit. The following plans require a REFERRAL prior to your appointment. If a referral is not presented to our office at the time of service, you will be responsible for payment in full. It is your responsibility to obtain a referral from your primary care physician if your insurance requires it. Aetna HMO (Select Choice) Aetna POS (Managed Choice) Aetna US Healthcare HMO Blue Choice HMO/POS Cigna HMO Coventry HMO First Health (Coventry) HMO Healthsource HMO/POS Humana Choice care HMO/POS Kaiser HMO/POS Prucare HMO The following plans do not require a referral, but an in-network physician must refer the patient in order for the visit to be considered in-network by your insurance plan. Aetna PPO (Open Choice) Beech Street PPO (PHCS) BCBS Indemnity Blue Choice PPO Cigna PPO First Health PPO (Coventry) Golden Rule PPO (United HealthCare) Great West PPO (Cigna) Healthsource PPO (Cigna) Humana Choice care PPO National Preferred Provider Network PPO (NPPN) Oxford Health Plan PPO (United HealthCare) Private Healthcare Systems (PHCS) Provident Cigna Prucare of Atlanta (Aetna) South care State Merit High Option Three Rivers Provider Network (TRPN) United Healthcare of GA PPO Unicare PPO University System of GA High Option Wausau Benefits (PHCS) Please Note: Even though we are providers for the above listed insurance plans, your particular plan may consider our charges or your child s diagnosis as non-allowable. Our Office will make every effort to comply with your insurance company s rules. However due to the many different plans, each with its own regulations and with several insurance companies having several different plans within its groups each with different benefits, WE CANNOT ASSUME ANY FINANCIAL RESPONSIBILITY FOR ESTIMATION OF BENEFITS YOUR INSURANCE COMPANY MAY GIVE. If any services or diagnosis are considered being non-allowable, the guarantor is responsible for those charges.

It is your responsibility to obtain a referral from your primary care physician if your insurance requires it.

3 PATIENT INFORMATION: Atlanta Southeast Center for Epilepsy & Neurodevelopment, P.C. PRE-REGISTRATION INFORMATION PATIENT LAST FIRST MIDDLE STREET APT DATE OF BIRTH PATIENT S SOCIAL SECURITY NUMBER GENDER (CIRCLE ONE) M F HOME PHONE NUMBER WHO CAN WE SPEAK WITH REGARDING YOUR CHILD Medical Care/Information and Insurance/Financial Information? LAST FIRST Telephone # RELATIONSHIP TO CHILD FINANCIAL INFORMATION Please bring all insurance cards and referral forms to every visit. PRIMARY INSURANCE: EFFECTIVE DATE SECONDARY INSURANCE: EFFECTIVE DATE INSURANCE COMPANY INSURANCE COMPANY ADDRESS TO MAIL CLAIM ADDRESS TO MAIL CLAIM OF POLICY HOLDER AND SOCIAL SECURITY NUMBER OF POLICY HOLDER AND SOCIAL SECURITY NUMBER GROUP NO. POLICY NO. GROUP NO. POLICY NO. I. FINANCIAL AGREEMENT I hereby assume full responsibility for all charges incurred for professional services rendered by ASCEND Pediatric Neurology, PC providers, unless the services are deemed paid in full as a result of a contractual agreement between, ASCEND Pediatric Neurology, PC and my insurer. I understand that all charges not covered by my insurer, including copays, co-insurance, deductibles and any charges for which I have failed to secure a referral or prior authorization, are due at the time of service. If I am not prepared to pay my copay or deductible at the time of service, my appointment may be rescheduled if medically appropriate. I understand that my insurance is billed as a courtesy and I am responsible for payment of balance in full if not paid by the insurance within 30 days. I understand that the parent or guardian who accompanies the child to the visit is responsible for payment. I understand that if, ASCEND Pediatric Neurology P.C. does not participate with my insurance plan; I will be responsible for payment in full at the time services are rendered. II. GROUP & INDIVIDUAL INSURANCE, ASSIGNMENT OF BENEFITS I authorize my health insurance medical benefit to be paid directly to ASCEND Pediatric Neurology, PC. I understand I am financially responsible to ASCEND Pediatric Neurology, PC for charges not covered by this assignment. III. KAISER HEALTH INSURANCE I understand that Kaiser will not pay ASCEND Pediatric Neurology, PC for any charge that a valid referral has not been obtained. I understand that ASCEND Pediatric Neurology, PC will not file my claim and I will be financially responsible for the cost of each visit, at the time service, that I have failed to secure a valid referral for. Signature of Responsible Party: Printed Name: Date:

