NeuroCare Institute of Central Florida, P.A.

FIRST VISIT

On your initial visit, we will obtain from you a personal history regarding your present condition and past medical history. The doctor will conduct a comprehensive neurological examination based on your history. The initial examination will usually last 45-60 minutes. If needed, subsequent visits will be scheduled. Please notify us within 24 hours of your scheduled appointment if you are unable to keep you appointment.

All appointments must be confirmed or they will be cancelled.

You will need to bring the following information with you on your initial office visit:

• Your insurance card
• Any referral forms required by your insurance provider
• A drivers license or current picture identification
• A list of current prescription and over-the-counter medications you are taking, including dose and frequency.
• Pertinent information about your medical and surgical history. Bring any pertinent x-rays or records you may have.
• New Patient Forms (8 pages)

FORMS

For your convenience you can download and print out our New Patient Information, Medical History, and Office Financial Policy forms from this website, following the instructions below.

To read these forms, you must have the free Adobe Acrobat Reader [printable page troubleshooting].

• New Patient Forms (8 pages)
• Application for Disabled Parking Permit

When you have printed the forms, the text may appear somewhat fuzzy; this is normal. Please complete the printed form and bring them to our office on your first visit.

CONFIDENTIALITY

As our patient, your records will always be held in the strictest confidence. We will not release your medical records to anyone without your written authorization. If you wish to have your records from Dr. Pineless' office sent to another physician, attorney, insurance company representative or another party, we will be happy to comply with this request after obtaining proper written authorization. We will mail your records to the above-mentioned persons once this is completed. We reserve the right to charge a fee for this service.

EMERGENCIES

Should an emergency arise at any time, call 911. If you need to speak with the doctor urgently, please call our office at 407.657.7900. At night or on weekends, our answering service will take your name and telephone number. They will contact the physician on call, who will return your call as soon as possible.

PRESCRIPTIONS

If you should run out of medications prescribed for you by Dr. Pineless before your next appointment, have your pharmacist call the office at 407.657.7900 during regular office hours.

FEES AND BILLING

Full payment is due at the time professional services are rendered. Our office accepts cash, checks, MasterCard, Visa, Discover and money orders. In addition, we accept Medicare assignment, and we are members of various PPO's and HMO's, the names of which are available upon request. You will be responsible for paying any deductible at the time of service unless you can show that the deductible has been met.

We will provide you with an itemized "superbill" to submit to your insurance carrier for reimbursement. For our Medicare patients, we will submit all claims on your behalf. As a courtesy to our Medicare patients we will also file your secondary insurance. If you do not have a secondary insurance you will be responsible for your 20% or any deductible at the time of your visit. For our HMO and PPO patients, your co-payment is due at the time of your visit. Claims to your insurance company will be filed on your behalf.

HOSPITAL AFFILILATIONS

Dr. Pineless is on the active staff of ORHS South Seminole Hospital in Longwood.

ADDITIONAL INFORMATION

Additional information must be given on Living Wills and Durable Power of Attorney for Healthcare. For your convenience, Dr. Pineless has provided you with the Living Wills form, and the Durable Power of Attorney form

PRIVACY PRACTICES

Dr. Pineless wishes to present a document outlining privacy practices. Please read it carefully. We have also provided other forms regarding your protected health information to be signed as needed.

• Notice of Privacy Practices
• Acknowledgement form
• Request to Inspect and Copy Protected Health Information
• Patient Authorization for Use and Disclosure of Protected Health Information
• Authorization for Release of Confidential Information