MEDICARE PATIENTS ONLY - Neurology Center Of Fairfax
Patient Information Appointment Date: Time of Appointment: Marital Status: Last Name First Name Middle Name S M D W Sex: M F Birthdate (Mo/Day/Yr) Race: White American Indian or Alaska Native Black or African American Asian Native Hawaiian or Other Pacific Islander Prefer not to say/Other Home Address Ethnicity: Hispanic or Latino/a Not Hispanic or Latino/a City, State, Zip Code Email Address Home Phone ( ) Cell Phone ( ) Business Phone ( ) Employer Name Employer Address Street Employer Phone: ( With whom is your appointment? ) Date of Onset of Condition Appointment Reason **Referring MD Name** **Referring MD Phone Number** ( **Primary Care Doctor Name** Primary Insurance Company ) **Primary Care Doctor Phone Number** ( ) Primary Ins. Phone ( Primary Ins. Policy Number Primary Ins. Group Number ) Name of Insured Person - Primary Ins. Birthdate of Insured-Primary Secondary Insurance Company Secondary Ins. Phone Secondary Ins. Policy ( Number ) Relationship to Insured-Primary Secondary Ins. Group Number Name of Insured Person - Secondary Ins. Birthdate of Insured - Secondary Relationship to Insured-Secondary Nearest Relative to Contact in Case of Emergency Address Phone ( ** IS THIS AN ACCIDENT/ AUTO ACCIDENT/ LEGAL CASE? YES NO ** IS THIS A WORKERS COMPENSATION CASE? YES NO ** ARE YOU A MEDICARE PATIENT? YES* NO ) *If yes, please complete the reverse side of this form. I certify the above information is correct. I understand I am responsible to notify the Neurology Center of Fairfax, LTD if my insurance coverage changes, if benefits change, or if the coverage I have reported is incorrect. I understand and agree that I am ultimately responsible for payment in full for services I receive from the Neurology Center of Fairfax, LTD. Patient Signature Date Rev. 07 13 2016
Patient Name: Date of Birth: : MEDICARE PATIENTS ONLY Are you Are you Are you Are you in in in in a rehabilitation facility? a skilled nursing facility? a nursing center? hospice? YES YES YES YES NO NO NO NO *If yes, please provide the name and address of the facility in the spaces below: Facility Name: Facility Address: Rev. 07 13 2016
New Patient Visit Patient Name: Date of Birth: Date: Family Doctor: Last Visit: To improve your visit with the doctor: v Prepare a summary (or chronology) of your illness (one page or less), including when symptoms began. What symptoms did you have at the beginning? v What brought on the symptoms or made them worse? v What other symptoms have occurred? When did they occur? v What tests have been done? What were the results? v What medications have you taken? What were the results of the treatment? LIST ALL CURRENT MEDICATIONS AND THE DOSE YOU ARE TAKING ON THE SEPARATE MEDICATIONS LIST (OR WE CAN MAKE A COPY OF YOUR LIST). INCLUDE ALL VITAMINS AND OVER-THE-COUNTER MEDICATIONS. Rev. 09 28 2016
Fairfax Office 3020 Hamaker Ct, Suite 400, Fairfax, VA 22031 Reston Office 1830 Town Center Dr. Suite 305, Reston, VA 20190 Office Phone 703.876.0800 Fax 703.876.0866 After hours emergency 703.755.1450 NAME: DOB: PATIENT # REVIEW OF SYSTEMS (Please check box next to symptoms you have had in the past 3 months) Constitutional Symptoms Weight Change Change in appetite Chills / Fever Other: Head Symptoms Headache Facial Pain Other: Neck Symptoms Pain in neck Stiffness Neck pain radiating down arm Other: Eye Symptoms Blurry vision Seeing double (diplopia) Total loss of vision Seeing flashing lights Other: Skin Symptoms Itching Rashes Easy bruising Other: Hematologic Symptoms Easy bleeding Anemia Blood Clots Other: Respiratory