New Patient Registration

New Patient Registration

"*" indicates required fields

Patient Demographics

MM slash DD slash YYYY
MM slash DD slash YYYY
Sex*
Please Call (select at least one):*
Address*
I also consent to Four Peaks Neurology communicating with me via*
I also consent to Four Peaks Neurology communicating with me via *
If you are unable to reach me
If you are unable to reach me
Do you approve of records being sent to your primary care physician?*
Do you approve of records being sent to your primary care physician? *
Do you approve of records being sent to your referring physician?*
Do you approve of records being sent to your referring physician? *
If you provided an E-Mail address belonging to someone other than yourself, do you consent to the usage of that third party email for the creation of your patient portal, with the understanding that said person will have access to the information within your patient portal?*
If you provided an E-Mail address belonging to someone other than yourself, do you consent to the usage of that third party email for the creation of your patient portal, with the understanding that said person will have access to the information within your patient portal? *

Emergency Contact

Emergency Contact Information
Please indicate what information may be shared with this individual:
Please indicate what information may be shared with this individual:

Insurance Information

Primary Insurance:
Are you a Self-Pay Patient?
Claims Address
Are you the policy holder?
If you, the patient, are NOT the policy holder, please provide the following information regarding the policy holder:
MM slash DD slash YYYY
Relationship to Policy Holder
Employer of Policy Holder (if different from above)
Employer of Policy Holder's Address (If different from above)
Employer of Policy Holder's Address (If different from above)
Employer of Policy Holder's Phone Number
Employer of Policy Holder's Email
Secondary Insurance:
Claim's Address
Are you the policy holder?
If you, the patient, are NOT the policy holder, please provide the following information regarding the policy holder:
MM slash DD slash YYYY
Employer of Policy Holder (if different from above)
Mailing Address
If a balance accrues on your account, whether you are self-pay or insured, who is responsible for the balance?
If a balance accrues on your account, whether you are self-pay or insured, who is responsible for the balance?
If you did not indicate that you are personally responsible, please provide the responsible party’s information:
Responsible Parties Address
clickWrapAgreement1*
The above information is true to the best of my knowledge. I understand that I am responsible for all charges regardless of insurance coverage. I agree to pay my balance with this office in accordance with the regular rates and payment terms of this office, as set forth in the Patient Financial Policy. If I hold health insurance or other benefits relating to my medical condition, and they are available to cover the cost of treatment provided by this office, I hereby assign those benefits to this office to be applied to my bill. I also authorize Four Peaks Neurology or insurance company to release any information required to process my claims. *

Medical Allergies

Name of Medication | Severity of Reaction (Mild, Moderate, or Severe) | Reaction/Nature of Allergy | If you have any additional allergies (foods, dyes, plants, animals, etc.) please list them below your medication allergies.
Any other allergies (foods, dyes, plants, animals, etc.)?

Medication List

Please list any medications you currently take. Please include vitamins, supplements, and over-the-counter remedies.

Reason for Visit

Please list the reason for your visit and describe your symptom(s)
Handed
1. When did your symptoms start?
2. Where are the symptoms located?
3. How severe are the symptoms on a scale of 1 to 10
4. Are they worse during any time of the day? If so, when?
5. What makes those symptoms worse?
6. What makes them better?
7. What makes them better?
7. What makes them better?

Family History

Mother
Father
Sister
Brother
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather

Social History

Student
What is the highest grade or level of school that you have completed, or the highest degree that you have received?

Activities of Daily Living

1. Are you blind or do you have difficulty seeing
1. Are you blind or do you have difficulty seeing
2. Are you deaf or do you have difficulty hearing?
2. Are you deaf or do you have difficulty hearing?
3. Do you have difficulty concentrating, remembering, or making decisions?
3. Do you have difficulty concentrating, remembering, or making decisions?
4. Do you have difficulty walking or climbing stairs?
4. Do you have difficulty walking or climbing stairs?
5. Do you have difficulty dressing or bathing?
5. Do you have difficulty dressing or bathing?
6. Do you have difficulty doing errands alone?
6. Do you have difficulty doing errands alone?

Substance Use

7. Do you use or have you ever used nicotine products?
7. Do you use or have you ever used nicotine products?
If yes, what types?
If yes, what types?
At what age did you start smoking tobacco?
How many years have you smoked tobacco?
What was the date of your most recent tobacco screening?
MM slash DD slash YYYY
8. Have you ever tried to quit tobacco?
8. Have you ever tried to quit tobacco?
If yes, what date did you quit?
MM slash DD slash YYYY
9. Do you drink alcohol?
9. Do you drink alcohol?
If yes, what is your level of consumption?
10. Do you currently use recreational or street drugs?
10. Do you currently use recreational or street drugs?
If yes, what type?
How often?
11. Do you drink caffeine?
11. Do you drink caffeine?
If yes, what is your level of consumption?

