Austin Neuropsychology - Patient Registration Form

PATIENT PAPERWORK

Welcome to Austin Neuropsychology! Please answer these first two questions in order to populate the applicable sections. Let us know if you have any questions!
Which neuropsychologist are you or the patient scheduled with?*

Dr. Melissa BunnerDr. Stephanie PaulosDr. Douglas "Greg" AllenDr. Alexandra ClarkDr. David Tucker - through Seton Epilepsy Program ContractNot scheduled yet (If this is the case, please make sure you reach out to our office via phone 512-637-5841 or email info@neuroaustin.com, if you have not already)
The patient is:*

A child (<18)An adult (18+)
children

PARENT & FINANCIALLY RESPONSIBLE PARTY CONTACT INFORMATION
Parent or Guardian Name*

First NameLast Name
Mobile phone*
Home phone
Email Address*
example@example.com
Work phone
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Occupation
Employer Name
Would you like to list another parent or guardian's contact information? By putting their information below, you grant us permission to contact them when neccessary or requested.*

Yes - I grant Austin Neuropsychology permission to contact themNo
Other Parent or Guardian's Name

First NameLast Name
Mobile phone
Email Address
Occupation
Employer Name
Home Address

Street Address

Street Address Line 2

CityState

Zip Code
Are you the financially responsible party?*

YesParent/ guardian listed as #2 is financially responsibleBoth guardians listed above share responsibilityNo - There is a third party paying for the evaluation
Financially Responsible Party Contact Information
Please initial to authorize permission, as the legal representativie of the patient, for Austin Neuropsychology to release information to the below financially responsible party, including but not limited to cost and medical records neccessary to recieve payment for the patient's services.*
Name of financially responsible party not listed above*

First Name & Middle InitialLast Name
Relationship to Patient*
Email Address*
Mobile phone*
Occupation
Company if applicable
Employer Name
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Would you like to list an additional emergency contact?*

Yes - I give permission for Austin Neuropsychology to contact the below person in an emergencyNo
Additional Emergency Contact

First NameLast Name
Primary phone

UPLOAD YOUR ID OR LICENSE
Relationship to Patient
Please upload a picture of your drivers licenses or state issued ID*

If the patient is under 18, please be sure to upload a license or state ID of their parent/ guardian.
Cancelof
Adults

PATIENT AND OTHER CONTACT INFORMATION
Patient Contact Information
Mobile phone*
Home phone
Email Address*
example@example.com
Work phone
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Is the patient the primary point of contact?*

YesNo
Primary Point of Contact's (if not the patient) Information
Primary Point of Contact Name*

First NameLast Name
Relationship to Patient*
Mobile phone*
Email Address*
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Is the patient the financially responsible party?*

YesNo
Financially Responsible Party Contact Information
Name*

First NameLast Name
Relationship to Patient*
Mobile phone*
Email Address*
Occupation
Employer Name
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Would you like to list a partner, family member, or close friend as a secondary contact in the case we are unable reach you? By listing their contact information below, you give us permission to reach them in such a case.*

YesNo
Alternate Contact Name

First NameLast Name
Relationship to Patient
Mobile phone
Email Address
Would you like to list an additional emergency contact? By listing their contact information below, you give us permission to reach them in an emergency.*

Yes - I give permission for Austin Neuropsychology to contact the below person in an emergencyNo
Emergency Contact Name

First NameLast Name
Relationship to Patient
Mobile phone

UPLOAD YOUR ID OR LICENSE
Please upload a picture of the patient's drivers license or state issued ID.

Cancelof

PATIENT CONSENTS AND PERMISSIONS
Patient Consents and Permissions

The following fields will be referring to our Office Policies and Procedures, please take the time to review these policies and let us know if you have any questions. All patients 18 and over must complete this portion themselves, unless the patient has a POA, who is able to complete it for them.
Office Policy and Procedures Agreements
Office, Confidentiality, and Financial Policies and Procedures*
COVID-19 Policy*
Policy regarding other illnesses*
Contact Permissions
Permission to leave Voice Messages*
Permission to use Email Messages*
Permission to Conduct Telemedicine Visits
Telemedicine services involve the use of secure interactive videoconferencing equipment and devices that enable health care providers to deliver health care services to patients when located at different sites. Please review and confirm your understanding of your rights and telemedicine limitations below.

