Smart PDF Form

Rows	Yes	No
Fever
Weight loss >5 lbs
History of Falls

Rows	Yes	No
Vision changes

Rows	Yes	No
Asthma
Shortness of breath
Breathing difficulties

Rows	Yes	No
Diabetes
Thyroid disease
Excessive thirst/urination

Rows	Yes	No
Skin disease
Breast pain, tenderness, nipple discharge
Unusual moles

Rows	Yes	No
Anxiety
Depression

Rows	Yes	No
Anemia
HIV

Rows	Yes	No
Food, Inhalant (nasal) allergies
Autoimmune disease (i.e., lupus)

I HEREBY AUTHORIZE LEON BARKODAR, M.D. TO FURNISH TO THE PROVIDED INSURANCE COMPANIES ALL INFORMATION WHICH THE INSURANCE COMPANIES MAY REQUEST. I HEREBY ASSIGN DR.BARKODAR ALL BASIC AND MAJOR MEDICAL BENEFITS TO WHICH I AM ENTITLED FOR MEDICAL EXPENSES RELATED TO THE SERVICES RENDERED, BUT NOT TO EXCEED INDEBTEDNESS THAT IS DUE. I UNDERSTAND THAT MONEY RECEIVED FROM THE INSURANCE COMPANIES WILL BE REFUNDED WHEN MY BILL IS PAID IN FULL. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE TO THE SAID DOCTOR FOR CHARGES NOT COVERED BY THE INSURANCE COMPANIES.
(Attention Medicare Patients: Certain tests may not be covered by Medicare. By signing below, you are agreeing that you are choosing to have any test(s) done whether today or in the future. This is called an "Advanced Beneficiary Notice". You may however, decline to do any tess.)
Patient Signature

Clear
Date:

MonthDayYear
Date
The information on this form is accurate to the best of my knowledge:
Patient Signature

Clear
Date completed

MonthDayYear
Date
I have reviewed the above information with the patient:
Physician Signature

Clear
Date reviewed

MonthDayYear
Date
4 of 4
Please complete all pages

CANCELLATION POLICY/NO SHOW POLICY FORDOCTOR APPOINTMENT
1. Cancellation/ No Show Policy for Doctor Appointment
We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment, you may be preventing another patient from getting much needed treatment. Conversely, the situation may arise where another patient fails to cancel and we are unable to schedule you for a visit, due to a seemingly "full" appointment book. If an appointment is not cancelled at least 48 hours in advance you will be charged a forty dollar ($40) fee; this will not be covered by your insurance company.
2. Scheduled Appointments
We understand that delays can happen however we must try to keep the other patients and doctors on time. If a patient is 15 minutes past their scheduled time we will have to reschedule the appointment.
3. Cancellation / No Show Policy for EEG Appointments:
Due to the large block of time needed for EEG, last minute cancellations can cause problems and added expenses for the office. All EEG appointments cancellations after the 24 hour period will incur a $40.00 technician fee.
Print Patient Name
Signature of patient/ guardian

Clear
Date

MonthDayYear
Date

PATIENT FINANCIAL AGREEMENT& ACKNOWLEDGEMENT OF OFFICE POLICIES
Our practice believes that part of good health care practice is to establish and communicate an office and financial policy to our patients. We are dedicated to providing the best possible care for you, and we want you to completely understand our policies.
1. PAYMENT is expected at the time of your visit. We will accept cash, check, or credit card. Payment will include any unmet deductible, co-insurance, copayment amount, or non-covered charges from your insurance company. If you do not carry insurance, or if your coverage is currently under a pre-existing condition clause, payment in full is expected at the time of your visit.
2.INSURANCE:
We are participating providers with several insurance plans. We will file all of the insurance claims for these plans. Please remember that insurance is a contract between the patient and the insurance company and ultimately the patient is responsible for payment in full. If your insurance company does not pay the practice within a reasonable period of time, you will be billed. If we later receive payment for your insurer, we will refund any overpayment to you. In order to bill your insurance and to meet filing guidelines we do ask for a copy of your policy card and an ID card or license is now required due to the many cases of identity theft in the news lately
If our providers are not listed in your plan's network, you may be responsible for partial or full payment. If you are insured by a plan with which we have no prior arrangement, we will prepare and send the claim in for you on an unassigned basis. This means the insurer may send the payment directly to you and therefore, our charges for you are due at the time of service.
Due to the many different insurance products out there, our staff cannot guarantee your eligibility and coverage. Especially, patients with HMO plans need to be eligible at time of service with their health plan with a valid authorization. It is your responsibility to check with you insurer's member benefits department about services and providers before your appointment.
3. RETURNED CHECKS:
Will incur a $25.00 service charge. You will be asked to bring cash, certified funds or a money order to cover the amount of the check plus the $25.00
PATIENT SIGNATURE

