1) NTINH: Demo Forms & Consents

New Patient Intake Forms

Please fill out the below forms. If you have any questions or difficulty answering the questions contained herein, please do not hesitate to speak to one of our staff members for assistance. If you are filling this out outside of the clinic and have questions, please reach out to our front office staff at 972-403-8184. Thank you, and welcome to North Texas Institute of Neurology & Headache.
Name*

Last Name
Today's Date

MonthDayYear
Date
Date of Birth*

MonthDayYear
Date
Sex*
Age (years)*
Driver's License #*
Upload Photo of Driver's License (skip if unable to upload; the front desk can do it for you when you come in for your consultation)
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone #*

Area CodePhone Number
Home Phone #*

Area CodePhone Number
Work Phone #

Area CodePhone Number
Email*
example@example.com
Marital Status*
Employer / Place of Work *

Provide Details for Emergency Contact: Spouse, Domestic Partner, or Responsible Party
Name of Spouse / Domestic Partner / Responsible Party*

First NameLast Name
Relationship to Patient*
Address for Spouse / Domestic Partner / Responsible Party*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone # of Spouse / Domestic Partner / Responsible Party*

Area CodePhone Number
Secondary Phone # of Spouse / Domestic Partner / Responsible Party

Area CodePhone Number
Sex of Spouse / Domestic Partner / Responsible Party*
Date of Birth of Spouse / Domestic Partner / Responsible Party*

MonthDayYear
Date
Employer of Spouse / Domestic Partner / Responsible Party*

Primary Insurance Information

On this page, please only provide information on your PRIMARY form of insurance. If you have secondary insurance as well, you will be able to enter that information on the next page.
Name of Primary Insurance Company*
Effective Date*

MonthDayYear
Date
Insured's Name*

First NameLast Name
Insured's Date of Birth*

MonthDayYear
Date
Insured's Social Security Number*
ID #*
Group #*
Insured's Employer*
Claims Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Secondary Insurance Information

On this form, please provide information on your SECONDARY form of insurance.
Name of Secondary Insurance Company
Co-Pay Amount ($)
Effective Date

MonthDayYear
Date
Insured's Name

First NameLast Name
Insured's Date of Birth

MonthDayYear
Date
Insured's Social Security #
ID #
Group #
Insured's Employer
Claims Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Consent Form - Signature Needed

I hereby authorize direct payment of my insurance benefits to NTINH for services rendered to myself or my dependents. I understand it is my responsibility to know my insurance benefits and whether or not the services I am to receive are a covered benefit. I understand I am responsible for any co-pay or balance due that is determined by my insurance carrier for any reason. I authorize release of any information that may be necessary for medical evaluation, treatment, consultation, or processing of insurance benefits. I hereby consent to evaluation, testing, and treatment as directed by NTINH, including downloaded medical history.
Patient's Signature*
Date Signed

Office Policies - Signature Needed
Office Hours:
- Monday - Friday: 8:00 AM - 4:00 PM
- Saturday and Sunday: Closed
Insurance Payment Policy:

Please present your insurance card and driver's license at the time of check in. We do not verify benefits for most follow up appointments. Please be aware that it is ultimately your responsibility to know your healthcare benefit coverage. If you do not know your benefits we strongly recommend that you contact your insurance carrier with any questions you may have regarding your coverage prior to your services rendered. On each date of service, you will be expected to pay the co-pay / coinsurance / deductible amount that is listed on your insurance card. Please note that this is only an estimated amount. After your insurance company has paid their portion, it is probable that you will receive a bill from North Texas Institute of Neurology & Headache for any amount that has been applied to your deductible or coinsurance.

Self-Pay Patients:

Our office does not see self-pay patients.

Forms of Payment:

We do not accept checks on the initial appointment. Payment is accepted in the forms of cash, checks, or debit cards (Visa, MasterCard, American Express, or Discover).

With the rising costs of credit card processing fees, we’ve found it necessary to implement a 3% transaction fee for all credit card payments.

***Please note that there will be *no additional fee* for payments made by debit card, cash, or check. ***

Medical Records:

Medical record requests are now handled by a third party, HealthMark Group. To request your records, submit a request by creating an account at https://medrelease.healthmark-group.com/360 . You may also request your records through our office. If you choose to submit a request through our office, a records release form will need to be completed in our office or sent to the office via fax. Should any fees be required, HealthMark Group will send out an invoice. Records will be available within 24-48 hours, unless pending payment. If you have not received any response regarding your request, please call our office.

