PATIENT HISTORY

Patient Name ________________ Date __________ _

Referring doctor's name: _____________ Phone number _______ _

Family doctor's name: ______________ Phone number _______ _

Reason for today's visit: _________________________ _

Diabetes

Tuberculosis

Cancer

Bleeding Disorder

AIDS

Migraines

Hearing Problems

Parkinson's Disease

Seizures

Heart Disease

Multiple Sclerosis

Narcolepsy

High Blood Pressure

Alzheimer's Disease

Provider you are here to see today:

Do you have, or have had the following problems: (check all that apply):

Stroke

Seizures

Hearing Loss

Headaches

Sinusitis

Nasal Polyps

Snoring

Sleep Apnea

Diabetes

Food Allergies

Pneumonia

Tonsillitis

Indigestion

Swallowing Disorder

Cancer

Tremor/Shaking

High Blood Pressure

Hoarseness

Bronchitis

Asthma

Thyroid Disease

Stomach Ulcers

Kidney Disease

Blood Transfusions

ADD/ADHD

Angina

Carpal Tunnel Syn

Emphysema

Tuberculosis

Heart Attack

Hepatitis

Lyme Disease

HIV/AIDS

Migraine

Diabetes

Other:

Please list all current medications including dosing and instructions:

Are you pregnant?

Please list any medication allergies:

Please list any surgeries or hospitalizations:

Handedness:

If yes, how much?

If yes, how much?

Do you drink alcohol?

Do you smoke?

Have you ever smoked?

Do you take caffeine?

Do any of your blood relatives, parents, grandparents, and siblings suffer from and of the following?

If yes, how much?

Left Right

Yes No

Yes No

Yes No

Yes No

Yes No

PLEASE NOTE: If your insurance is an HMO, you MUST have a referral for EVERY visit. Your

Primary care doctor writes the referral and you must present it each time you are seen in our

office. Occasionally, your PCP will allow for more than 1 visit. If this is the case, the first must

occur within 30 days of the date of the referral or it will be considered invalid. Additionally,

depending on your plan, your referral may expire before all of the visits are used. In this case,

you will be required to obtain a new referral prior to your office visit. Please note that it is the

patient's responsibility to obtain a referral and verify that it is accurate and current. Our office

will not obtain referrals and you will be asked to reschedule your appointment should you arrive

without one. If you have questions regarding your insurance or how to obtain a referral, please

contact your Primary Care Physician.

Patient's Initials: ______ _

I understand the Privacy Policy, Office Policy and HIPPA policy: ----------

Medical Tests:

Have you had an MRI of the brain? Yes No

Have you had an MRI of the spine? Yes No

Have you had an EEG? Yes No

Have you had an EMG/NCV? Yes No

If yes, then when?

If yes, then when?

If yes, then when?

If yes, then when?

As a Workers Compensation patient, you may be covered by insurance if your injury is reported at work

and verified with your employer. Be sure to inform the office personnel that your injury resulted during

employment. The patient is ultimately responsible for any unpaid balance.

Are you seeing the doctor for a work related injury? Yes No

Workers Compensation Claim number:

Insurance Carrier:

Insurance address:

Name of Employer:

Date of injury:

Contact Person:

Phone number:

Employer's Phone Number:

We will obtain a copy of insurance cards, but ask that you complete this section, if applicable. The "insured"

refers to the individual who subscribes to the insurance plan.

Primary Insurance:

ID number:

Group number:

Name of insured:

SSN of insured:

Insured's Date of Birth:

Secondary Insurance:

ID number:

Group number:

Name of insured:

SSN of insured:

Insured's Date of Birth:

REGISTRATION

Marital Status: _Single _Married _Divorced __ Separated _Widowed

Employer:------------------------------------

Employer Address:--------------------------------

I consent to the treatment necessary for the care of the above named patient. I authorize the release of all medical records to the referring and

family physicians and to my insurance company, if applicable and that a copy of this authorization can be used in place of the original. I allow fax

transmittal of my medical records, if necessary. I understand that my medication history will be obtained by Chesapeake Neurology Associates,

via CRISP and POMP. I understand that my insurance is a contract between myself and my insurance company and Chesapeake Neurology

Associates assumes no responsibility for unpaid claims. I authorize claims to be billed electronically. I understand and agree that I am responsible

for any charges not paid by the insurance after 90 days. I acknowledge full financial responsibility for services rendered by Dr. Kerasidis, Dr.

Schmaltz, Gabriella Reed, CRNP, Tara Wood, CRNP, Shannon Seney, CRNP, Amanda Schmermund, PA-C, Lori Maddox, PA-C, Alexandria Rigby,

LCSW, and D.N. Anderson, LCPC including deductibles, copays, non-covered services, coinsurance and items considered "not medically necessary"

including appeals and rejections by my insurance company. I further understand that testing performed at CNA may be subject to a different fee

that will be my responsibility and I will need to contact my insurance company directly for information on those fees. I understand that payment

of charges incurred is due at time of service, unless other definitive financial arrangements have been made prior to treatment. Interest will

accrue at 18% annually on all unpaid balances. I understand that there is a $50 returned check fee. I also understand that 24 hours' notice Is

required for cancellations. A $50 "No Show" fee will be charged for any missed appointments not cancelled with more than 24 hours' notice.

The practice reserves the right to increase this fee for habitual no shows. I agree to pay all reasonable attorney fees and collection costs in the

event of default of payment on my charges. I further authorize and assign insurance payments to be made directly to Harry Kerasidis, MD should

they elect to receive such payment. I have read and fully understand the above consent for treatment, financial responsibility, release of medical

information and insurance authorization.

