Greater Monmouth Neurology P.C. 130 Maple Avenue Suite 1-A Red Bank NJ, Phone Fax Please Print Clearly

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1 130 Maple Avenue Suite 1-A Red Bank NJ, Phone Fax Please Print Clearly Dr. Schuber C. Fan Dr. Edgar Y. Chen Dr. Philip V. Ilaria Patient Name: Last First MI Home Address City State Zip Home Phone Cell Phone Work Phone Sex : M F Date of Birth Social Security# Race: White Black Hispanic Asian Other Marital Status : M W S D E Primary Language Ethnicity Employment Status: Full Time Part Time Disabled Retired Student Not Employed Employer Name Address Contracted Laboratory Local Pharmacy Address Mail Away Pharmacy Primary Care Physician Phone# Address *Emergency Contact Name Relation Primary Phone Secondary Phone Insurance Information The Patient will assume Financial Responsibility for any incorrect information. We must have a copy of your Insurance Card and ID with Home Address. Primary Insurance Carrier Insurance Address Policy # Group # Co-Pay $ Subscriber Name Relation D.O.B. Subscriber Address Marital Status: M W S D E Secondary Insurance Carrier Insurance Address Policy # Group # Co-Pay $ Subscriber Name Relation D.O.B. Subscriber Address Marital Status: M W S D E I hereby authorize Greater Monmouth Neurology PC to furnish information to Insurance Carriers concerning my illness and treatments, and authorize the Assignment of Benefits to Greater Monmouth Neurology PC for Neurological Treatment. Signature Date

2 Patient Name Today's Date Treating MD Height Weight Current Medications Drug Allergies Reason for today's visit Patient Medical History: Previous Hospitalization/Surgeries/Serious Injuries When? Diabetes No Yes Hypertension No Yes Cancer No Yes Stroke No Yes Heart Trouble No Yes Arthritis/Gout No Yes Medications Convulsions No Yes Bleeding Tendency No Yes Acute Infections No Yes Venereal Disease No Yes Hereditary Defects No Yes Patient Social History: Marital Status Single Married Separated Divorced Widowed Alcohol Use Never Rarely Moderate Daily Tobacco Use Never Previously, but Quit Current Smoker/Packs per Day? Drug Use Never Type/Frequency Excessive Exposure Air-borne At Home or Work Fumes Dust Solvents Particles Noise Family Medical History: Age Diseases If Deceased, Cause of Death Father Mother Siblings Spouse Children

3 Review of Systems: Please Indicate Any Personal History Below Constitutional Symptoms Musculoskeletal Good General Health Lately No Yes Joint Pain No Yes Recent Weight Change No Yes Joint Stiffness or Swelling No Yes Fever No Yes Weakness of Muscles/Joints No Yes Fatigue No Yes Muscle Pain or Cramps No Yes Headaches No Yes Back Pain No Yes Eyes Cold Extremities No Yes Eye Disease or Injury No Yes Difficulty in Walking No Yes Wear Glasses/Contact Lenses No Yes Integumentary (Skin/Breast) Blurred or Double Vision No Yes Rash or Itching No Yes Glaucoma No Yes Change of Skin Color No Yes Ears/ Nose/ Mouth/ Throat Change in Hair or Nails No Yes Hearing Loss or Ringing No Yes Varicose Veins No Yes Earaches or Drainage No Yes Breast Pain No Yes Chronic Sinus Problem or Rhinitis No Yes Breast Lump/Mass No Yes Nose Bleeds No Yes Breast Discharge No Yes Mouth Sores No Yes Neurological Bleeding Gums No Yes Frequent or Recurring Headaches --- No Yes Bad Breath or Bad Taste No Yes Light Headed or Dizzy No Yes Sore Throat or Voice Change No Yes Convulsions or Seizures No Yes Swollen Glands in Neck No Yes Numbness or Tingling Sensations --- No Yes Cardiovascular Tremors No Yes Heart Trouble No Yes Paralysis No Yes Chest Pain or Angina Pectoris No Yes Stroke No Yes Palpitations No Yes Head Injury No Yes Shortness of Breath w/walking or Lying No Yes Psychiatric Swelling of Feet, Ankles, Hands No Yes Memory Loss or Confusion No Yes Respiratory Nervousness No Yes Chronic or Frequent Coughs No Yes Depression No Yes Spitting Up Blood No Yes Insomnia No Yes Shortness of Breath No Yes Endocrine Asthma or Wheezing No Yes Glandular or Hormone Problem No Yes Gastrointestinal Thyroid Disease No Yes Loss of Appetite No Yes Diabetes (Insulin or Non-Insulin)----- No Yes Change in Bowel Movements No Yes Heat or Cold Intolerance No Yes Nausea or Vomiting No Yes Skin Becoming Dryer No Yes Frequent Diarrhea No Yes Change in Hat or Glove Size No Yes Painful Bowel Movements/Constipation No Yes Hematology/Lymphatic Rectal Bleeding or Blood in Stool No Yes Slow to Heal after Cuts No Yes Abdominal Pain No Yes Bleeding or Bruising Tendency No Yes Peptic Ulcer (Stomach or Duodenal) ---- No Yes Anemia No Yes Genitourinary Phlebitis No Yes Frequent Urination No Yes Past Transfusion No Yes Burning or Painful Urination No Yes Enlarged Glands No Yes Blood in Urine No Yes Allergic/Immunologic Change in Force of Strain w/urinating -- No Yes History of Skin or other Adverse Reactions To: Incontinence or Dribbling No Yes Penicillin or Other Antibiotics No Yes Kidney Stones No Yes Morphine Demerol Other Narcotics-- No Yes Sexual Difficulty No Yes Novocain or Other Anesthetics No Yes Male - Testicle Pain No Yes Aspirin or Other Pain Remedies No Yes Female-Pain With Periods No Yes Tetanus Antitoxin or Other Serums -- No Yes Irregular Periods No Yes Iodine Methiolate or Other Antiseptic No Yes Vaginal Discharge No Yes Food Allergies # of Pregnancies # of Miscarriages Environmental Allergies Date of Last Pap Smear