1. I understand that the same standard of care applies to a telemedicine visit as applies to an in-person visit.

2. I understand that I will not be physically in the same room as the neuropsychologist. I will be notified of and my consent obtained for anyone other than my healthcare provider present in the room.

3. I understand that there are potential risks to using technology, including service interruptions, interception, and technical difficulties.

a. If it is determined that the videoconferencing equipment and/or connection is not adequate, I understand that my health care provider or I may discontinue the telemedicine visit and make other arrangements to continue the visit.

4. I understand that I have the right to refuse to participate or decide to stop participating in a telemedicine visit, and that my refusal will be documented in my medical record. I also understand that my refusal will not affect my right to future care or treatment.

a. I may revoke my right in writing at any time.

5. I understand that the laws that protect privacy and the confidentiality of health care information apply to telemedicine services.

6. I understand that my health care information may be shared with other individuals for scheduling and billing purposes.

a. I understand that my insurance carrier will have access to my medical records for quality review/audit.

b. I understand that I will be responsible for any out-of-pocket costs such as copayments or coinsurances that apply to my telemedicine visit.

c. I understand that health plan payment policies for telemedicine visits may be different from policies for in-person visits.
By checking this box below, I attest that I (1) have personally read the telehealth consent information (or had it explained to me) and fully understand and agree to its contents; (2) have had my questions answered to my satisfaction, and the risks, benefits, and alternatives to telemedicine visits shared with me in a language I understand; and (3) am located in the state of Texas and will be in Texas during my telemedicine visit(s).*
Permission to Audio-Record Appointments

We recently started working with AI for dictation and note taking, recording appointments may assist with this. The audio record will not be kept by Austin Neuropsychology, it will be deleted as soon as the neuropsychological report is finalized.
Permission to View Radiology Results
Permission to Photograph
Patient photographs are never shared by our office. They are only used occasionally as a memory jogger for the doctors if the patient is needing something and hasn't been evaluated in a while. This is not required.
Research Participation and Teaching
In our effort to learn more about how the brain functions and how to better help our patients, we sometimes carry out research. For any type of research, we will need your authorization. We want to emphasize that participation in research at Austin Neuropsychology, PLLC is purely voluntary. Your decision to participate or decline to participate in research will in no way affect your relationship with Austin Neuropsychology, PLLC or our commitment to your clinical care.

In this research, all identifying information is removed and confidentiality is protected.

These types of research mainly include:
- Statistical analysis of clinical information from past patients
- Specific cases examples, which are a powerful teaching tool when training psychologists or physicians.
- Occasionally we also contact past patients to see if they are interested in participating in new research studies. The specifics of any potential research project would be explained to you at that time, and you would have a choice to volunteer or decline participation at that time as well.
Permission to use anonymous clinical data
Permission to contact with invitations for future research
By signing below, I confirm that I;
- Am the patient or the legal representative of the patient,
- Have personally read Austin Neuropsychology's Policies and Procedures (or have had it explained to me) and fully understand and agree to such, and
- I understand that this document will become a part the patient's record
What is your relationship to the patient?*

I am the patientParentLegal GuardianPatient AdvocatePower of AttorneyOther
Name of person completing this form

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date

PATIENT PAPERWORK

children

Financially Responsible Party Contact Information

Adults

Patient Contact Information

Primary Point of Contact's (if not the patient) Information

Financially Responsible Party Contact Information

Insurance and Assignment of Benefits

Release of Information

Office Policy and Procedures Agreements

Contact Permissions

Permission to Conduct Telemedicine Visits

Permission to Audio-Record Appointments

Permission to View Radiology Results

Permission to Photograph

Research Participation and Teaching