Symptoms Shortness of breath Cough Other: Genitourinary Symptoms Increased urinary frequency Urinary loss of control Urinary tract infection Pain during urination Sexual dysfunction Other: Ear, Nose & Throat (ENT) Hearing Loss Ringing in the ears (tinnitus) Vertigo/dizziness/lightheaded Sinus Pain Taste or smell disturbance Other: Sleep Symptoms Snoring Gasping at night Insomnia Daytime sleepiness Restless legs Other: Back Symptoms Back Pain Lower back pain radiating to the legs Leg pain with exercise (claudication) Other: Neurological Symptoms Headache/facial pain Memory lapses or loss Confused or disoriented Total loss of vision Worsening vision Seeing double (diplopia) Hearing Loss Ringing in the ears (tinnitus) Dizziness / Vertigo / Light Headedness Difficulties in speech Difficulty swallowing (dysphagia) Bowel/bladder changes Sexual complaints Localized pain/where: Generalized pain Numbness (hypesthesia)/tingling Feeling tired (fatigue) Muscle weakness Muscle cramps Walk is wobbly or unsteady(ataxia) Poor coordination Tremor Convulsions/seizures Fainting/passing out Transient alteration of awareness Sleep disturbances Head injury / Concussion Spinal cord disease Musculoskeletal Symptoms Diffuse joint pains Pain in arms/hands Pain in the legs/feet Muscle aches/muscle pain Muscle twitches (Fasciculations) Muscle cramps Other: Gastrointestinal Symptoms Difficulty swallowing Nausea/ Vomiting Abdominal pain Liver Disease Diarrhea Constipation Other: Cardiovascular Symptoms Chest pain or discomfort Palpitations/ rapid heart beat Irregular Heartbeat Leg Swelling Other: Gynecological Symptoms History of pregnancy(s) Other gynecological history Other: Psychiatric Symptoms Anxiety Depression Unable to control anger Hallucinations Other: Endocrine Symptoms Excess Thirst Heat or Cold Intolerance Other: Allergic/ Immunologic Drug/ Food/ Pet Allergies Hives Other: I HAVE REVIEWED ALL BOXES (UNCHECKED BOXES “NO”) Rev 02.26.2020
Fairfax Office 3020 Hamaker Ct, Suite 400, Fairfax, VA 22031 Reston Office 1830 Town Center Dr. Suite 305, Reston, VA 20190 Office Phone 703.876.0800 Fax 703.876.0866 After hours emergency 703.755.1450 NAME DOB PATIENT # Past Medical History YES YES Hypertension (High Blood Pressure) Coronary Disease/Heart Attack/Angina Heart Disease – Any Heart Problem Atrial Fibrillation or Irregular Heartbeat High Cholesterol Diabetes Mellitus Type 1(Childhood/Juvenile) Type 2 (Adult onset) Arthritis/Osteoarthritis Cancer (including Skin) Thyroid Disorders (Hyper- or Hypothyroid) Other Endocrine (PCOS / Cushings) GI Disorders / Reflux / GERD Stomach Ulcer / GI Bleed Liver Disease Muscle Disease Fibromyalgia Myasthenia Gravis Nerve Pain - Neuralgia Nerve Palsy Neuropathy Radiculopathy (Pinched/Trapped Nerve) Cervical Thoracic Lumbar Paralysis Stroke / TIA Carotid Disease / Stenosis Intracranial Hemorrhage Brain Aneurysm Eye Disease/Vision Loss/Double Vision Lung Disease (Asthma/COPD) Dementia Parkinson's Disease Pneumonia Tremor Kidney Disease – Any Kidney Problem History of Infections – incl. Lyme, HIV, Hepatitis Multiple Sclerosis Blood Disease / Disorder Autoimmune Disease – SLE, Rheum., Sjogren Depression / Other Psychiatric Disorders Seizure Disorder / Epilepsy Genetic Disease (yours) Fainting (Syncope) Sleep Disorders / Narcolepsy / Restless Legs Brain Tumor Surgeries – List Below Sleep Apnea Cervical Spine (Neck) Surgery – date(s) Migraine Headache Thoracic Spine Surgery – date(s) Other Headache Condition – Type: Lumbar Spine Surgery – date(s) Other Surgeries – List Below Other Medical History List Below None/Negative Rev. 2.2020 2.26.2020 Rev.