PRE-REGISTRATION INFORMATION PATIENT LAST FIRST MIDDLE STREET APT DATE OF BIRTH PATIENT S SOCIAL SECURITY NUMBER GENDER (CIRCLE ONE) M F HOME PHONE NUMBER WHO CAN WE SPEAK WITH REGARDING YOUR CHILD

4 PAGE 2 PARENT INFORMATION (if foster care parent, please complete guardian section): PARENT S MARITAL STATUS Single married partnered separated divorced widowed MOTHER S LAST FIRST MIDDLE FATHER S LAST FIRST MIDDLE MOTHER S DATE OF BIRTH MOTHER S SOCIAL SERCURITY # FATHER S DATE OF BIRTH FATHER S SOCIAL SERCURITY # MOTHER S ADDRESS (IF DIFFERENT FROM PATIENT S) FATHER S ADDRESS (IF DIFFERENT FROM PATIENT S) MOTHER S EMPLOYER FATHER S EMPLOYER MOTHER S PHONE (BUSINESS) FATHER S PHONE (BUSINESS) MOTHER S CELL PHONE FATHER S CELL PHONE OPTIONAL: MOTHER S (will not be used to provide test results, only as a way to contact you) OPTIONAL: FATHER S (will not be used to provide test results, only as a way to contact you) PATIENT S GUARDIAN: SOCIAL SERCURITY # RELATIONSHIP TO PATIENT ADDRESS (IF DIFFERENT FROM ABOVE) EMPLOYER IF FOSTER CARE, LIST DFCS COUTY AND SOCIAL WORKER PHONE NUMBER WORK: HOME: PEDIATRICIAN: LAST FIRST PHONE NUMBER STREET REFERRING DOCTOR (if different from Pediatrician): LAST FIRST PHONE NUMBER STREET

FROM PATIENT S) MOTHER S EMPLOYER FATHER S EMPLOYER MOTHER S PHONE (BUSINESS) FATHER S PHONE (BUSINESS) MOTHER S CELL PHONE FATHER S CELL PHONE OPTIONAL: MOTHER S EMAIL (will not be used to provide

5 Atlanta Southeast Center for Epilepsy & Neurodevelopment, P.C. INFORMATION SHEET FOR REVIEW OF SYSTEMS AND PAST HISTORY Child s name: DOB: MR# Review of Systems: Please indicate if your child has ever had any medical problems in the following areas, with approximate dates. This confidential information will be part of the patient s permanent record. Yes No Comments Recent fever or weight loss Eye problems (cataracts, blindness, etc) Ear, nose or throat problems Blood abnormalities (anemia, leukemia, etc) Heart or blood pressure problems Stomach or intestinal problems Kidney, bladder problems Thyroid problems, Diabetes Skin problems (rashes, acne, etc) Previous Neurological problems (seizures, headache, stroke) Behavioral problems (behavior, depression, learning problems attention span problems) Allergies Respitory problems (asthma, excessive daytime sleepiness, sleep issues, snoring) Musculoskeletal (joint or bone problems) Other not listed above

INFORMATION SHEET FOR REVIEW OF SYSTEMS AND PAST HISTORY Child s name: DOB: MR# Review of Systems: Please indicate if your child has ever had any medical problems in the following areas, with

6 General Development: Complications of pregnancy Complications of delivery Birth Weight Born on Time / weeks at what age did child...? Gross Motor: Roll over Sit unsupported Crawl Walk Pedal tricycle Jump Fine Motor: Pick up raisin with 2 finger grasp Use spoon Cut with scissors Mature pencil grasp Language: At age first words other than Mama, Dada 2 words together Sentences Learn colors Count 1-10 Social: Toilet Trained Past Medical History: Please describe any past medical problems your child may have had. Where possible, give dates of illnesses / surgeries : Major illnesses requiring hospitalization: Surgeries: 1 2 Other known medical problems not listed above: 1 2 Past Family Medical History: Please describe any medical problems that exist or have existed in close family members. List the problem and affected individual (s) if known Social History: Who currently resides in your child's home? Are there any factors related to custody? Pls explain: Please list your child's school and current grade: If your child attends day-care, pls list number of days/week Is there any known history of alcohol, tobacco or drug abuse? Yes Is there any litigation pending on your child's medical condition? Yes No No Signature of responsible party: Date:

other than Mama, Dada 2 words together Sentences Learn colors Count 1-10 Social: Toilet Trained Past Medical History: Please describe any past medical problems your child may have had.

Horizon Eye Care, P.A. Patient Information Sheet. For your convenience, please print and complete the pre-registration forms before your visit.

Horizon Eye Care, P.A. Patient Information Sheet. For your convenience, please print and complete the pre-registration forms before your visit. Patient Information Sheet For your convenience, please print and complete the pre-registration forms before your visit. Section 1: Patient's Legal Name: (First, MI, Last) Parent / Guardian: (If applicable)