Welcome to Spartanburg Neurological Services, P.A.
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Date: / /

Name:

Age:

Sex: FM

Addess:

City:

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Zip:

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Date of birth: / /

Social Security number: - -

Marital status (select one): Single Married Widowed Divorced

Employer:

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Spouse's name:

Date of birth: / /

Employer:

Business telephone: ( ) -

Address:

City:

State: South Carolina Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip:



Parent or guardian:

Date of birth: / /

Employer:

Business telephone: ( ) -

Address:

City:

State:

South Carolina Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip:



In case of emergency, contact:

Telephone: ( ) -





List any drug allergies:


Referring doctor:

Address:

City:

State: South Carolina Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip:

Telephone: ( ) -

Primary care doctor:

Address:

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INSURANCE INFORMATION

I hereby authorize Spartanburg Neurological Services to furnish information to insurance carriers concerning my teratment and hereby assign to the doctor all payments for medical services renbered to dependents of myself. I understand that I am reponsible for any amount not covered by insurance. (Sign in accordance below).

Name of primary coverage:

Address:

City:

State: South Carolina Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip:

Telephone: ( ) -

Policy holder's name:

Policy number:

Group number:

Social Security number: - -





Name of secondary coverage:

Address:

City:

State: South Carolina Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip:

Telephone: ( ) -

Policy holder's name:

Policy number:

Group number:

Social Security number: - -



At this point on the printed form, a dated signature will be required from both the patient and the insured.

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Electromyography Evoked Potentials Autonomic Function Studies Quantitative Sensory Testing

Spartanburg Neurological Services, P.A. 362 North Pine Street Spartanburg, South Carolina 29302 (864) 542-2510 Fax: (864) 583-1311 CONSENT TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION

Electroencephalography Sleep Studies Carotid Ultrasound Transcranial Doppler Studies

USE AND DISCLOSURE OF YOUR PROTECTED HEALTH INFORMATION:
Your protected health information will be used by Spartanburg Neurological Services, P.A. or disclosed to others for the purposes of treatment, obtaining payment, or supporting the day-to-day health care operations of the practice.

NOTICE OF PRIVACY PRACTICES:
Spartanburg Neurological Services, P.A. is required to provide you to a notice that describes how much information about you may be used to disclosed. Additionally, we must provide your information on how you may get access to this information. These policies and practices are defined in the "Notices of Privacy Policies and Practices" brochure provided to you. Please review it carefully.

REQUESTING A RESTRICTION ON THE USE OR DISCLOSURE OF YOUR INFORMATION:
You may request a restriction on the use or disclosure of your protected health information. Spartanburg Neurological Services, P.A. may or may not agree to restrict the use or disclosure of your protected health information. If Spartanburg Neurological Services, P.A. agrees to your request, the restriction will be binding on the practice. Use or disclosure of protected information in violation of an agreed upon restriction will be in violation of the Federal Privacy standards.

REVOCATION OF CONSENT:
You may revoke the consent to use and disclose of your protected health information. You must revoke this consent in writing. Any use or disclosure that has already occurred prior to the date on which your revocation of consent is received will not be affected.

RESERVATION OF RIGHTS TO CHANGE PRIVACY PRACTICES:
Spartanburg Neurological Services, P.A. reserves the right to modify the privacy practices outlined in the notice. I understand that Spartanburg Neurological Services, P.A. will notify me of these changes via the method I have authorized or upon my next appointment.

SIGNATURE:
I have read and reviewed this consent form, received the brochure entitled "Notice of Privacy Policies and Practices" and give my permission to Spartanburg Neurological Services, P.A. to use and disclose my health information in accordance with this consent and the noticed provided.

At this point on the printed form, a dated signature will be required from both the patient and a witness.

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Spartanburg Neurological Services, P.A.

Authorization of Use and Disclosure of Protected Health Information

Appointment Reminders. The practice may use your informationto remind you about upcoming appointments. Typically, appointment reminders are sent by mail in a sealed envelope, or, a brief, non-specific message may be left on your answering machine. Occaisonally, we may also use "appointment cards" to remind you about upcoming appointments. If you don't approve of these methods and would like alternative reminder methords (i.e., email) please indcate those methods in the space provided (samples of appointment reminders are available upon request).

How would you like to be contacted regarding appointments, teratment, and/or other information pertinent to your healthcare and/or payment for your healthcare provided at Spartanburg Neurological Services? (Check all that apply).

Regular Mail	Home Telephone	Work Telephone
Appointment Cards	E-mail	Home Fax Machine

If you have an answering machine, may we leave messages regarding appointments, treatment, and/or other information pretinent to your healthcare and/or payment for your healthcare provded at Spartanburg Neurological Services? (Select one).

YesNoN/A

If "NO," how else may we contact you regarding this information?


Please list any other restrictions regarding messages or reminders about your healthcare:


Other uses and disclosures. Disclosure of your health information or its use for any purpose other than those listed in the "Notice of Privacy Policies and Practices" brochure and/or consent require your specific written authorization. If you change your mind after authorizing a use ot disclosure of your information you may submit a written revocation of the authorization of information that occurred before you notified us of your desicion. You have the right to request restrictions on use and disclosure of your health information.

I would like the following restrictions regarding the use and discolsure of my health information:


Persons Authorized to Receive Information:
Health information Spartanburg Neurological Services collects or receives about you may be disclosed to the following persons:


Name of person/relation/organization


Name of person/relation/organization

Use and Disclosure of Information:
I authorize the person(s) listed above to receive all health information about appointments treatment and/or other information pertinent to my healthcare and/or payment for my healthcare provided at Spartanburg Neurological Services.

I do not authorize the following information to be disclosed to any other parties except to me as the patient. (Please specify).

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Expiration Date of Authorization
This authorization is effective through / / unless revoked or terminated by the patient or patient's personal representative.

Right to Terminate or Revoke Authorization
You may revoke or terminate this authorization by submitting a written revoation to Spartanburg Neurological Services. You should contact the PRIVACY OFFICIAL or other authorized representative to terminate this authorization.

Potential for Re-disclosure
The person or organization to which health information is sent may repeatedly disclose health information that is identified by this authorization. The privacy of this information may not be protected under the federal privacy regulations.

At this point on the printed form, the patient's name and signature, the date, patient representative's signature, and the patient representative's relationship to the patient will be required.

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Please verify that all above information is correct BEFORE submitting this form.

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