4 Office Policies Fees and Payments All of our fees are consistent with the customary charges for Neurological care in this area, and are reflective of the level of care that you receive. We participate with Medicare and other, but not all insurance carriers. With those insurance carriers in which we do not participate with, it is our policy that payment in full is made at the time our professional services are rendered. Our office staff will be pleased to assist you with your claim, by providing you with an itemized statement. Please be aware that your insurance contract is between you and your insurance. Should you be unable to meet your financial responsibility to our practice, a special payment plan may be arranged through our Office Manager. Non-Payment If your account is over 30 days due, you will receive a letter stating that you have 14 days to pay your account in full. Partial payments will not be accepted unless otherwise negotiated with our Office Manager. Please be aware that if a balance remains unpaid, we may refer your account to a National Credit Agency, authorized to credit report all outstanding debts to the four major National Credit Agencies, litigate in a court of law (other legal fees may apply) and charge a service fee of $ Additional Cost of Collections Services Invoices shall be deemed to be accepted by you unless Greater Monmouth Neurology P.C. is notified in writing within 14 days of the invoice being issued, that you dispute the amount of the invoice. In the event of non-payment, Greater Monmouth Neurology P.C. may in addition to the invoice amount charge: 1) Interest on any outstanding amounts from the due date, calculated at the statutory penalty rate of 6%. 2) In addition, legal and debt collection fees incurred by Greater Monmouth Neurology P.C., in relation to recovery of outstanding amounts owed. When any portion of your medical account with Greater Monmouth Neurology P.C. has fallen into arrears, then the totality of that account shall be due, whether or not in arrears, and shall become immediately due and payable. Appointments Please plan to arrive 15 minutes prior to your scheduled appointment and bring all your insurance information, ID and any pertinent medical records. If you are unable to keep your appointment, we require a minimum of 24 hours notice. If you are required to have a referral and do not have one, you cannot be seen by our Doctors. We are required to reschedule your appointment. This is an insurance carrier requirement as well as that of the Health Insurance Portability and Accountability Act. (HIPAA) Missed Appointments Our Policy is to charge $25.00 for missed appointments not cancelled 24 hours prior to your appointed time. These charges will be your responsibility and will be billed directly to you. Please help us to serve you better by keeping your appointment. Prescription Policy If you request that a prescription be mailed to your home, a service charge of $5.00 will be required. This is necessary due to our increased costs of office administration. Additional Options: 1) You may pick up prescription in our office. 2) You may have a prescription called in or faxed to your pharmacy. We require both Fax and Phone numbers to your pharmacy. Please be aware that pharmacies, when filling certain prescriptions, require the original prescription form. MRI and Cat Scan Films We strongly recommend that our patients keep and maintain their MRI and Cat Scan Films. This will allow the patient to have immediate access to these documents should the need arise in the future. I have read and understand the Office Policies and agree to abide but the guidelines: Signature of Patient Date

5 HIPAA Health Insurance Portability and Accountability Act I authorize the following individuals to receive information pertaining to any medical history and treatment received to the following, in addition to my referring M.D. Name Relationship Name Relationship If the above information is not provided, my medical files will not be disclosed. Home Phone Number Cell Phone Number Communication Approval Please Check Approval for our office to leave message with detailed information. Approval for our office to leave message with call back numbers only. Approval for our office to leave message with detailed information. Approval for our office to leave message with call back numbers only. I acknowledge the use of my Address for Electronic Health Record Patient Portal. Signature of Patient Date ******************************************************************************************* Patient acknowledges the opportunity to read and if desired, take home a copy of the "Notice of Privacy Practices" Signature of Patient Date

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