NAME DOB PATIENT # Family and Social History Mother Father Sister Brother Mother Diabetes Mellitus Sleep Disorder / Narcolepsy / Restless Legs Hypertension/High Blood Pressure Sleep Apnea Heart Disease – Any heart problem Migraine/Other Headache Condition Coronary Disease/Heart Attack/Angina Peripheral Nerve/Muscle Atrial Fibrillation – Irregular Heartbeat Polyneuropathy - Neuropathy Heart failure (CHF) Stroke / TIA / Paralysis High Cholesterol Intracranial Hemorrhage Arthritis Dementia Cancer (including Skin) Parkinson’s Disease Thyroid Disorders – Hyper/Hypo Tremor Other Endocrine Disorder Psychiatric Disorders GI Disorders / Stomach Disorder Depression Liver Disease Anxiety Eye Disease / Vision Loss Genetic Disease Lung Disease Autoimmune Disease - SLE / Rheumatoid Kidney Disease – any type Multiple Sclerosis Blood Disease / Disorder BrainTumor Seizure Disorder/Epilepsy Other illness not listed Fainting/ Passing Out Father Sister Brother No Significant Family History Family history is unobtainable Patient adopted Patient orphaned Are You: Y Currently married YES NO Occupation: Y N Domestic Partner Y Working Part Time Occupation: Y N YES NO Y N Single Separated Y N Unemployed Y N Divorced Y N Homemaker Y N Widowed Y N Retired Y N Currently on disability Alcohol Assessment Y N Student Y N Do you drink alcohol? Y N Military service Y N Social drinker YES NO Y N 2 or less drinks/day Exercise Habits Y N More than 2 drinks/day Y Left-handed N Do you use tobacco products? N Current every day smoker Y N Current some day smoker N Former smoker Y N Never smoked Y N Smoker, status unknown Y N Unknown if ever smoked Y N Y Tobacco Assessment: Y Y Right-handed N Caffeine Use YES NO Marital History Working Full Time Y YES NO Y Occupation: N N Y Good exercise habits ( 3 days/wk) Y Poor exercise habits YES NO YES NO
Medication List Mail Order Pharmacy: Phone: Fax: Name: DOB: Local Pharmacy: Phone: Fax: Cell Phone: Medication/Allergies: Please include all prescriptions, vitamins, and over-the-counter medications. PLEASE PRINT. Medication Dosage Frequency/Time Prescribed By Taken For Continue on reverse side or attach a second sheet, if necessary. Rev. 07 13 2016
Patient Authorizations Patient Name: Date of Birth: (Please read carefully. You are authorizing these actions.) I hereby authorize the Neurology Center of Fairfax, Ltd. (NCF) to apply for benefits on my behalf for covered services rendered by NCF, to myself or to my dependent. Authorization is effective as of today. I request payment from my insurance carrier and/or Medicare Part B to be made directly to NCF. I certify that the information I have reported with regard to my insurance coverage is correct and further authorize the release of any necessary information, including protected health information (PHI) for this or any other related claim, to my insurance carrier or in the case of Medicare Part B benefits to the Social Security Administration and Centers for Medicare and Medicaid Services (CMS). I permit a copy of this authorization to be used in place of an original. It is possible that services provided to me by NCF may not be covered by Medicare or by my insurance. I agree to assume responsibility for full payment of all services if Medicare or other insurance payment is denied. I further agree to be responsible for the outstanding balance on this account and to pay all reasonable costs of collection including attorney’s fees at 40% of the outstanding balance and monthly interest at 1.5%, should this account become overdue. I understand that payment for all services is due and payable in full at the time of service, and that full payment for services may be required at the time of service. This includes, but is not limited to, my co-payment, co-insurance and deductibles. I agree to provide NCF with my current insurance card, government issued identification, and a valid referral (if required) at the time services are rendered. I understand that it is my responsibility to obtain required referrals. I understand that although my insurance may pay part or all of the charges I incur, I am still ultimately liable and responsible for all charges. I understand that it is my responsibility to know the correct amount of my co-payment and deductible. I understand that my co-payments, co-insurance, and any deductibles are due at the time of service. I understand there is a 10 administrative fee if I do not pay my co-payment, co-insurance, and deductible at the time of service, and a separate 10 administrative fee each time a bill is generated for payment due, but not paid at the time of service. I understand I will be charged a “no-show” fee for any missed appointment, or any appointment not cancelled more than 24 hours in advance. I authorize NCF to release my medical records (protected