Neurology Specialists of the Treasure Coast, P.A. Daniela Saadia, M.D. 900 SE Ocean Blvd. Suite 220 C Stuart, FL 34994 Phone 772-888-2611 Fax 855-667-1903 First Name_________________________________ Middle _______ Last Name _____________________________________ Date of Birth_______________________________ Gender: Male Female Address________________________________________ City_______________________ State ______ Zip________ EMAIL ADDRESS: (Print clearly) _____________________________________________________________________________ Primary Phone Number: _________________________________________ Home Cell Secondary Phone Number: _________________________________________ Home Cell Marital Status: Married Single Separated Divorced Widowed Emergency Contact: ________________________________________________ Relationship to Patient: ______________________________ Phone Number:____________________________________ Primary Insurance:___________________________________ Secondary Insurance: _______________________________ CONSENT FOR E-PRESCRIBING & MEDICATION HISTORY I understand that as a part of my electronic health record, Neurology Specialists of the Treasure Coast will transmit my prescriptions electronically as permitted, to the pharmacy that I designate as my primary pharmacy provider. Additionally, Neurology Specialists of the Treasure Coast will obtain the history of all of my past prescriptions dating back two years from pharmacy benefit managers and I understand that those prescriptions will become a part of my electronic health record. By signing below I hereby give consent to the above actions. Signature of Patient or Legal Representative: _____________________________________Date: ________________ CONSENT TO TREAT, RECORD RELEASE & ASSIGNMENT OF INSURANCE I voluntarily consent to any and all health care treatment and diagnostic procedures provided by Neurology Specialists of the Treasure Coast, P.A. I hereby authorize Neurology Specialists of the Treasure Coast., to re-release any and all medical information that has been previously requested from any physician, hospital, or clinic where I have been treated. I understand this authorization to re-release medical information shall only be valid for the purposes of second opinions or referral from Neurology Specialists of the Treasure Coast, P.A. I acknowledge full responsibility for the payment of services rendered to me and agree to pay for them in full, at the time of service, unless other arrangements are made in advance. I understand I am financially responsible for all non-covered services, copays, deductibles and/or coinsurance. I understand that I am financially responsible for any charges incurred in the collection of this account, should I default on payment. Such charges include, but are not limited to legal fees, collections fees, interest charges or late charges. I authorize the physician to release any medical information required to process my claims. I hereby assign my insurance benefits to be paid directly to the physician. Signature of Patient or Legal Representative: _____________________________________Date: ________________
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Neurology Specialists of the Treasure Coast, P.A. Daniela Saadia, M.D. 900 SE Ocean Blvd. Suite 220 C Stuart, FL 34994 Phone 772-888-2611 Fax 855-667-1903
First Name_________________________________ Middle _______ Last Name _____________________________________
Date of Birth_______________________________ Gender: Male Female
Address________________________________________ City_______________________ State ______ Zip________ EMAIL ADDRESS: (Print clearly) _____________________________________________________________________________
Primary Phone Number: _________________________________________ Home Cell Secondary Phone Number: _________________________________________ Home Cell Marital Status: Married Single Separated Divorced Widowed
I understand that as a part of my electronic health record, Neurology Specialists of the Treasure Coast will transmit my prescriptions electronically as permitted, to the pharmacy that I designate as my primary pharmacy provider. Additionally, Neurology Specialists of the Treasure Coast will obtain the history of all of my past prescriptions dating back two years from pharmacy benefit managers and I understand that those prescriptions will become a part of my electronic health record. By signing below I hereby give consent to the above actions.
Signature of Patient or Legal Representative: _____________________________________Date: ________________
CONSENT TO TREAT, RECORD RELEASE & ASSIGNMENT OF INSURANCE
I voluntarily consent to any and all health care treatment and diagnostic procedures provided by Neurology Specialists of the Treasure Coast, P.A. I hereby authorize Neurology Specialists of the Treasure Coast., to re-release any and all medical information that has been previously requested from any physician, hospital, or clinic where I have been treated. I understand this authorization to re-release medical information shall only be valid for the purposes of second opinions or referral from Neurology Specialists of the Treasure Coast, P.A. I acknowledge full responsibility for the payment of services rendered to me and agree to pay for them in full, at the time of service, unless other arrangements are made in advance. I understand I am financially responsible for all non-covered services, copays, deductibles and/or coinsurance. I understand that I am financially responsible for any charges incurred in the collection of this account, should I default on payment. Such charges include, but are not limited to legal fees, collections fees, interest charges or late charges. I authorize the physician to release any medical information required to process my claims. I hereby assign my insurance benefits to be paid directly to the physician.
Signature of Patient or Legal Representative: _____________________________________Date: ________________
Neurology Specialists of the Treasure Coast, P.A. Daniela Saadia, M.D.
900 SE Ocean Blvd., Suite 220C Stuart, FL 34994 Phone (772) 772-888-2611 Fax (855) 667-1903
PRIVACY PRACTICES AND HIPAA RELEASE
I authorize this practice to discuss my medical care, test results and financial information with the family members or friends listed below, who are involved in my medical care. Furthermore, I authorize voicemail messages and text messages, if applicable, to be left for me at the phone numbers I have provided to this practice.
Name Phone Number Relationship
CANCELLATION AND NO SHOW POLICIES
Neurology Specialists of the Treasure Coast, P.A. requires a cancellation notice at least 24 hours in advance when I am unable to keep an appointment.
If I do not provide a proper cancellation notice or NO SHOW for an appointment, I am aware there is a $50 fee per occurrence.
I am aware if I incur this fee, it must be paid in full, by cash or check, prior to being seen at my next appointment.
Multiple cancellations or missed appointments in any 12 month period will result in dismissal from the practice.
By signing below, I acknowledge I have read this notice and understand the cancellation and no show policies for Neurology Specialists of the Treasure Coast, P.A. I acknowledge that I have received, or am aware of how I can obtain, a copy of the Neurology Specialists of the Treasure Coast. P.A. “Notice of Privacy Practices” which sets forth their privacy practices and my rights regarding privacy of my PHI (Protected Health Information). ____________________________________________ Patient Name ____________________________________________ ___________________________ Patient Signature (or Legal Representative) Date
Neurology Specialists of the Treasure Coast, P.A. Daniela Saadia, M.D. (772) 888-2611
Please briefly describe the symptom(s) or diagnosis that brought you to our office: _______________________________________________________________________________________
How long have you had these symptom(s) or diagnosis:___________________________________________