Public Health and Travel

12. Have you been to an area known to be high risk for COVID-19 in the past 14 days?
12. Have you been to an area known to be high risk for COVID-19 in the past 14 days?
13. Over the past 14 days, have you had close contact with a person who is under investigation for COVID-19 while that person was ill?
13. Over the past 14 days, have you had close contact with a person who is under investigation for COVID-19 while that person was ill?

Diet & Exercise

14. What is your exercise level?
14. What is your exercise level?
15. How many days of moderate to strenuous exercise, like a brisk walk, have you done in the last 7 days?

Marriage and Sexuality

16. What is your relationship status?
16. What is your relationship status?

Lifestyle

17. Do you feel stressed (tense, restless, nervous, anxious, or unable to sleep at night)
17. Do you feel stressed (tense, restless, nervous, anxious, or unable to sleep at night)

Neurology

18. Do you use a Vaporizer or an E-Cig?
18. Do you use a Vaporizer or an E-Cig?
19. Do you use Medical Marijuana?
19. Do you use Medical Marijuana?
20. Have you had a previous Neurologist?
20. Have you had a previous Neurologist?
If yes, please provide the name of the doctor or practice:

Falls & Mobility Notes

21. Have you had any falls within the last 3 months?
21. Have you had any falls within the last 3 months?
22. Do you use an assistive device?
22. Do you use an assistive device?
If yes, please select all that apply:
If yes, please select all that apply:
23. Do you live alone?
23. Do you live alone?
If not, who do you live with?
24. Do you live in a(n):
24. Do you live in a(n):
If yes, what is the facility name?

Surgical History/Hospitalization

Please indicate if you have had any of the following surgeries or if you have been hospitalized for any of these conditions:
Please indicate if you have had any of the following surgeries or if you have been hospitalized for any of these conditions:
Other Surgeries, Hospitalizations?
Past Medical History
Past Medical History
Do you have or do you use any of the following?
Do you have or do you use any of the following?
If you have a pacemaker, what is the model?
Manufacturer?
*** Please provide your pacemaker card at check in.
Do you wear eyeglasses or contact lenses?
Do you wear eyeglasses or contact lenses?
Do you wear skin patches?
Do you wear skin patches?
Do you have tattoos?
Do you have tattoos?
Are you claustrophobic?
Are you claustrophobic?

General Adult Review (Select any symptoms you have had in the last month)

Constitutional
ENMT
Eyes
Cardiovascular
Respiratory
GI
Genitourinary
Musculoskeletal
Skin
Neurologic
Psychiatric
Endocrine
Heme/Lymph
Allergic/ Immunologic
Have you had any of the following tests ? Please Select all that apply and please provide dates performed.
Have you had any of the following tests ? Please Select all that apply and please provide dates performed.
If you had an MRI/MRA, which parts were tested?
Test dates?
Which Facility were you tested at?
Which Facility were you tested at?
Test dates?

Authorizations for Disclosure, Communication and Release of Medical Information

Do we have your permission to discuss your case with certain specified relatives and/or friends of your choosing?*
Do we have your permission to discuss your case with certain specified relatives and/or friends of your choosing? *
Spouse?*
Spouse? *
Spouse Name
Please list any other persons that you authorize your health care information to be released to in coordinating your care or payment for care. Select what information may be shared.
Information is not to be released to anyone
Information is not to be released to anyone
Please indicate what information may be shared with this individual
Please indicate what information may be shared with this individual
Please indicate what information may be shared with this individual
Please indicate what information may be shared with this individual
Please indicate what information may be shared with this individual
Please indicate what information may be shared with this individual
Would you like to enroll in our Portal?*
Would you like to enroll in our Portal? *
If yes, please provide your email address for Portal Access
Is there anyone else that you would like to communicate via the Portal on your behalf?
Is there anyone else that you would like to communicate via the Portal on your behalf?
If yes, please provide their email address for Portal Access
Do you have a power of attorney or a medical power of attorney (POA/MPOA) ?*
Do you have a power of attorney or a medical power of attorney (POA/MPOA) ? *
(You are required to provide a copy at the time of your appointment for it to be enforceable)
(You are required to provide a copy at the time of your appointment for it to be enforceable)
Do you authorize Four Peaks Neurology to communicate with your pharmacy?*
Do you authorize Four Peaks Neurology to communicate with your pharmacy? *
cwAgreement2*
I authorize the listed individuals to receive information about and/or discuss my medical care, to the extent and persons indicated, with any and all providers and employees affiliated with Four Peaks Neurology. I hereby acknowledge that I have been presented with a copy of Four Peaks Neurology’s Notice of Privacy Practices. *

Patient Financial Policy

Thank you for choosing us for your neurological care. We are committed to giving you the best medical care possible and committed to your treatment being successful. In return, we expect that you demonstrate the same commitment to your medical care and your financial responsibility associated with this care. Please understand that payments for services rendered are what makes your treatment possible. It is important that we work together to ensure that payment for services rendered is as simple and straightforward as possible.

