New Patient Appointment Request Form

If you need help filling out the form, please ask a friend, family member, or caregiver for assistance. You can also reach us directly at 727-498-0808 if you have any questions.

Hello! Thank you for choosing Dr. Khousakoun at Tampa Bay Neurocognitive Institute for your care. To request an appointment, please fill out this form. Our office is located at 1433 Gulf to Bay Blvd, Suite F, Clearwater.

Once you submit the form, our office will review your information and contact you to confirm your appointment and answer any questions.

Please note: We currently accept the following insurance plans: Cigna, Medicare, Aetna, Blue Cross Blue Shield (BCBS), Tricare, Multiplan, PHCS. Additionally, we take Medicare Advantage Plans only with Aetna and Cigna. As a courtesy, we do offer billing for United Healthcare PPO (UHC) and Medicare BCBS adv PPO for out-of-network benefits. We also offer a self-payment option.

If you need to reschedule or cancel your appointment, please let us know at least 24 hours before your scheduled time. Late cancellations will result in $50 charge (not covered by insurance).

Dr. Khousakoun is only treating memory and cognitive disorders at the moment. It is required that you bring a trusted companion with you on the day of your appointment. This allows Dr. Khousakoun to develop a thorough and personalized care plan.

We look forward to welcoming you to our office soon!

Have you seen Dr. Khousakoun prior to June 2024 at Baycare in the past?

Yes No

First Name

Last Name

Date of Birth

Sex Assigned at Birth (Gender)

Male Female

Address Street, City, State, Zipcode

If you live in a different location during part of the year (e.g., during winter/summer), please provide your secondary address (Address Street, City, State, Zipcode):

Home phone if applicable

Mobile Phone

Preferred pharmacy (Name, Address, phone #)

Please input your emergency contact below

Emergency Contact First and Last name

Emergency contact phone #

Insurance

Please note: We currently accept the following insurance plans: Cigna, Medicare, Aetna, and Blue Cross Blue Shield (BCBS), Tricare. As a courtesy, we do offer billing for United Healthcare (UHC) for out-of-network benefits. We also offer a cash payment option. If you have multiple insurance cards, please upload a photo of all cards + ID.

Primary Insurance Company Name

Member/Policy Id

Is your primary insurance an HMO? An HMO is a type of insurance plan that typically requires referrals from your primary care provider and only covers services provided by in-network providers. Please look at your card to see if it is listed.

Yes

Please have your primary care provider fax a referral to 727-477-8303

Group # if applicable

Secondary Insurance Company Name

If applicable

Member/Policy Id

Group # if applicable

Upload a photo of all your insurance cards

File option for uploading insurance cards

Add file

Please upload a file

Upload a photo of your Driver's license

File option for uploading driver's license

Add file

Please upload a file

Appointment Scheduling

Once you submit the form, our office will review your information and contact you to confirm your appointment and answer any questions.
If you need to reschedule or cancel your appointment, please let us know at least 24 hours before your scheduled time. Late cancellations will result in $50 charge (not covered by insurance).

Please give us a brief reason why you are seeking a neurology appointment

(Dr. Khousakoun only treats patients with memory issues)

What days do you prefer

Monday

Tuesday

Wednesday

Thursday

Earliest Availability (No preference)

Do you prefer mornings (9AM-11:00) or afternoons (1:00 PM-3:30 PM)

Mornings (9AM- 11:00) Afternoons (1:00-3:30PM) Earliest Availability (No preference)

Records

We will now ask for more information to obtain your past health records from your primary care provider, specialists, and any MRI, CT, or PET scans and reports you may have.

Who is your Primary Care Provider?

Is your primary care provider affiliated with Baycare?

Yes No

Have you seen any neurologists in the past? If so, please type their full names

Have you had any brain imaging in the past two years? (MRIs, CT, PET scans)

Yes No

Where did you get your brain scans done? (if applicable)

Thank you for filling out the appointment request form!

Our office will review your information and contact you to confirm your appointment and answer any questions.

If you are seeking an appointment for cognitive issues, it is required that you bring a trust companion with you on the day of your appointment. This allows Dr. Khousakoun to develop a thorough and personalized care plan.

You can also reach us directly at 727-498-0808 if you have any questions.

We look forward to welcoming you to our office soon!

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