NEUROLOGY OF ARKANSAS, PA
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2400 Crestwood Dr. Ste 101, North Little Rock, AR 72116
P.O. Box 16563, Little Rock, AR 72231
Phone: (501) 945-4710 Fax: (501) 955-9027
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JULIA M. McCOY, M.D.
Dear Patient,
You have been scheduled for an appointment in our office. In order to provide the best, most efficient care, we ask that you fill out the attached paperwork and bring with you at the time of your appointment.
THINGS TO KNOW OR ITEMS TO BRING TO YOUR APPOINTMENT:
1. PLEASE CALL OUR OFFICE IMEDIATELY if you have seen a neurologist in the last year, if your problem is related to a Motor Vehicle Accident, Workman's Compensation, and/or you have an attorney assisting in your care.
2. Bring completed paperwork, (FRONT & BACK ), insurance cards(s) insurance referral (if required by your insurance company) and current medication or list.
3. Bring any MRI or CT films and reports
4. For EMG/NCV testing we ask that you DO NOT WEAR lotions, oils, Vaseline, gels or creams on your skin the day of testing. (Deodorant and make-up are okay)
All the items mentioned above are very important to provide you with the best care. In the unlikely event you cannot provide all the information we’ve requested, your appointment may be rescheduled. Please call our office the day before your appointment to confirm your appointment time and AVOID cancellation.
You have been scheduled for:______
Please arrive 30 minutes prior to your scheduled appointment time.
Should you need to cancel or reschedule your appointment, please call 501-945-4710
Within 24 hours of your appointment time to avoid a cancellation fee.
Thank You,
Julia M. McCoy, M.D.
NEUROLOGY OF ARKANSAS, PA
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2400 Crestwood Dr. Ste. 101, North Little Rock, AR 72116
P.O. Box 16563, Little Rock, AR 72231
Phone: (501) 945-4710 Fax: (501) 955-9027
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JULIA M. McCOY, M.D.
Please answer the following questions. We ask that you sign and date the bottom of the page when completed.
If you answer yes to any of the following questions you must contact our office immediately to ensure proper care.
1. Has a neurologist seen you in the last 6-12 months? Y N
If so, who? Please obtain records and bring them to our office ASAP.
2. Have you had an Nerve Conduction study done in the last 6-12 months? Y N
If so, when and by whom? Please supply our office with a copy of the results.
3. Is your condition related to a Motor Vehicle Accident? Y N
4. Do you have an attorney handling a personal injury case for you? Y N
5. Is this Work Comp? Y N
I have answered the above questions to the best of my knowledge. I understand I am to
Contact Neurology of Arkansas @ 501-945-4710 if I have answered yes to any of the
above questions.
______
Signature of Patient Date
NEUROLOGY OF ARKANSAS, PA
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2400 Crestwood Dr. Ste.101, North Little Rock, AR 72116
P.O. Box 16563, Little Rock, AR 72231
Phone: (501) 945-4710 Fax: (501) 955-9027
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JULIA M. McCOY, M.D.
Patient Name: ______
Social Security #: ______
Today’s Date: ______
I understand in the event that my visit is not covered by my insurance company I am fully responsible for charges incurred and will pay the balance upon notification. This includes EMG/NCV testing.
______
Signature of Patient Date