Date: ___________ _ Signature: ______________________ _

PATIENT INFORMATION (Please print and complete all information)

Last Name: __________ Sex: __F __M Age ___ Date of Birth: ______ _ First Name: Middle Initial Home phone _________ _

Street Address:---------------------------------

City: ________________ State: _____ Zip code: _____ SSN _____ _ Person to contact if patient is a minor: Phone number: ________ _

Cell number: __________ Email Address: _________________ _

Preferred Method of Contact: _Home _Work _Cell phone _ Email

What type of message can we leave at this #? _detailed _doctors name only _do not leave message

Patients Marital Status:_ Single _Married _Separated _Divorced _Widowed

Spouses Name: ___________ Contact Number: ______________ _

Emergency Contact Person: Number: ______________ _

Patients Employer: _________________ Phone# __________ _

Address:---------------------------------- City: _____________ State: _______ Zip code: ___________ _

Employment Status: _ Full time _Part Time _ Unemployed _Retired _Student

Have you or any of your family members been seen here before: Yes No If yes, then who?

Have you been seen by Dr. Kerasidis in the hospital prior to today's visit? Yes No

INSURED (name of the person your insurance is in, disregard of same as patient)

Relationship of patient to the insured: _Spouse _Parent _Child __ Adopted Child _Other

Last Name: ___________ Sex: _F _M Age: ___ Date of Birth: ________ _ First Name: __________ Middle Initial: ____ Home Phone: __________ _

Street Address: _____________________ Work phone: ________ _ City: ____________ State: ___ Zip Code ______ SSN: ______ _

( _ I -I L _') /\ 1 ) l /\ 1<. l 1 ' I I _./

Chesapeake Neurology Associates Insurance and Financial

Agreement

By signing below, I understand that Chesapeake Neurology Associates is agreeing

to bill my personal health insurance. In doing so, I agree to comply with all of the

terms within my insurance policy. This includes but is not limited to payment of

copays at the time of service and any deductible that my policy requires that I pay as part of my responsibility. I further acknowledge Chesapeake Neurology

Associates will not forward any bills to my attorney or my personal injury

protection insurance{PIP) nor will the company wait until a settlement is reached

in any pending litigation that I may_be involved'and that payment is to be made

directly by me to-Chesapeake Neurology Associates· immediately upon receiving a

statement of any balance due.

Patient/Guarantor Signature: _______ _

Patient Name: -------------

Patient DOB: _____ _

Date: ____ _

Witne<;<. Ciignature· _______ _

Witness Name Printed: _________ _

• ·,1 ' ' .

Signature of Patient/Guardian:

Patient Controlled Substance Agreement

The purpose of this contract Is to establish an agreement between the clinician and patient on conditions for prescribing controlled substances In the event that the use of these agents Is deemed medically necessary. Controlled substances may Include pain medications, sleeping agents, some forms of anxiety medications and stimulant medications. Should controlled medication be a part of your treatment, th� frequency and type of medication prescribed will be determined by our providers. These rules are intended to protect you and others from the improper use of controlled substances. These terms are in compliance with current DEA regulations. This contract Is valid for the duration of my treatment at Chesapeake Neurology

Associates.

1. I will take my medications as prescribed. Prescriptions provided to me are to last for thirty {30) days.

2. I am responsible for the controlled substance medications prescribed to me. I will not receive replacements for lostor stolen medkatiom, unle;s I provide CNA w1th a sig11ed, valid µ,.)l1ce repo:. and contact number ot the reportingofficer. I will not receive controlled substances from any other providers, unless it Is approved by the providers atCNA. Concomitant use of controlled substances not approved by CNA will result in discharge from the practice.

3. I will not ask for early refills.

4. I may be required and will agree to have random drug testing to confirm compliance and/or usage of other drugs. Iunderstand that I will be responsible for the cost of this testing. I agree to comply with drug screening and pill countsas they are deemed necessary by the CNA providers. Presence of unauthorized substances detected in toxicologyscreens may result in discharge from our practice.

S. I understand that (48) hour business notice Is required for all prescription refills. I will not call on the day that myprescription is due to be refilled. Medications can only be refilled Monday-Friday during office hours. I will not call forprescription refills after office hours.

6. I will schedule an appointment every two (2) months. Failure to be seen every two {2) months may result in theInability to receive further presciiptions, or discharge from the practice. Due to the volume of patients seen by CNA, Jmay be scheduled with any of the providers In the practice in order to remain compliant with my follow upappointments.

7. I understand that emergencies do arise and that if for any reason my appointment is cancelled, that it is myresponsibility to secure the next available appointment. This appointment mav be scheduled with any of th"'providers ir, the pract:Ce to er.su;e compliance with Di:A regulations.

8. All patients are expected to comply fully with their individual treatment recommendations. ff my providerrecommends additional specialized care, I agree to follow their recommendations. Specialized care may includephysical therapy, psychotherapy, occupational therapy or management by a pain specialist.

9. I understand that I must provide photo Identification when picking up my prescriptions. I will provide sfg��d writtenconsent if someone else will be picking up a prescription on my behalf. This applies to all patients 18 years of age orolder.

10. In the event that I need to change medications between appointments, I understand that I will be required to bringmy remaining medication to the office for disposal.

11. I understand that if I violate any of the above conditions, my prescriptions for controlled medications may beterminated and it may result in discharge from the practice. If the violation involves obtaining these medications fromanother Individual, or the concomitant use of non-prescription illicit drugs, I may also be reported to other physicians,pharmacies, and the proper authorities.

Print Patient's Name: __________ _

Today's Date: __________ _

Signature of Patient of Guardian:

Chesapeake Neurology Associates

RECEIPT OF PRIVACY PRACTICES

WRITTEN ACKNOWLEGEMENT FORM

I, _____________ have received and/or reviewed a copy of

Chesapeake Neurology Associates Notice of Privacy Practices.

Signature of Patient Date

I I