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PATIENT INFORMATION
Preferred Name
City, State, Zip
Cell Phone Number
Preferred Language
PRIMARY CARE INFORMATION
PHARMARY INFORMATION
EMERGENCY INFORMATION
Hospital visits, stays and surgery (Please list and and all emergency room, Urgent care, Hospital admissions and surgeries, Including C Sections)
Hospital visits, stays and surgery (Please list and and all emergency room, Urgent care, Hospital admissions and surgeries, Including C Sections)
Hospital visits, stays and surgery (Please list and and all emergency room, Urgent care, Hospital admissions and surgeries, Including C Sections)
COVID
Were you hospitalized?
Have you received the COVID vaccine?
MEDICATIONS (Please list ALL medications that you are CURRENTLY taking. Please include any over the counter medication, vitamins, birth control pills, and herbal supplements.)
MEDICATIONS (Please list ALL medications that you are CURRENTLY taking. Please include any over the counter medication, vitamins, birth control pills, and herbal supplements.)
MEDICATIONS (Please list ALL medications that you are CURRENTLY taking. Please include any over the counter medication, vitamins, birth control pills, and herbal supplements.)
MEDICATIONS (Please list ALL medications that you are CURRENTLY taking. Please include any over the counter medication, vitamins, birth control pills, and herbal supplements.)
MEDICATIONS (Please list ALL medications that you are CURRENTLY taking. Please include any over the counter medication, vitamins, birth control pills, and herbal supplements.)
MEDICATIONS (Please list ALL medications that you are CURRENTLY taking. Please include any over the counter medication, vitamins, birth control pills, and herbal supplements.)
MEDICATIONS (Please list ALL medications that you are CURRENTLY taking. Please include any over the counter medication, vitamins, birth control pills, and herbal supplements.)
MEDICATIONS (Please list ALL medications that you are CURRENTLY taking. Please include any over the counter medication, vitamins, birth control pills, and herbal supplements.)
PAST MEDICAL HISTORY (Have you ever been diagnosed with any of the following?)
ALLERGIES
WOMEN ONLY

Our notice of privacy practices provides information about how we may use or disclose protected health information. This notice contains a patient's rights section, describing your rights under the law. You ascertain with your signature that you have reviewed our notice.

The terms of the notice may change, if this happens, you will be notified at your next visit, and asked to sign and date the updated policy.

You have the right to restrict how your Protected Health Information (PHI) is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your PHI and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, at any time. However, such a revocation will not be retroactive.

By signing this form, I understand that:

  • PHI may be disclosed or used for treatment, payment or healthcare operations
  • This practice reserves the right to change the privacy policy as allowed by law
  • This practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions
  • You, the patient have the right to revoke this consent in writing at any time and any and all disclosures will cease
  • This practice may condition receipt of treatment upon execution of this consent
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May we discuss your medical condition with a member of your family? Please circle one
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This consent was signed by:
This consent was signed by:

Our providers may order multiple tests for each patient to ensure the most accurate diagnosis. If you are asked to take a machine home with you, such as the 48 hour EEG machine or the Sleep Study machine, you must bring the machine back to our office on the day requested. There will be a $100 a day fine for every day that you do not bring the machine back.

The machine MUST be in the same, working order as when we gave it to you. If there are any missing or broken pieces, you, the patient will be held financially responsible. The MINIMUM financial penalty charge will be $500, due at the time of drop off. Please treat our equipment with respect.

Thank you,
All Island Neurology Management

Patient Signature and Date

Please read and initial next to each section:

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NO SHOW POLICY

We understand that situations arise in which you must cancel your appointment. It is therefore requested that, if you must cancel your appointment, you provide a 36 hour notice. Patients that do not show up, or cancel without proper notice will be considered a NO SHOW. Patients who no-show will be subjected to a fee of:

Follow up appointment-$40

Testing Appointment- $50

If you have 2 or more no show appointments in a 12-month period, may be dismissed from the practice. You will be asked to pay this fee BEFORE we can schedule you for a new appointment.

By signing this agreement, you agree that you have read and understood All Island Neurology's No Show Policy. You also understand that such terms may be amended by the practice at any time.

Print Name of Patient
Print Name of Patient

All Island Neurology believes that part of good health care practice is to establish and communicate an office financial policy to our patients. We are dedicated to providing the best possible care for you, and we want you to have a full understanding of our financial policies.

  • INSURANCE: Please contact your insurance plan to be sure All Island Neurology is In-Network with your plan. It is also your responsibility to be aware of any deductibles, spend downs, coinsurance or copayments you are required to pay. Please remember that insurance is a contract between the patient and the insurance company and ultimately the patient is responsible for payment in full. As a courtesy to our patients, we will verify your insurance coverage, however, our verification is not a guarantee of benefits payable by your insurance. If you have a managed care plan that requires a referral, it is your responsibility to obtain a referral in order for your office visit to be covered under medical insurance. If you do not have a valid referral and still wish to be seen, you will be asked to pay for the visit prior to being seen by our providers.

  • Payment: Is expected at the time of your visit. We accept cash and credit cards. Payment will include any unmet deductible, co-insurance, co-payment amount or any other charges not covered by your insurance.

    • By signing this agreement, you agree that you have read and understood All Island Neurology's financial agreement and you are bound by its terms. You also understand that such terms may be amended by the practice at any time.

Signature of Patient

Insurance will be verified before each visit for referral, deductible and to be it has not termed

Name
Signature of Patient
Signature of Patient
Signature of Patient
Signature of Patient
Signature of Patient