Neurology Practice Patient Care Agreement

Patient Information

Name: _________________________ Date of Birth: _____________ Medical Record #: _______________ Date: ____________________

Agreement Terms

1. Appointment Policies

• I agree to arrive 15 minutes before scheduled appointments
• I understand that missing three appointments without 24-hour notice may result in discharge from the practice
• I will notify the office at least 24 hours in advance if I need to cancel or reschedule

2. Medication Management

• I understand that medication refills require 48-72 hours' notice
• I agree to use one pharmacy for all neurological medications
• I will take medications only as prescribed and inform the provider of any side effects
• I understand that certain controlled substances require monthly visits

3. Communication

• I agree to respond to calls regarding test results within 48 hours
• I will use the patient portal for non-urgent communication
• I understand that emergency situations require calling 911 or visiting the ER

4. Testing and Procedures

• I agree to complete recommended diagnostic tests within the timeframe specified
• I understand that certain procedures require preparation and will follow instructions
• I will inform the practice of any changes in my medical condition or medications

5. Financial Responsibility

• I understand I am responsible for applicable copays and deductibles
• I agree to maintain current insurance information with the practice
• I will notify the practice of any changes in insurance coverage

Acknowledgment

I have read and understand the above agreement. I agree to comply with these policies as a condition of receiving care at [Practice Name].

Patient Signature: _________________ Date: _______________

Provider Signature: ________________ Date: _______________

[Practice Name and Contact Information]