health information) to my treating physicians and other healthcare providers and to discuss my care with those providers, as my physician deems necessary. I authorize NCF to contact the people whom I list as emergency contacts in the event of an emergency. I authorize NCF to obtain contact information from my other health care providers, my emergency contacts, my employer or my health insurance carrier, if NCF is unable to contact me directly for any reason. I authorize my treating NCF physician to provide information to my caregiver or a family member, if my physician judges this disclosure to be important for my well-being. I authorize NCF to leave messages for me on answering devices attached to my telephones or to contact me by email or text message. I authorize NCF to contact me by email to inform me that information is available for me on the NCF secure patient portal. These authorizations may be revoked by me at any time in writing. I agree that a facsimile or a scanned copy of this agreement may be treated as an original for all purposes. I take these actions in Fairfax County, Virginia. I acknowledge I have received a copy of the Neurology Center of Fairfax, Ltd.’s Notice of Privacy Practices dated October 27, 2020. I have read, I understand, and I agree to the terms and conditions specified in this Notice of Privacy Practices Signature: Date: ********************** **If the patient is under the age of 18, please complete the following: The undersigned is a parent/guardian of the patient and executes this form on behalf of the patient. Name: Signature: Relationship: Date: For Patients Who Do Not Have Their Insurance Card, and/or Referral, If Required, (includes Work Comp) I acknowledge that I did not bring a referral as required by my insurance company and/or do not have my insurance card. I am electing to be seen today and agree to pay in full today for the services rendered today since I do not have a valid referral and/or insurance card, or worker’s comp authorization. Signature: Date: Rev. 10.27.2020 12.2021
Rev. 2.2020 Fairfax Office 3020 Hamaker Ct, Suite 400, Fairfax, VA 22031 Reston Office 1830 Town Center Dr. Suite 305, Reston, VA 20190 Office Phone 703.876.0800 Fax 703.876.0866 After hours emergency 703.755.1450 NAME DOB PATIENT # Past Medical History YES YES Hypertension (High Blood Pressure) Muscle Disease
Neurology Dejong's the neurologic examinaiton 2020 Neurology Differential diagnosis in neurology and neurosurgery 2019 Neurology Medical neuroscience Q&A 2019 Neurology Merritt's neurology 2016 Neurology Neurology :
NEWSLETTER FOR NEUROLOGY INTERVIEW SEASON 2021-2022 DEPARTMENT OF NEUROLOGY N Y P - W E I L L C O R N E L L N E U R O L O G Y R E S I D E N C Y Meet Our Department Leadership Dr. Matthew Fink (Chair of Neurology) Dr. Matthew E. Fink, is the Louis and Gertrude Feil Professor of Clinical Neurology, chairman of the Department of Neurology and
Centers for Medicare & Medicaid Services National Train‐the‐Trainer Workshops Instructor Information Sheet Module 1: Understanding Medicare Module Description Original Medicare, Medicare Advantage and Other Medicare Health Plans, and Medicare Prescription Drug Coverage are choices in the Medicare program.
Medicare 101: The Basics of Medicare. . Original Medicare, Medicare Advantage, and Medicare Cost plans Other COVID-19 related benefits are available if Medicare guidelines are met Those who are in a Medicare Advantage Plan should check . PowerPoint Presentation Author:
Medicare Medicare Contact Center Operations PO Box 1270 Lawrence, KS 66044 Phone: (800) MEDICARE (633-4227) www.medicare.gov Medicare beneficiaries, family members, and caregivers can visit Medicare.gov, the Official U.S. Government Site for People with Medicare, for the latest information on Medicare enrollment, benefits, and other helpful tools.
Medicare Supplement Insurance (Medigap) policies, Medicare Advantage Plans, or Medicare prescription drug coverage (Part D). For more information . Remember, this guide is about Medigap policies. To learn more about Medicare, visit Medicare.gov, look at your “Medicare & You” handbook, or call 1‑800‑MEDICARE (1‑800‑633‑4227).
Iowa Medicare Supplement and Premium Comparison Guide Medicare Advantage & Other Health Plans in Iowa Guide SHIIP Counselors can help you: Understand your Medicare benefits Compare and evaluate Medicare Supplement policies Understand and compare Medicare Advantage plans Compare Medicare Part D plans 20
Medicare Advantage Plans, stand‑alone Medicare drug plans, employer/ union group health coverage, Medicaid, or TRICARE. If you have Original Medicare and a Medigap policy, Medicare will pay its share of the . Medicare‑approved amounts for covered health care costs. Then, your Medigap policy pays its share. Medicare doesn't pay any of the
