Post-Hospital Neuro Evaluation 2023

JEFFERSON PARK

3632 West Market Street,

Suite 102

Fairlawn, Ohio 44333-2494

Tel: 330.836.5333

Fax: 330.836.1775

SELSON CLINICS NEUROLOGY

SELWYN-LLOYD Mc PHERSON MBBS, MD

E-mail: drmcpherson@selsonclinicsneuro.com Website: selsonclinicsneuro.com

PATIENT'S PERSONAL INFORMATION

REFERRED BY:

Date

PATIENT LAST NAME:

PATIENT FIRST NAME:

GENDER:

MALE FEMALE

Date of Birth:

SOC SEC NUMBER (last 4 numbers):

MARITAL STATUS

ADDRESS:

STREET ADDRESS:

CITY/STATE/ZIP:

CELLPHONE:

HOME PHONE:

NAME OF NEXT OF KIN:

REALTIONSHIP TO YOU:

PHONE NUMBER:

NAME OF PERSON TO CALL IN CASE OF EMERGENCY:

PHONE NUMBER OF PERSON TO CALL IN CASE OF EMERGENCY:

INSURANCE INFORMATION

PRIMARY INSURANCE

NAME:

ID#

PHONE NUMBER:

SUBSCRIBER NAME:

SUBSCRIBER DATE OF BIRTH:

SECONDARY INSURANCE

NAME:

ID#

PHONE NUMBER:

SUBSCRIBER NAME:

SUBSCRIBER DATE OF BIRTH:

TO PAY BENEFITS TO SELSON CLINICS , INC

In order to control the cost of billing, we request that our charges for office visits or any co-pays be paid in full, before each visit.

The responsibility for paying for the services provided, lies with you the patient, even if you have insurance coverage for our inpatient and outpatient health care services. Some companies pay fixed allowances for certain procedures, and it is your responsibility to pay for any deductible amount or any other balances not paid for by your insurance.

I hereby assign to Selson Clinics Inc., all medical and laboratory benefits rendered by Selson Clinics Neurology, to include major medical benefits to which I am entitled, including Medicare, private insurance, and other health care plans. This assignment (responsible party) is responsible for all charges whether or not paid by insurance. I hereby authorize the assignee, Selson Clinics Neurology, to release all information necessary to secure payment.

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

RESPONSIBLE PARTY SIGNATURE:

RESPONSIBLE PARTY NAME:

Date

PLEASE LIST THE NAMES OF THE PHYSICIANS OR OTHER AUTHORIZED PERSONS TO WHOM WE SHOULD SEND COPIES OF THIS INITIAL ASSESSMENT, FOLLOW-UP ASSESSMENTS AND LAB REPORTS.

PLEASE SUPPLY ALL REQUESTED INFORMATION

PHYSICIAN

Name:

Phone:

Fax:

Name:

Phone:

Fax:

PRESCRIPTION DRUG HISTORY

Patient Name:

I am giving my permission for Dr. McPherson and his staff at Selson Clinics Neurology, to electronically review my prescription history, including but not limited to narcotics, benzodiazepines, psychotropic and stimulant drugs

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

PATIENT’S SIGNATURE:

MEDICATION HISTORY

(Include all over-the-counter drugs including vitamins, antacids, and aspirin products)

Add new row

DRUG ALLERGIES

Yes No

If yes please provide information below

PHARMACY

FAX

PHONE:

DATE OF HOSPITALIZATION:

NAME OF HOSPITAL:

DURATION OF HOSPITALIZATION:

REASON FOR HOSPITALIZATION:

PLEASE LIST YOUR REASON TO SEE DR.MCPherson

Your information will be encrypted.