Medication Refills:

Please allow our office 72 hours for medication refills. Medication refills will only be filled during our normal business hours listed above. The on-call medical provider will not fill standard, non-urgent refills after hours.

Outside Venues:

Our office may have contractual financial interests in venues such as Sleep Studies, EEGs, UAs, MRIs, and Compound Pharmacies. These interests do not in any way impact medical decisions, treatment options, or financial obligations for our patients.

Courtesy Policy:

Due to the sensitive nature of the conditions that we treat, we ask that all patients and guests refrain from cell phone use, the use of heavy perfumes, lotions, and tobacco products, as well as any video or audio recording and photography. We thank you in advance for your cooperation and understanding.

***Please note that the patient is the only one allowed back at the time of the visit***

Cancellation / No Show Policy:

We do our best to confirm appointments with our patients 72 hours in advance, however it is ultimately the responsibility of the patient to confirm or cancel their appointment within one business day. Appointments that have not been confirmed by 3:00 PM the day prior to their appointment will be canceled and considered a ‘no show’, so that we are able to accommodate patients who are on the waiting list. Patients that ‘no show’ their appointment or ‘cancel it on the same day’ (inside of one business day) of service will be charged with the fee listed below and a deposit, all are nonrefundable. The deposit will go up in $25.00 increments per no show and/or same day cancel.

Follow up appointments: $50.00 + $50.00 deposit
Procedures (including EMG/NCV, injections, Biopsy or Botox/Dysport/Xeomin/Daxxify): $100.00 + 50.00 deposit
Consult with different Provider in office: $75.00 + $50.00 deposit
Psychiatric Consult and Follow Up: $150.00 + $50.00 deposit
Radiology: $150.00 + $50.00 deposit
Massage: $25.00/Allergy $25.00 + $50.00 deposit

Late Policy
If you are more than 15 minutes late, please call our office, so we can reschedule your appointment. Please be aware, this will be considered a No Show and a fee will be assessed. Please respect this policy as it ensures that physicians and patients stay on time.

I have read the above standard policies for North Texas Institute of Neurology and Headache, and I agree to abide by these policies.
Patient Name*

First NameLast Name
Patient / Guarantor Signature*

Clear

Patient Consent & Acknowledgement of Receipt of Privacy Notice - Signature Needed
I understand that as part of the provision of healthcare services, North Texas Institute of Neurology and Headache creates and maintains health records and other information; this includes but is not limited to my health history, symptoms, examination, test results, diagnoses, treatment, and any plans for future care or treatment.

I have been provided with a Notice of Privacy Practices that provides a more complete description of the uses and disclosures of certain health information. I understand that I have the right to review the notice prior to signing this consent. I understand that the organization reserves the right to change their Notice and Practices and prior to implementation will mail a copy of any revised notice to the address I have provided. I understand that I have the right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations (quality assessment and improvement activities, underwriting, premium rating, conducting or arranging for medical review, legal services, and auditing functions, etc.) and that the organization is not required to agree to the restrictions requested.

By signing this form, I consent to the use and disclosure of protected health information about me for the purposes of treatment, payment, and health care operations. I have the right to revoke this consent, in writing, except where disclosures have already been made in reliance on my prior consent. This consent is given freely with the understanding of the below:
1. Any and all records, whether written, oral, or electronic, are confidential and cannot be disclosed for reasons outside treatment, payment, or health care operations iwthout my prior written authorization, except as otherwise provided by law.
2. A photocopy or fax of this consent is as valid as this original.
3. I have the right to request that the use of my Protected Health Information, which is used or disclosed for the purposes of treatment, payment, or health care operations, be restricted. I also understand that the Practice and I must agree to any restriction in writing that I request on the use and disclosure of my Protected Health Information and agree to terminate any restriction in writing on the use and disclosure of my Protected Health Information which have been previously agreed upon.
Patient Name*

First NameLast Name
Last 4 of SSN#*
Patient / Guarantor Signature*

Clear
Today's Date

No Fault (Automobile Accident Cases) / Personal Injury / Workman's Compensation Policy - Signature Needed

