NEW PATIENT REGISTRATION

NEW PATIENT REGISTRATION
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender (Based on at Birth)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number (No dashes)
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Email
Patient's Employer
Work Phone Number
Please enter a valid phone number.
Spouse or Significant Other

First NameLast Name
Spouse/Significant Other Phone Number
Please enter a valid phone number.
EMERGENCY CONTACT
Name of Emergency Contact

First NameLast Name
Relationship of Emergency Contact
Emergency Contact Phone number
Please enter a valid phone number.
**Name and Relation of Person we may speak with other than yourself regarding your medical care:
Type Name and Relation
**Phone Number** of Person we may speak with other than yourself regarding your medical care:
Please enter a valid phone number.
Notification Preferences

May we leave a message or send reminders to:

	YES	NO
Home Phone
Cell Phone
Email
Work Phone, (ok to call work?)

List of Current/Recent providers

(Please include phone and fax if possible); Please indicate which provider is the referring with a " * "
PCP Name (Primary Care Provider)
PCP Phone Number
Please enter a valid phone number.
PCP Fax Number
Please enter a valid phone number.
2) Other Provider Name and Specialty
2) Other Provider Phone Number
Please enter a valid phone number.
2) Other Provider Fax Number
Please enter a valid phone number.
3) Other Provider Name and Specialty
3) Other Provider Phone Number
Please enter a valid phone number.
3) Other Provider Fax Number
Please enter a valid phone number.
4) Other Provider Name and Specialty
4) Other Provider Phone Number
Please enter a valid phone number.
4) Other Provider Fax Number
Please enter a valid phone number.
Preferred Pharmacy and Phone Number
Preferred Pharmacy Name
Preferred Pharmacy Phone Number
Please enter a valid phone number.

Insurance Information
Primary Insurance company name
Name of subscriber

First NameLast Name
Subscriber Relation to patient
DOB of subscriber

MonthDayYear
Date
SSN of policy holder (no dashes)
Group ID#
Policy/ID #
Employer
Employer phone #
Please enter a valid phone number.
Secondary Insurance company name
Name of subscriber

First NameLast Name
Subscriber Relation to patient
DOB of subscriber

MonthDayYear
Date
SSN of policy holder (no dashes)
Group ID#
Policy/ID #
Employer
Employer phone #
Please enter a valid phone number.

Peak Neurology Financial Policy
Name

First NameLast Name
Middle Initial
Today's Date

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
SSN (No dashes)
Please carefully review this information and sign where indicated. We are committed to providing you the best possible medical care. If you have medical insurance, we would like to help you receive the maximum allowable benefits. In order to achieve this goal, we will need your assistance and understanding of our financial policies.

Please present current insurance cards at each visit. Any changes to personal information must be given to the office immediately.

Assignment: I request that payment of authorized insurance, medicare, and medicaid benefits be payable to Peak Neurology on my behalf for services furnished to me. This assignment will remain in effect until revoked by me in writing. A photocopy of this authorization shall be considered as effective and valid as the original. In the event my account is turned over to a collection agency, I agree to pay all reasonable costs of collection and understand that I may no longer be a patient at this office.
Initial - I have read and agree to the above statement

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Co-pay/coinsurance/deductible: I understand that my primary insurance will be billed; billing secondary insurance is a courtesy only and and I am ultimately responsible for assigned co-payments, co-insurance and deductible amounts by primary and/or secondary insurance. Tertiary insurance billing remains my responsibility.
Initial - I have read and agree to the above statement

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Release of Information: I authorize the holder of medical information about me to release any and all information to Centers for Medicare and Medicaid Services, its agents, my insurance carrier(s), or other entities as needed to determine these benefits or the benefits for my dependents or myself. If I have health insurance coverage under an HMO, I authorize Peak Neurology to release information concerning my diagnosis and treatment to my primary care or referring physician after each visit.
Initial - I have read and agree to the above statement

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Requests for Information: Should I receive any requests from my insurance company in regards to my services at this office, I must respond to that correspondence immediately in order to have the claim processed and paid.
Initial - I have read and agree to the above statement

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Self-Pay: Self-pay and previous balance amounts are due and payable at the time of service. Insurance co-payments are mandated by your insurance company and MUST be paid at each visit. Patients with insurance claims pending will be sent statements for the full amount due until the account is satisfied. I agree that if the insurance company denies benefits for any reason, I am responsible for the full amount owed for services provided.
Initial - I have read and agree to the above statement

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Workers’ Compensation: I will provide approval/authorization by the Workers’ Compensation carrier at the initial visit. If the claim is deferred, the private medical insurance will be billed. I understand if the claim is denied, I will be responsible for payment in full. If the claim is in litigation, a verification of this from an attorney and/or the Workers’ Compensation carrier will be provided to this office.
Initial - I have read and agree to the above statement

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Returned Checks: I understand and agree to pay a returned check charge of $35.00 for each check that is returned for any reason. I agree to pay the amount of the check plus the service charge within 30 days of receipt of notification.
Initial - I have read and agree to the above statement

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Late Cancellation/No Show Policy: Late cancellations (<24 hours notice) or no show for a routine office visit (follow up or new patient appointment) will be charged $75. For late cancellation or no show for EMG/NCS studies a $150 dollar fee applies. This must be paid prior to scheduling any further appointments.

I have read and agree to the above information and I, the undersigned/patient, are ultimately responsible for the fees. By signing below, I consent be contacted by regular mail, by email or by telephone (including cell phone number) regarding any matter related to the above referenced account by the creditor, its successors or assigns. This consent includes any updated or additional contact information that I may provide and includes contact that employs auto dialer technology and/or pre recorded messages and text messaging. You may choose to discontinue your participation in our online communication system at any time simply by notifying the office by phone or email to stop further communication. Standard text messaging rates may apply.
Print Name

First NameLast Name
Signature

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Date

MonthDayYear
Date

Phone: 719-445-9902 or 719-212-0770

Fax: 719-387-0312

Email: bpriebe@peakneurocos.com

www.peakneurocos.com
Acknowledgement of receiving Privacy Practices

I acknowledge that I have been offered to review and reviewed a copy of this medical practice’s Notice of Privacy Practices. I further acknowledge that a copy of the current notice will be posted in the reception area, and that a copy of the amended Notice of Privacy Practices will be available at each appointment if I request one.
Indicate relationship if not signed by patient

Guardian or conservator of an incompetent patient.Parent of guardian or minor.
Patient Name

First NameLast Name
Signature

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Date

MonthDayYear
Date
Please complete below if refusing to sign the above acknowledgement
Patient Name

First NameLast Name
Signature

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Date

MonthDayYear
Date
Reason for refusal

Text appointment reminders
Patient Name

First NameLast Name
By signing you consent to receiving appointment reminders by text message and/or email.

You may choose to discontinue your participation in our digital communication any time by notifying the office by phone or email to stop further communication. Standard text/data rates may apply.
Signature (Must be 18 or older to sign, parent of minor)

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Date

MonthDayYear
Date
Should be Empty:

NEW PATIENT REGISTRATION

EMERGENCY CONTACT

Notification Preferences

List of Current/Recent providers

Preferred Pharmacy and Phone Number

Insurance Information

Medical Information

Social History

Peak Neurology Financial Policy

Please complete below if refusing to sign the above acknowledgement

Text appointment reminders