Please carefully read and initial (check) ALL of the following:
agreement1*
1. I understand that I am ultimately responsible for payment on my account. Payment of my co-pay is ALWAYS expected at the time of service. I understand that I AM RESPONSIBLE for any referral or authorization that my insurance may require. *
agreement2*
2. I understand that due to the large number of insurance plans and policies, it is MY responsibility to know services covered by MY plan. Furthermore, I understand that it is MY responsibility to verify that the provider I am scheduled to see is in network with MY particular insurance plan. I also understand that it is MY responsibility to notify Four Peaks Neurology and provide new insurance information to ensure proper claim submission. I understand that I will be responsible for any balances due that result from non-disclosure of insurance information. I understand that if my insurance is not active on the day of my appointment, I will be required to pay the entire bill. *
agreement3*
3. I understand that I am financially responsible for ANY copayments, deductibles, coinsurance, and all charges, which are not covered by my insurance. I understand that verification of coverage is not a guarantee of payment of benefits. It is MY responsibility to clearly know and identify my Primary and Secondary Insurance if they exist. I understand that any confusion with respect to multiple insurance plans that results in non-payment of covered services IMMEDIATELY becomes MY responsibility. I also understand that if my insurance does not issue payment within 30 days of the date that services are provided, the entire balance will become MY responsibility. *
agreement4*
4. I understand that Four Peaks Neurology will provide me with my itemized statement in order to bill my respective insurances. I understand that Four Peaks Neurology will bill my insurance once, and when needed, will appeal once. Service during gaps in insurance coverage are MY responsibility. *
agreement5*
5. I understand that certain services I receive may not be covered or may be deemed “unreasonable” or “unnecessary” by MY insurance carrier. If a situation arises such that MY insurance carrier refuses to pay for a service rendered by Four Peaks Neurology on this basis, I understand that I will be PERSONALLY and FULLY responsible for payment for that service. *
agreement6*
6. I understand that any balance more than 15 days old will be considered past due. At that point, it will become due BEFORE my next appointment. I recognize that failing to pay on a past due balance before my next scheduled appointment will result in the cancellation and rescheduling of my appointment, and that my balance must be zero before my next appointment. I understand that a $25 monthly statement fee will apply to ANY balance not paid with 30 days of the initial statement. I understand that if Four Peaks Neurology is forced to refer my account to a collection agency or an attorney, a $50 collection agency fee will be added to my account. *
agreement7*
7. I understand that if I so choose, I may contact Four Peaks Neurology to set up a payment plan. I understand that a credit card must be on file for patient payment plans. *
agreement8*
8. I understand that HMO/PPO claim denials due to cancelation of policy, lack of referral, lack of authorization, or reversals of authorizations are MY responsibility regardless of whether they were previously obtained. I understand that Four Peaks Neurology Office staff will try to obtain referral, pre-certification, and eligibility, however I understand that the final responsibility lies with me to comply with their specific insurance requirements. Referrals must be presented to Four Peaks Neurology office before seeing the doctor. *
agreement9*
9. I understand that if Four Peaks Neurology is not contracted with my insurance, I am FULLY RESPONSIBLE for PAYMENT at the TIME OF SERVICE. I understand that Four Peaks Neurology will provide me with an itemized statement for me to file a claim with my insurance. *
agreement10*
10. I understand that if I need to cancel my appointment or if I do not intend to attend my appointment, I am required to provide at least 24-hours’ notice in order to avoid the late fee. I understand that if I miss an appointment or cancel at the last minute, a fee of $50 will be applied to my account for not showing up, or not providing Four Peaks Neurology advanced notice of my impending absence. I understand that missed appointments will NOT be rescheduled until the fee is paid. *
agreement11*
11. I understand that completion of forms such as applications, FMLA, disability, and forms requiring physician review and signature will be billed to the patient or representative that requested the completion of the form. I understand that it will take approximately 5-7 business days or longer for the work to be finalized, depending on the weight of the physician’s schedule. I understand that an up-front payment in the amount of $50 per page is required before processing can commence. *
agreement12*
12. I understand that it takes approximately 5-7 business days for Four Peaks Neurology to process a medical record request. I understand that medical records will be released to the physician’s office upon written request and authorization as a courtesy. I understand that there is a fee for NON-TREATMENT MEDICAL RECORDS [medical records requested by my attorney, disability or other non-medical entities. I understand that this is a service, and not an element of neurologic care, and therefore payment of the $50 fee is required up front for these services before processing can commence. *
agreement13*
13. I understand that checks written at the time of my visit or mailed as a payment on an account balance, that are returned by the bank, will be subject to a $40 return check charge. If such a scenario arises, I understand that the original check amount, as well as the return check charge MUST be paid within 30 days by cash or credit card. *
agreement14*
14. I understand that refunds will be issued when my balance for ALL rendered services is $0. *
agreement15*
15. I understand that after hour and weekend contact with my covering physician to refill a prescription(s) will result in a $50 charge per prescription. *
cwAgreement3*
I have read and understand the Four Peaks Neurology Patient Financial Responsibility Policy and agree to abide by the terms of the policy. I understand that I am financially responsible for all charges whether or not they are covered insurance. In the event of default, I agree to pay all costs of collection, and reasonable attorney’s fees. I hereby authorize this healthcare provider to release all information necessary to secure the payment of benefits. *

