NEUROLOGY SPECIALISTS of Monmouth County, NJ 107 Monmouth Rd #110 West Long Branch, NJ

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1 107 Monmouth Rd #110 West Long Branch, NJ We are grateful that you have chosen our practice for your medical needs. We look forward to seeing you at your initial appointment. It is extremely important to us that you bring all items necessary so that we may provide a comprehensive medical examination and correctly handle the financial aspects of your account. Please bring with you: Medical Information Results of any recent blood work MRI and/or CAT Scan reports MRI and/or CAT Scan films Any other recent test results and reports Completed Health History Form (included in this packet) List of all current medications Financial Information Insurance card(s) Referral Form from your primary care physician and made out to Neurology Specialists (or the doctor you are scheduled with) Completed and Signed Registration Form (included in this packet) Signed Financial Policy (included in this packet) Completed and Signed Consent for Use and Disclosure of Private Health Information (included in this packet) Completed and Signed Records Release Authorization (included in this packet) Directions to our office: From Garden State Parkway rth or South: Exit 105 onto Route 36 East. Follow Route 36 East through 5 traffic lights. At the 6 th light, you will make a left onto Route 71 rth (Monmouth Road.) We are located in the Atlantic Executive Center which is approximately ¼ mile on the left. Our office is in the front building. From Route 18 rth and South: Exit 13B onto Route 36 East. Follow Route 36 East through 5 traffic lights. At the 6 th light, you will make a left onto Route 71 rth (Monmouth Road.) We are located in the Atlantic Executive Center which is approximately ¼ mile on the left. Our office is in the front building.

2 NEUROLOGY SPECIALISTS PATIENT REGISTRATION FORM Patient Information Last Name First Name MI Soc. Sec. # Date of Birth Gender Street Address Apt. # Home Work Marital Status Single Married Divorced Widowed Other Emergency Contact Referring Doctor Family Doctor If Patient is a Minor, Parent or Guardian Last Name First Name MI Relationship Street Address Apt. # Insurance Policy Holder Information Subscriber: Last Name First Name MI Date of birth Employer Name Name of Insurance Type of Insurance: HMO PPO Other Policy # Effective dates of insurance coverage Group # Mail Claims to (Address on ins. Card): Patient s Relationship to the Policy Patient Step Child Grand Parent Parent Spouse Holder Foster Child Grand Child Natural Child Ward of Court (Check one) Niece / Nephew Secondary Insurance Information Subscriber: Last Name First Name MI Date of birth Employer Name Name of Insurance Type of Insurance: HMO PPO Other Policy # Effective dates of insurance coverage Group # Mail Claims to (Address on ins. Card): Patient s Relationship to the Policy Patient Step Child Grand Parent Parent Spouse Holder Foster Child Grand Child Natural Child Ward of Court (Check one) Niece / Nephew I HEREBY AUTHORIZE THIS OFFICE TO RELEASE ANY INFORMATION NECESSARY TO EXPEDITE INSURANCE CLAIMS. I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES, REGARDLESS OF INSURANCE COVERAGE, AND THAT FAILURE TO PAY BILLS OR RETURNED CHECKS MAY INCUR ADDITIONAL FEES AND/OR COLLECTION FEE. I AUTHORIZE NEUROLOGY SPECIALISTS TO FURNISH INFORMATION TO REFERRING OR CONSULTING DOCTORS CONCERNING MY ILLNESS AND/OR TREATMENT. PATIENT S SIGNATURE (IF MINOR, PARENT OR GUARDIAN) DATE