Clear
DATE

MonthDayYear
Date

VEENA SENGUPTA, M.D.
Diplomate, American Board of Neurology
LEON BARKODAR, M.D.
Diplomate, American Board of Neurology
ADEL OLSHANSKY, M.D
Diplomate, American Board of Neurology &
Clinical Neurophysiology
DESIREE LEVYIM, M.D.
Diplomate, American Board of Neurology
7301 MEDICAL CENTER DR. STE 410 WEST HILLS, CA 91307
(818)593-2191 Fax: (818)593-2194
AUTHORIZATION TO RELEASE MEDICAL RECORDS
Patient Name:

First NameLast Name
Patient's DOB:

MonthDayYear
Date
Ph#:
Format: (000) 000-0000.
I authorize doctor or group name:
Ph#
Format: (000) 000-0000.
Fax#
Format: (000) 000-0000.
To release the following health/medical records relating to my identity, diagnosis, and prognosis and/or treatment:
Entire medical recordsSpecific records relating to time period _____ to ____Diagnostic: Labs, MRI's, CTOther
Records to be sent to:
Name:
Ph#:
Format: (000) 000-0000.
Fax#:
Format: (000) 000-0000.
Change of Doctor/clinicReferral to SpecialistOther
Patient signature:

Clear
Date:

MonthDayYear
Date
This release of records shall remain in force until revoked in writing.
Should be Empty:

Rows	Medication:	Dose:	Frequency:
1
2
3
4
5
6
7

Rows	Yes	No	Type/Affected Relative
Brain Tumor
Seizures / Epilepsy
Dementia
Parkinson’s Disease
Multiple Sclerosis
Muscle Disease
Neuropathy
Hypertension (High Blood Pressure)
Diabetes
Migraines
Thyroid Disease

Rows	Yes	No
Wear hearing aid(s)
Hearing loss
Ear pain/infections
Ringing in ears
Nasal congestion/drainage Inability to smell
Sinus problems
Balance (vertigo, spinning, etc.)

Rows	Yes	No
Chest pain or angina
Irregular pulse
Heart murmur
Swelling in hands or feet

Rows	Yes	No
Nausea
Vomiting
Change in bowel habits
Ulcers or gastritis

New Patient Intake Form Dr. Barkodar

Primary Care Physician:

III. Reason for visit - Chief Complaint (History of Present Illness)

VI. Social History

VII. Family Hiastory Do you have a family member affected with:

VIII. Review of Symptoms Do you currently, or have you had a problem with:

CANCELLATION POLICY/NO SHOW POLICY FORDOCTOR APPOINTMENT

1. Cancellation/ No Show Policy for Doctor Appointment

2. Scheduled Appointments

3. Cancellation / No Show Policy for EEG Appointments:

PATIENT FINANCIAL AGREEMENT& ACKNOWLEDGEMENT OF OFFICE POLICIES

AUTHORIZATION TO RELEASE MEDICAL RECORDS

Rows	IV. Surgical History Please list all operations you have had:	Date:
1
2
3
4

Rows	V. Medical History Please list all active medical conditions:	Duration:
1
2
3
4

Rows	Yes	No
Urinary tract infections
Painful urination
Blood in your urine
Difficult slartinglstopping stream
Incontinence
Kidney stones

Rows	Yes	No
Broken bones
Ann or leg weakness
Arm or leg pain
Joint pain or swelling
Arthritis

Rows	Yes	No
Fainting spells or "black outs"
Headaches
Seizures
Problems with memory
Disorienlalion
Difficulty with speech
Inability to concentrate
Double or blurred vision
Weakness in arms and/or legs
Loss of sensation
Difficulty with balance