Authorization for the Release of Medical Records

MM slash DD slash YYYY
Address*
authorize1*
I hereby authorize the release of medical information which may include, but is not limited to notes, lab results, diagnostic test results, etc. concerning the above-name patient. *
ToFrom1
ToFrom2
The type of Information to be disclosed is:
The type of Information to be disclosed is:
Dates of Service:
MM slash DD slash YYYY
MM slash DD slash YYYY
HIV/AIDS: I consent to the release of any positive or negative results for HIV/AIDS infections, antibodies to AIDS, or infection with any other causative agent of AIDS, with the rest of my medical records.
MM slash DD slash YYYY
cwAgreement3*
If the health information that I have requested Four Peaks Neurology to disclose contains any privileged psychiatric or psychological information related to the treatment of and/or mental illness, chemical dependency or alcohol abuse, or testing or treatment of any communicable or infectious disease such as acquired immunodeficiency syndrome (AIDS), human immunodeficiency (HIV), Venereal disease, Tuberculosis, or Hepatitis, I hereby waive any privilege concerning such information for the purpose(s) of releasing it to the party or parties authorized above. I also release Four Peaks Neurology and their provider and employees from any and all liabilities, damages, and claims, which might arise from the release of the health information authorized by me above. I have given consent freely without coercion. I understand that any releases, which were made prior to my revocation, in compliance with this authorization, shall not constitute a breach of my right to confidentiality. I understand that a photocopy, facsimile of this authorization is considered acceptable in lieu of the original.

This authorization shall be considered invalid after 60 days. I may revoke this authorization at any time by providing Four Peaks Neurology with written notice or revocation. However, I may not revoke the authorization retroactively for information already released. I hereby waive all provisions of law and privilege relation to the disclosure hereby authorized. *

Notice of Privacy Practices

cwAgreement5*
THIS NOTICE "CLICK BUTTON TO OPEN" DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY AND CLICK "AGREE" TO CONTINUE. *

Acknowledgement of Receipt of Notice of Privacy Practices

cwAgreement6*
Acknowledgement of Receipt of Notice of Privacy Practices, "Click button to open". *

Four Peaks Neurology Credit Card on File Agreement

Four Peaks Neurology has implemented a new credit card policy. We kindly request our patients or patients’ guardian/guarantor provide a credit card which may be used as a convenient method of payment for the portion of services that insurance does not cover, but for which the patient or guardian/guarantor is liable.

Your credit card information is kept confidential and secure, and payments to your card are processed ONLY after the claim has been filed and processed by your insurer, after all appeals have been exhausted and the insurance portion of the claim has paid and posted to the account.
Credit Card city/state/zip
Please fill out information below for any person(s) you authorize this credit card for:
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
agreement7*
I, the undersigned, authorize and request Four Peaks Neurology to charge my credit card, indicated above, for balances due for services rendered that my insurance company identifies as my financial responsibility. This authorization relates to all payments not covered by my insurance company for services provided to me by Four Peaks Neurology.

This authorization will remain in effect until I cancel this authorization. To cancel authorization, I must provide a 60-day notification to Four Peaks Neurology in writing, and my account must be in good standing. *

Four Peaks Neurology Office Policy, Procedure, and Code of Conduct

Informed Consent for Telehealth Services

cwAgreement8*
I have read and understand the information provided above regarding telehealth, have discussed it with my provider or such assistants, and all my questions have been answered to my satisfaction. I have read this document carefully and understand the risks and benefits related to the use of telehealth services and have had my questions regarding the procedure explained. I hereby give my informed consent to participate in the use of telehealth services for treatment under the terms outlined herein. *

This field is for validation purposes and should be left unchanged.

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Copyright © 2015 Four Peaks Neurology. All Rights Reserved.

Copyright © 2015 Four Peaks Neurology. All Rights Reserved.