SETH TUWINER,M.D.

Riverside Office Park

19490 Sandridge Way•Suite260•Lansdowne,VA 20176

Office 703.293.5244 • Fax703.858.5323

DATE:


CO-PAY:

NAME: DATE OF BIRTH:

ADDRESS

MARITAL STATUS:SS#:

HOME#:WORK PHONE#: CELL#:

PLACEOFEMPLOYMENT:

ADDRESS OF EMPLOYER:

SPOUSE/PARENT NAME:

SPOUSE/PARENTPLACEOFEMPLOYMENT:

ADDRESS OFEMPLOYER:

PHONE NUMBER:

EMERGENCY CONTACT:

PHONE NUMBER:

PRIMARY INSURANCE COMPANY

NAME OF SUBSCRIBER: ______SS#:

SUBSCRIBER'S DOB:

MEMBER ID#: ______GROUP#: ______

INSURANCE CO. ADDRESS:

INSURANCE CO. PHONE #:

SECONDARY INSURANCECOMPANY:

NAME OF SUBSCRIBER: SS#:

SUBSCRIBER'S DOB: ______

MEMBER ID # GROUP#: ______

INSURANCECO.ADDRESS:

INSURANCE CO. PHONE#:

FOR WORK RELATED INJURIES

DATE OF INJURY:REPORTEDTOSUPERVISORYES NO

NAME OF SUPERVISOR:PHONE#:

WORKERS COMPENSATIONINSURANCE CARRIER

MAILING ADDRESS

PHONE #:CLAIM#

CASE MANAGER NAME: PHONE#:FAX#:

SETH TUWINER,M.D.

Riverside Office Park

19490 Sandridge Way•Suite260•Lansdowne,VA 20176

Office 703.293.5244 • Fax703.858.5323

Please answer ALL questionsDate: ______

Name How did you hear about thispractice? ______

Primary care physician’s name:

Birthdate:__Age Height Weight

Right-handedLeft-handed

CurrentMedications(list:Name,Dose,Frequency)orNone

AllergiesYesNo

Reason forvisit

Dateofsymptomonset

Medical/SurgicalHistory

SETH TUWINER,M.D.

Riverside Office Park

19490 Sandridge Way•Suite260•Lansdowne,VA 20176

Office 703.293.5244 • Fax703.858.5323

Social History

Marital StatusOccupation

Number ofchildren

Do yousmoke? Yes No

Do you consumealcohol? Yes


Do you use Drugs?

Have you recently traveled?(Dates/location):

Family History

Hypertension

Diabetes Mellitus

High Cholesterol HeartDisease

Stroke

Cancer

NeurologicalConditions

Parkinson'sdisease

MultipleSclerosis

Epileptic

Other

(If other, and/or neurological condition(s) exist, please specify)

Additional relevant medicalhistory/information

PatientSignatureDate

SETH TUWINER,M.D.

Riverside Office Park

19490 Sandridge Way•Suite260•Lansdowne,VA 20176

Office 703.293.5244 • Fax703.858.5323

DearPatient,

HIPAAregulationsprohibityourphysicianfromsharinginformationregardingyourmedicalcarewithotherfamilymembersorfriendsunlesspriorauthorizationbythepatient isgiven.

I, authorizeDr.SethTuwiner andhisstafftodisclosemymedicalinformationtothefollowingfamilymembersorclosefriendswhoassistinmycare.

NAME:RELATIONSHIP:

PleasecheckallthatapplyforcallsthataremadetoyoufromDr.Tuwinerorstaff:

Messages may be left on my cellphone

Messagesmaybe leftonmyhomephone

Donotleavemessagesonanyphonenumber

PatientsignatureDate

Pleasebeadvised,itisyourresponsibilitytokeepthisinformationuptodateregardingaddingorremovingnamesfromyourdisclosurelist.

SETH TUWINER,M.D.

Riverside Office Park

19490 Sandridge Way•Suite260•Lansdowne,VA 20176

Office 703.293.5244 • Fax703.858.5323

ASSIGNMENT OFBENEFITS

Asthepatientwhosenameappearsbelow,IherebyauthorizeSethTuwiner,M.D.,NeurologyConsultantServices,P.CtofileonmybehalfforpaymentforanymedicalbenefitsarisingoutofanyinsurancecoveringmeandherebyassigningthebenefitstoSethTuwiner,M.D.,NeurologyConsultantServices,

P.C. for application on the patient's bill. I certify that the information reported with regard tomyinsurancecoverageandmedicalhistoryisaccurateandcompleteandfurtherauthorizethereleaseofnecessary information, including medical information, for this or any related claim or medical benefits.Ipermitphotocopyofthisauthorizationtobeusedinplaceoftheoriginal.

IunderstandthatIamliableforpaymenttoSethTuwiner,M.D.,Virginia Center for Neuroscience,forallco-insurance, co-pays,anddeductiblesasrequiredbymyinsuranceandparticipatingagreements(ifany)betweentheinsurancecarrierandSethTuwiner,M.D.,Virginia Center for NeuroscienceFurthermore,Iwillberesponsibleforpaymentofchargesnotcoveredbymyinsuranceplan.

Payment is requested at the time of services are rendered. If expensive or extended treatmentisanticipated, arrangements may be made for a payment plan. All professional services renderedarechargedtothepatientandthepatientisresponsibleforallfeesregardlessoftheinsurancecarrier.SethTuwiner,M.D.,Virginia Center for Neurosciencewillbillchargestotheprimary and/or secondaryinsurance carrier. Seth Tuwiner, M.D., Virginia Center for Neuroscience will bill theremainingamounttothepatient.Anybalancedue,forwhateverreason,i.e.co-payments,failuretohaveproperreferral, denial of workers compensation benefits, is the patient's responsibility. Payments forchargeswhich are the patient's responsibility are to be paid within 30 days. The patient/guarantor signingbelowacceptsresponsibilityforpayment.Shouldthepatient'saccountbeturned overforcollection/andoranattorneyforpaymentdue,thepatientand/orguarantorshallpayanycollectioncostsand/orreasonableattorneyfees.Thestaffwillgladlyassistyouwithanyaspectofthispolicy.

PatientSignatureGuarantorSignature

CANCELLATIONPOLICY

IF YOU ARE UNABLE TO KEEP YOUR APPOINTMENT, WEREQUIRE24 HOURS NOTIFICATION IN ORDER TO AVOID

A$75.00FEE.