PATIENT INFORMATION
I understand that I am responsible for my bill. I authorize Sugar Land Neurology & Sleep to act as my agent in helping me obtain payment from my insurance company/companies. I authorize payment directly to Sugar Land Neurology & Sleep M.D., P.A.. I authorize the release of information necessary to collect payments to all my insurance companies. I further authorize release of medical information to any and all physicians involved in my care. I permit a copy of this authorization to be used in place of the original. I authorize the use of the “Signature on File” to be used on all my insurance submissions. I understand that I am responsible for notifying the office of any Precertification or referral needed for my insurance.
DISCLOSE INFORMATION
PERMISSION TO DISCLOSE RELEVANT HEALTH INFORMATION TO FRIENDS AND FAMILY
We value your privacy and ask that you help us identify the people whom you would like us to discuss your health care with. (Including, but not limited to: test results, recent visits, medication requests, appointment information, and billing/insurance information).
** I wish to be contacted by the following manner:
*This does not authorize copies of PHI to be mailed or faxed to the people listed. To obtain copies of PHI, a valid HIPAA release form is required.*
PAST MEDICAL HISTORY
CURRENT MEDICATIONS & DOSAGE
SOCIAL HISTORY
EMPLOYMENT
FAMILY HISTORY
PHARMACY INFORMATION
In terms of absence of the providers, test results/advice regarding disease process will be discussed/revealed on his/her return or by a qualified office staff. In the meantime, patience and good manners are expected from the patients, keeping in view the sanctity of the practice.
All the new patients will be seen by Dr. Khan while his Nurse Practitioner will see the follow ups. Exceptions can only be made depending on the individual case basis.
Our physicians offer clinical rotations in which we provide valuable hands-on experience for medical students, whom we teach today will become the doctors of tomorrow, carrying our values and skills shaping them into the future of medicine.
We do not see any type of accident related cases or Workmen’s Compensation.
CANCELLATION POLICY / NO SHOW POLICY FOR APPOINTMENTS
We understand there are times when you may need to miss an appointment due to emergencies or unexpected obligations related to work or family. However, when you do not call to cancel an appointment, it may prevent another patient from receiving much-needed care. Similarly, if another patient fails to cancel, we may be unable to schedule your visit due to a seemingly “full” appointment book. We understand emergencies can happen, and such situations will be evaluated on a case-by-case basis.
To ensure that we can provide timely care to all our patients, we require at least 24 business hours notice for an appointment cancellation. Failure to cancel within this timeframe or failure to attend your appointment without notice (no-show) will result in a $30 charge. This charge is not billable to insurance and it is your personal responsibility.
We appreciate your cooperation in helping us serve all patients as efficiently and fairly as possible. We thank you for choosing Sugar Land Neurology & Sleep for your care – we look forward to continuing to serve you. If you have any questions about this policy, please don’t hesitate to contact our office.
NOTICE OF PRIVACY PRACTICES
You have been given the Notice of Privacy Practices for Sugar Land Neurology & Sleep and its associates. This Notice describes your legal rights regarding your health information and will inform you of the legal duties and privacy practices of Sugar Land Neurology & Sleep with respect to health information created for services generated by Sugar Land Neurology & Sleep M.D., P.A. If you receive services by your physician or other health care provider at a different location, you may want to ask about that office or clinic’s health information privacy policies and notices because they could be different.
Your name and signature below indicate that you have been provided a copy of this Notice of Privacy Practices.
If you have a question regarding any of the information set forth in this Notice of Privacy Practices, please do not hesitate to call the Privacy Official at 713-234-7132.
Note: In the case of an Obstetrical patient, this signed acknowledgment for receipt of the Notice of Privacy Practices also serves as receipt of the Notice of Privacy Practices on behalf of the newborn(s).
Muhammad Faisal Khan, M.D.
Board Certified in Adult Neurology & Sleep Medicine
We appreciate the trust placed in us to provide your specialty care. The following information clarifies our respective responsibilities in providing and receiving information. Our patient care procedures have been developed over time to maximize your visit experience and outcome.
NEW PATIENTS: New patients are usually referred by their primary care physician or other specialist. If you have received any diagnostic testing of any kind (X-Ray, MRI, CT, Laboratory) related to this visit, please bring the test results with you or have them forwarded to us prior to your visit.
If you are insured with a health maintenance organization (HMO), your primary care physician will need to complete a prior authorization through your insurance BEFORE you are scheduled. Without a referral, we will not be able to bill your insurance and you may be asked to pay in full at the time of your visit.
We do not see any type of accident related cases or Workmen’s Compensation.
Please bring the following to your visit: Insurance Card, Photo ID, Any Medical Records
APPOINTMENTS: We attempt to contact patients 24-48 hours prior to their appointment. Our schedule is usually booked several weeks in advance, so we ask for at least 1 business day notice for cancellation.
TEST RESULTS: Test results are given during a follow-up visit only. You will be asked to schedule an appointment to discuss results of any tests ordered by the physician to avoid misunderstandings and improve the patient care outcome. Please do not contact the office for a copy, fax, or verbal disclosure prior to your follow-up appointment. NOTE: You will be contacted should any result require action prior to your scheduled follow-up appointments.
FORMS: Your primary care physician will complete any disability, FMLA, or functional capacity evaluation forms.
REFILLS: Medications prescribed by our physician may be refilled if you have been seen within 6 months. Refills will not be approved after office hours or on weekends. If you need a refill on medication, please contact your pharmacy BEFORE calling our office, they will send us an electronic request. Please allow 24-48 business hours for any refill request.
MESSAGES: Please allow our staff 24 business hours to return any phone calls.