This office; it's providers and staff practicing herein, DO NOT participate in No Fault (automobile accident cases), Personal Injury, or Workman's Compensation cases.
Do you have an open MVA (Motor Vehicle Accident) case or any other automobile lawsuits currently open?*
***NTINH does NOT participate in any open MVA Cases***
Is this visit related to a Workman's Compensation lawsuit / claim / case?*
***NTINH does NOT participate in any open Worker's Compensation Cases***
Is this visit related to a Personal Injury lawsuit / claim / case?*
***NTINH does NOT participate in any open Personal Injury Related Cases***
Sign here to signify your understanding that the providers and staff at North Texas Institute of Neurology & Headache can not and will not participate in any open No Fault, Personal Injury, or Workman's Compensation cases, even if this occurs during the course of treatment for which you are being seen at our facility. *

Clear
Date

MonthDayYear
Date
Disability Paperwork

Our migraine/ headache providers DO NOT participate in filling out disability paperwork, however if you are a patient of Dr. Annette Okai and are seeing her for Multiple Sclerosis, please submit paperwork via email to her Medical Assistant. Please understand there is a charge associated with our office to fill out your paperwork.

Authorization for Disclosure of Protected Health Information - Signature Needed
Patient Name*

First NameLast Name
Social Security #*
Date of Birth*

MonthDayYear
Date
I, the above-named person, release that the following medical information be sent from North Texas Institute of Neurology and Headache.

All Medical RecordsAll Billing Records
I, the above-named person, release North Texas Institute of Neurology and Headache, and their staff, from any liability concerning the above-mentioned records. Information can be released and sent to the following individuals, who are authorized to receive information:
1) Name

First NameLast Name
2) Name

First NameLast Name
3) Name

First NameLast Name
By signing this form, I, the above-named person, release the physician and his/her staff from any liability concerning my medical records.
Patient's Name*

First NameLast Name
Patient's Signature*

Clear

Additional Facility Policy Acknowledgments & Consent Forms - Signatures Needed
I understand the providers and staff are here to help my condition. The testing and recommendations are for my benefit. I understand non-compliance can result in a significant hindrance in my care, and may result in dismissal from the practice. I agree to be an active participant in my individual treatment plan. *

Clear
NTINH is here to improve your quality of life and productivity. There is no permanent, one-time Cure or Fix for headache disorders. We strive to bring productivity and quality back into your life. As a rule, our providers are happy to support FMLA regulations, however, we do not fill out disability paperwork or file disability claims.*

Clear
I understand the providers and staff at North Texas Institute of Neurology & Headache are to conduct themselves in a professional and courteous manner, and I also understand that the same behavior is expected of me as a patient in this practice. North Texas Institute of Neurology & Headache does its best to facilitate and accommodate ease of diagnostic work-up, follow-up and treatment plan. Headache Medicine can be confusing for some patients, but we are here to help you improve your quality of life for years to come. Many Headache syndromes may require the aid of another specialty such as ophthalmology, rheumatology, surgery, pain management and, most importantly, the support of your primary care provider. Individual Headache management requires patience, mutual cooperation and respect. We look forward to working with you toward a happier and healthier life. *

Clear
I understand that if I do not show-up (aka, if I "no-show") to my first visit / consultation, I will NOT be rescheduled with any NTINH providers in the future.*

Clear
Are you the patient and over the age of 21?
North Texas Institute of Neurology and Headache is a practice geared toward treatment & management of adult patients over the age of 21; however, under special circumstances, exceptions will be considered. For patients under 21 approved by the office to be seen by one of our providers; both the patient and guardian are in agreement that the patient will obtain the following mandatory testing: initial counseling through our office, allergy testing, and sleep study evaluation. If these requests are not met by the first follow up after consultation, this will result in automatic dismissal from this practice. The patient's guardian may sign below to indicate their agreement with and understanding of this policy. *

Clear
Should be Empty:

New Patient Intake Forms

Provide Details for Emergency Contact: Spouse, Domestic Partner, or Responsible Party

Primary Insurance Information

Secondary Insurance Information

Consent Form - Signature Needed

Office Policies - Signature Needed

Patient Consent & Acknowledgement of Receipt of Privacy Notice - Signature Needed

No Fault (Automobile Accident Cases) / Personal Injury / Workman's Compensation Policy - Signature Needed

Disability Paperwork

Authorization for Disclosure of Protected Health Information - Signature Needed

Additional Facility Policy Acknowledgments & Consent Forms - Signatures Needed