3 FINANCIAL POLICY We are pleased that you have chosen Neurology Specialists for your healthcare needs. It is our goal to provide you with the highest quality healthcare services possible. In choosing our services, you have accepted the financial responsibility to ensure full payment for our services. OUR POLICY REGARDING: Copayment: Your copayment, as stated on your insurance card, will be collected from you prior to your visit. You may make your payment either by cash, check or credit card. We gladly accept Visa, MasterCard and Discover cards for payment. Private Pay: Patient agrees to pay Neurology Specialists at the time of treatment for services rendered. We will provide a statement which can be used to submit claims for reimbursement or kept for personal records. Medicare: Neurology Specialists is a participating provider with Medicare Part B program. We will bill Medicare directly for services rendered. You will be responsible for any deductibles and coinsurance. HMO/PPO/POS: Our office participates in most HMO, PPO, and POS plans. You are responsible at the time of service for any copayment stated on your insurance identification card. Any additional amounts due by you will be billed to you once your insurance processes the bill. Major Medical: Your major medical insurance coverage is a contract between you and your insurer. As a courtesy to you Neurology Specialists will bill your insurance carriers directly. You are responsible for any deductible and co-payment or coinsurance that is determined by your insurance carrier. Out of Network Carrier: Our practice does not participate with your plan. It is the policy of your carrier that you pay us at the time of your visit and receive reimbursement from them. We will provide you with a statement which you can submit to your carrier directly. Workers Compensation: Neurology Specialists will bill your insurance carrier for you. Should your claim be found to be noncompensable, we will bill your private health insurance carrier, and you will be responsible for any applicable co-payment or coinsurance. Motor Vehicle Accident: Neurology Specialists will bill your motor vehicle and health insurance(s) directly. Should your motor vehicle insurance deny your claim, we will send your bill to your private health insurance carrier,. You will be responsible to pay for patient responsibility as stated by your health insurance. It is not our policy to await the results of your litigation to receive payment; we will not hold a Letter of Protection or Lien on your account. We do not waive any financial responsibility in litigation cases. Referrals/Authorizations: You are responsible for obtaining a referral or authorization as required by your insurance for our services. You may be financially responsible for any charges denied due to absence of a referral or authorization. Your scheduled visit may also be rescheduled due to the absence of a referral or authorization. Cancellation Policy: If you fail to call and cancel your appointment, you will be billed a cancellation fee of $25.00 which your insurance company will not pay. Returned Checks: If your personal check is returned to us by your bank for any reason, you will be charged a fee of $ Both your original payment and check fee are payable in cash or credit card. Any future payments you need to make to our office must be either cash or credit card. I have read the above policy regarding my financial responsibility to Neurology Specialists for providing medical care to me or the below named patient I understand that my failure to comply with the financial policies of Neurology Specialists may cause interruptions in my medical care. I understand that it is my responsibility to inform this office of any correspondence that I receive from my insurance company notifying me of a change or cessation of my insurance coverage. Patient name (print): Responsible Party Signature: Date

4 Records Release Authorization I hereby authorize Name of Provider/Facility Address To release complete medical records in their possession with reference to my illness and/or treatment during the period: From To Send my medical records Personal and Confidential to: Neurology Specialists of Monmouth County, NJ 107 Monmouth Road West Long Branch, NJ Office Fax Patient Name Address Signature of Patient or Patient Representative

5 Consent to use and Disclosure of Private Health Information (PHI) Use and Disclosure of your PHI Your PHI will be used by Neurology Specialists, or disclosed to others, for the purpose of treatment, obtaining payment, or supporting the day-to-day health care operations of the practice. tice of Privacy Practices You should review our tice of Privacy Practices for more complete description of how your health information may be used or disclosed. A copy of this notice will be provided to you upon your request. Requesting a Restriction on the Use or Disclosure of Your Information You may request a restriction on the use or disclosure of your protected health information. Neurology Specialists may or may not agree to restrict the use or disclosure of your PHI. If Neurology Specialists agrees to your request, the restriction will be binding on the practice as a whole. Unauthorized use and disclosure of protected information is a violation of an agreed upon restriction, and will be a violation of federal privacy standards. Designation of Certain Relatives, Close Friends and other Caregivers as my Personal Representative: I agree that the practice may disclose certain of my health information to a Personal Representative of my choosing, since such person is involved with my care or payment relating to my healthcare. In that case, Neurology Specialists will disclose only info that is directly relevant to the person s involvement with my healthcare or payment relating to my healthcare. Print name: Print name: It is OK to contact me at: Home Work Cell NO Revocation of Consent You may revoke this consent to the use and disclosure of your PHI at any time. You must revoke this consent in writing. Any use or disclosure that has already occurred prior to the date on which your revocation of consent is received will not be affected. Reservation of Right to Change Privacy Practices Neurology Specialists reserves the right to modify the privacy practices outlined in the notice. Signature I have reviewed this consent form and hereby give my permission to Neurology Specialists to use and disclose my PHI in accordance with these guidelines. Patient Name (print): Signature and Date of Patient/Patient Representative

