Please correct the errors described below.


Insurance Information

I, the undersigned, authorize payment of medical benefits to Winchester Neurological Consultants, Inc. for any services furnished to me by the physician. I authorize release of any medical or other information necessary to process insurance claims/related treatment to the health care financing administration and its agents. I am responsible for payment of serviced rendered.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.


Thank you for choosing our physicians for your Neurological health care needs. We are committed to providing the very best medical care and treatment. The following is a statement of our Financial Policy, which you must read, agree to and sign, prior to treatment.

Practice Payment Policy Guidelines:

  • Patients/ (guardians) are financially responsible for all charges, regardless of third-party involvement.
  • Full payment is due at time of services, unless prior insurance billing arrangements have been made.
  • Patients with insurance will be required to pay all “out-of-pocket” financial obligations at time of service.
  • We accept: Cash, Check, and debit/credit cards: Visa/ Master Card.

Patient Responsibilities and Financial Policies:

Provide Accurate Information: You have a responsibility to provide accurate and complete information about your health history, mailing address, health insurance and other billing information. If any information changes – name, address, phone, insurance coverage, etc. – you must inform this practice immediately. Insurance denials or billing errors due to patient supplied information will result in the transfer of the account balance to the patient’s immediate financial responsibility.

Know Your Insurance Coverage, Benefits and Referral Requirements:

Your health insurance is a contract between you and your health insurance plan(s). Patients are responsible for understanding their health insurance coverage(s), benefits and referral requirements pre-authorizations or pre-certifications from their primary care physicians. Patients are responsible for securing the necessary written referrals, received the necessary pre-authorizations or pre-certifications from your primary care physician or health plan prior-to service rendered. If you have not received the necessary authorizations prior to your appointment, the appointment will be rescheduled. Please present your Insurance ID card to our staff upon registration for each office visit.

Self-Pay Patients:

Patients without insurance coverage are expected to pay for service received in full at time of service.

Patient with Private Insurance / Medicare / Medicaid Coverage:

Our physicians participate with the Medicare and Medicaid Programs, and with most major insurance companies. We will file claim(s) to your insurance provided you authorize the “assignment of benefits” below for payment directly to our practice. For participating insurance plans, the practice will accept payment based on contractual agreements. For plans that we don’t participate in (i.e., there is no contractual agreement), the practice will expect full payment from the patient at time of service. Any coverage or payment dispute is a matter between the insurance policyholder and the insurance company.

Patient Payment Agreement:

I understand that I am financially responsible for all charges, regardless of third-party involvement. I agree to pay any deductible coinsurance, co-payment, or serviced deemed as “non-covered” by my insurance carrier at the time of service. If my insurance has not paid on my account in 60 days, the outstanding serviced will become my responsibility for immediate payment (unless Medicare and Medicaid). Should any balances arise due to insurance co-payments, co-insurance, deductibles, termination of coverage, non-payment at time of service and/or any other reason, I agree to pay all charges within 30 days of notice. I understand that if I fail to pay outstanding balances or make payment arrangements within 75 days, the amount due will be considered delinquent and subject to legal action. I further understand that delinquent accounts will be assessed a 1.5% interest charge per month (18% APR), and will be subject to the possible dismissal of the patient from our care. If my account is forced to collection I agree to pay all collection costs, including, but not limited to, court costs, attorney’s fees equal to 33.33% of the amount owed, and accrued interest charges to date. I agree to pay a $25.00 returned check fee. Copies of my medical records can be obtained with advance notice in accordance with §8.01-413 of the Code of Virginia, with charges not to exceed $0.50 per page for the first 50 pages and $0.25 per page thereafter, in addition to a $10.00 handling fee plus postage expense. The completion of special forms or reports has a minimum charge of $25.00 for each form.

Authorization & Assignment of Insurance Benefits:

I permit a copy of this authorization and signature to be used in place of this original on all insurance claim submissions and for the vrelease of specific medical or other protected health information, whether manual, electronic or telephonic. I authorize the Practice to apply for benefits for services rendered to myself or minor child under any health insurance policies providing benefits and do hereby also assign and authorize payment of benefits from my insurance company to the Practice (including benefits payable under Title XVIII of the Social Security Act and/or any other governmental agency.) I irrevocably authorize all such payments to the Practice. I authorize the Practice to contact the employer or insurance company regarding insurance information, existence of insurance and coverage of my benefits.

In consideration for medical service rendered, I acknowledge receiving notice of the financial policy and agree to pay for said medical services according to the above terms. My signature below indicates that I have read and agree to the above policy.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

Consent for Release and Use of Confidential Information And Acknowledgement of Notice of Privacy Practices

I, (Insert Name of Patient or Authorized Agent below) hereby give my consent to Winchester Neurological Consultants, Inc. to use or disclose, for the purpose of carrying out treatment, payment, or health care operations, all information contained in the patient record of (insert Patient Name below).

I acknowledge the review and /or receipt of the physician’s Notice of Privacy Practices. The Notice of Privacy Practice provides detailed information about how the practice may use and disclose my confidential information. I understand that the physician has reserved a right to change his or her privacy practices that are described in the Notice. I also understand that a copy of any revised Notice will be available to me upon a written request to the Privacy Officer.

I understand that this consent is valid until it is revoked by me. I understand that I may revoke this consent at any time by giving written notice of my desire to do so, to the physician. I also understand that I will not be able to revoke this consent in cases where the physician has already relied on it to use or disclose my health information. Written revocation of consent must be sent to the physician’s office.

I understand that I have the right to request that the practice restrict how my individually identifiable health information is used and/or disclosed to carry out treatment, payment or health operations. I understand that the practice does not have to agree to such restrictions, but that once such restrictions are agreed to, the practice and their agents must adhere to such restrictions.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Due to the HIPAA Privacy Act, we are not permitted to release information regarding your care. If you wish to grant your permission, please list below the person(s) that we may speak with on your behalf. Please be aware that these persons designated by you will have full access to your Private Health Information (PHI).

Add new row

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.


To the Patient or Caregiver:

This information will be placed in the medical record. It is important to complete each section to the best of your ability and knowledge. If you are uncertain of dates, give approximate dates.

Family History

Please list any significant medical or neurological conditions in your family, including those who are deceased (please give approximate age at time of death and cause of death).

Social History:

How many children do you have?

Current Medications:

(Please include over-the-counter, non-prescription, and complementary medical treatments)

Add new row

Review of Systems: To help us best evaluate you, please check any symptoms which you have recently experienced, and add note, if applicable.

If you suffer from headaches, please answer the following:

(0 = No pain at all, and 10 = pain as bad as it can be)

Diagnostic Studies:

Please check all diagnostic studies you have had related to this visit.

The Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the situations described in the chart below, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you haven’t done some of these things recently, try to work out how they would have affected you.

Use the following scale to choose the most appropriate number for each situation:

0 = I would never doze

2 = Moderate chance of doing

1 = Slight chance of dozing

3 = High chance of dozing

STOP-Bang (If not already provided by your office.)

Your information will be encrypted.