Patient Paperwork New Patient Registration Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Patient InformatonPatient Name *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSocial Security NumberCell Phone *Home PhoneDate of Birth *AgeGenderEmailPrimary Care PhysicianWould you like to receive email communication from our office? YesNoEthnicityPrimary Language SpokenHow did you hear about our practice?Emergency Contact OR Primary Contact Information (other than patient):Emergency Contact Name *Relationship *Phone Number 1: *Phone Number 2:Emergency Contact AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePerson responsible for Payment: (complete only if different that patient)Name *Relationship *Phone Number 1: *Phone Number 2:AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeInsurance InformationPrimary Insurance *Secondary InsurancePolicy Holder Date of Birth *Primary Policy Number (ID) *Secondary Policy Number (ID)Effective Date * of like Email Is your visit related to a recent hospital stay or physician referral?YesNoSignature * Clear Signature I authorize the release of any medical information necessary to process this bill to my insurance company. I acknowledge that I am financially responsible for payment, whether or not covered by insurance. Co-payments are expected at time of visit. Signed Date *Medical InformationMedical History (for example: previous diagnosis, high blood pressure, diabetes, COPD, etc.) 1)2)3)4)5)6)7)8)9)10) Current Medications: Including supplements and over the counter medications 1)Dose2)Dose3)Dose4)Dose5)Dose6)Dose7)Dose8)Dose9)Dose10)Dose Drug Allergies 1)RXN2)RXN3)RXN4)RXN5)RXN6)RXN Past surgeries: 1)Date2)Date3)Date4)Date5)Date6)DateReason for visit/referral: Have you ever had any of these symptoms in the past? Check those that applyHeadacheDizzinessLoss of ConsciousnessConfusionConcentration issuesMemory lossSpeech difficultyPersonality changeHallucinationsSeizuresStiffnessClumsinessNauseaVomitingBalance difficultyPoor coordinationRinging in earsVertigo (room spinning)Hearing lossTrouble swallowingDroolingLoss of smell or tasteHoarseness of voiceWeaknessLoss of bowel or bladder controlPainVision changeFamily History check those that apply (per each family member) FatherHeart DiseaseHypertensionDiabetesCancerBleeding DisorderStrokeMigrainesMovement DisorderMuscle or nerve disorderDementiaSeizuresMental IllnessOtherMotherHeart DiseaseHypertensionDiabetesCancerBleeding DisorderStrokeMigrainesMovement DisorderMuscle or nerve disorderDementiaSeizuresMental IllnessOtherFather's ParentsHeart DiseaseHypertensionDiabetesCancerBleeding DisorderStrokeMigrainesMovement DisorderMuscle or nerve disorderDementiaSeizuresMental IllnessOtherMother's ParentsHeart DiseaseHypertensionDiabetesCancerBleeding DisorderStrokeMigrainesMovement DisorderMuscle or nerve disorderDementiaSeizuresMental IllnessOtherChildrenHeart DiseaseHypertensionDiabetesCancerBleeding DisorderStrokeMigrainesMovement DisorderMuscle or nerve disorderDementiaSeizuresMental IllnessOtherSiblingsHeart DiseaseHypertensionDiabetesCancerBleeding DisorderStrokeMigrainesMovement DisorderMuscle or nerve disorderDementiaSeizuresMental IllnessOtherSocial History Place of Birth:Years resided here:Marital Status:Please Choose StatusSingleMarriedSeperatedWidowedChildren?YesNoHow many?Ages?Occupation:Years of Education:Handedness:Please chooseLeft handedRight handedAmbidextrousTobacco use:Please chooseNever SmokerFormer SmokerCurrent SmokerIf you quit smoker how long have you been a non-smoker?If current smoker how many packs per day?How many years have you been smoking?Amount:Please chooseNone1-3 drinks4-6 drinks6+ drinksFrequency:Please chooseDayWeekMonthYearPast History:Caffeine intake:Do you have a living will?YesNoNext of kin or heath care surrogate:No Show Policy We are honored that you have chosen to obtain your care with Penn-Tampa Neurology, however, if you miss a scheduled visit, that compromises your care. In addition, it compromises the care of patients who might have wanted to be seen during that time slot. Please provide us with 24-hour notice for cancellations. 1st event: we will call to reschedule you. You will be charged a $35 fee 2nd event: we will call to reschedule you. You will be charged a $35 fee 3rd event: you may be discharged from the practice. You will be charged a $35 fee Regarding diagnostic testing: when we schedule patients for diagnostic testing, we schedule the physician, reserve equipment, and often schedule a technologist. This is similar to what is involved with scheduling surgery. A no-show for diagnostic testing will be charged $50, and unless there are extenuating circumstances, testing may not be rescheduled. Our main concern is to provide you and the other patients in our practice with the best neurology care possible. I understand the missed appointments policyPrint NameFinancial Policy Copays are due at the time of service. Our billing management team is Healthcare Support Technologies, Inc. They bill insurances first; balance billing for whatever insurance does not cover is invoiced to the patient twice on a monthly cycle over 60 days. The phone number, contact, and address for the billing company will be clearly see on invoices. Please communicate financial questions with them. Please address outstanding bills on a timely basis, as we are much more interested in focusing on your healthcare needs than we are on following financial issues, which are viewed more as a necessary evil. If the billing management team has no response from two billing cycles, the account is forwarded to a collections agency which is separate from our practice. That agency charges us a fee of 30% of the balance for accounts with a balance less than $1000, and a fee of 40% fee of the balance for accounts with a balance over $1000. That fee to us will be added to the balance when it is turned over to collections and will be the responsibility of the patient. Patients who habitually allow their accounts to remain unpaid will be discharged from the practice. Authorization for Release of Medical Information I authorize Dr. Pearson to release my information in my record to any medical practitioner, physician, hospital, medical institution or facility to which I may be referred to assist in my care. I authorize Dr. Pearson to obtain any information any medical practitioner, physician, hospital, medical institution or facility to which I may be referred to assist in my care. PPO / HMO Patients Financial Responsibility I understand that I am insured through an HMO /PPO Ian. I understand that it is my responsibility to obtain the proper and necessary referrals from my primary care physician before seeing Dr. Pearson. Name *FirstLastPatient Signature * Clear Signature Date *Submit New Patient Registration