6 Name: CONSTITUTIONAL SYMPTOMS Good general health lately..." Recent weight change... Fever... ~... Fatigue... Headaches... EYES Eye Pain... Wear glasses/contact lens... BlUITed vision... Double vision... EARS-NOSE-MOUTH-THROAT Hearing loss or ringing..._.. Earaches or drainage... se bleeds... Mouth sores... Bleeding gums..._... Bad breath or bad taste..._... _... Sore throat or voice changes... Swollen glands in necl... CARDIOVASCULAR Chest pain or angina pectoris... Palpitation... ~... _... Shortness of breath with walking or lying flat... Swelling of feet, ankles or hands... RESPIRATORY Chronic or frequent coughs..."... Spitting up blood... Shortness of breath... Wheezing... u... GASTROINTESTINAL Loss of appetite..._... Change in bowel movements... Nausea or vomiting... Frequent diarrhea... Painful bowel movements or constipation... Rectal bleeding or blood in stool... Abdominal pain or heartburn... GENITOURINARY Frequent urination... Burning or painful urination Blood in urine... Change in force of stream when urinating.... Incontinence or dribbling Sexual difficulty... Male - testicle pain or lump... Female - pain with periods... Female.. irregular periods Female.. vaginal discharge... Female.. 41 pregnancies # miscarriages I Date ' ' MUSCULOSKELETAL Jointpaln.... Joint stiffness or swelling.... Muscle pain or cramps.... Back pain.... Cold extremities.... Difficulty in walking..... INTEGUMENTARY (skin, breast) Rash or itching.... Change in skin color..... Change in hair or nails.... Breast pain.... Breast lump.... Breast discharge.... NEUROLOGICAL Frequent or recurring headaches.... Light headed or dizzy.... Convulsions or seizures.... Numbness or tingling sensations..... Trernors..... Paralysis.... PSYCHIATRIC Memory loss or confusion... _.... Nervousness.... Depression.... Insomnia... _..... ENDOCRINE Glandular or honnone problem..... Excessive thirst or urination..... Heat or cold intolerance Skin becoming dryer.... Change in hat or glove size.... HEMATOLOGICAL LYMPHATIC Slow to heal after cuts.... Bleeding or bruising tendency.... Past transfusion.... Enlarged glands... MM.... ALLERGIC - IMMUNOLOGIC History ofskin re«rion or other adverse reaction ro: Penicillin other antibiotics... Morphine, Demerol or other narcotics... vacaln or other anesthetics... Aspirin or other pain remedies... Tetanus antitoxin or other serums... Iodine, methiolate or other antiseptic Other drugs f medications Known food allergies:

7 HEALTH HISTORY PAST MEDICAL HISTORY: Check (") conditions you have or have had in the past; Q " Aids Q Eye Disease or Injury Q Pacemaker 0 Alcoholism 0 Glaucoma 0 Phlebitis 0 Anemia 0 Goiter Q Polio 0 Arthritis CJ Gout 0 Prostate Disease 0 Asthma 0 Head Injury 0 Psychiatric Disease 0 Bleeding Disorders 0 Heart Disease 0 Rheumatic Fever Q Bronchitis 0 Hepatitis Q Sinus Disease 0 Cancer 0 High Blood Pressure I Hypertension 0 Stroke 0 Cataracts Q High Cholesterol 0 Suicide Attempt 0 Chemical Dependency 0 HIV Positive 0 Thyroid Disease 0 Diabetes 0 Kidney Disease I Stones 0 Tobacco Use 0 Drug Use 0 Liver Disease 0 Tuberculosis 0 Emphysema 0 Migraine Headaches 0 Ulcer Disease 0 Epilepsy Q Multiple Sclerosis 0 Venereal Disease Other Serious Illnesses or Injuries: MEDICATIONS - List medications you are currently taking: Pharmacy Name: : SOCIAL IDSTQRY: :# of children Marital Status: Occupation: Family History: " DISEASE RELATIONSHIP TO YOU a CANCER a DIABETES a EPILEPSY a HEART D'SE.A,SE a HIGH BLOOD PRESSURE a HIGH CHOLESTEROL.-.. a MIGRAINE a STROKES a OTHER