Neurology Forms

Patient Demographics

New patient demographic paperwork to be filled out before your first appointment. Please do not forget to bring along your photo identification card and your health insurance card.

Patient Request for Records

Request for Access to PHI (Protected Health Information) This page is filled out when patients are needing to obtain their medical records. Please note: It is free to inspect your medical records, however obtaining copies of your medical records will cost $0.60 per page.

Narcotic Agreement

This is a written agreement/understanding between the patient and provider that when narcotic medications are prescribed, you will only obtain that medication from the same provider.

Hippa Patient Information

If you have suffered from any type of seizure activity or syncope spell, the DMV will require you to have your provider complete a Confidential Physician’s Report.

DMV – Physicians Report

New patient demographic paperwork to be filled out before your first appointment. Please do not forget to bring along your photo identification card and your health insurance card.

Request Access for PHI

Protected Health Information