Authorization for Neurological Treatment and Services

Patient Information

Name: _________________________ Date of Birth: _____________ Medical Record #: ______________ Date: _____________________

Authorization for Treatment

I, _________________________________, hereby authorize the neurological healthcare providers at [PRACTICE NAME] and their clinical staff to provide neurological evaluation, treatment, and services as deemed necessary for my medical care. This may include but is not limited to:

• Neurological examinations and assessments
• Diagnostic testing and procedures
• Administration of medications
• Laboratory studies
• Electroencephalogram (EEG) studies
• Electromyography (EMG) and nerve conduction studies

Financial Agreement

I understand that:

1. I am financially responsible for all charges whether covered by insurance or not
2. Insurance coverage verification is not a guarantee of payment
3. Co-payments and deductibles are due at the time of service
4. Any unpaid balance may be subject to collection procedures

Release of Information

I authorize [PRACTICE NAME] to:

• Release medical information necessary for treatment
• Submit claims to insurance providers
• Share relevant information with other healthcare providers involved in my care

Emergency Contact

Name: _________________________ Relationship: ______________ Phone: _________________________ Alt. Phone: _______________

Signatures

Patient/Guardian Signature: _________________ Date: __________ Witness Signature: ________________________ Date: __________

Certification

I certify that I have read and understand the above information and agree to the terms specified.

Initials: _______ Date: _______