Sugar Land Neurology & Sleep M.D., P.A.
1111 Hwy 6, Ste. 275 Sugar Land, TX 77478
(713) 234-7132

NEW PATIENT REGISTRATION

PATIENT INFORMATION
Do you have a Primary Care Doctor?

Do you have a referring Physician?

Do you have a Insurance?


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 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 persons whom you would like us to discuss your health care. (Including, but not limited to: test results, recent visits, medication requests, appointment information, and billing/insurance information).
I wish to be contacted in the following manner:
*This does not authorize copies of PHI to be mailed or faxed to persons listed. To obtain copies of PHI a valid HIPAA release is required.
HISTORY

SURGICAL HISTORY

MEDICAL HISTORY

CURRENT MEDICATIONS & DOSAGE

SOCIAL HISTORY


Any use of illicit drugs?

EMPLOYMENT

FAMILY HISTORY


EYES



ENT



CARDIOVASCULAR



RESPIRATORY



GASTROINTESTINAL



GENITOURINARY

MUSCULOSKELETAL



NEUROLOGICAL (HEAD)



PSYCHIATRIC



ALLERGIES



CONSTITUTIONAL SYMPTOMS



OTHER MEDICATIONS

PHARMACY INFORMATION
ACKNOWLEDGMENT
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).

DR. M. FAISAL KHAN, M.D., DABSM
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 diagnostic testing of any kind (x-ray, MRI, CT, laboratory) related to this visit, please bring the test results with you or have then 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 AND 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. Failure to notify the office of cancellation at least one full business day prior to your scheduled appointment or not appearing for your scheduled appointment may result in a No Show Charge.

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 the last year. Refills will not be approved after office hours or on weekends. Please allow 24 business hours for any refill request.

MESSAGES
Please allow our staff 24 business hours to return any phone calls.
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 Physician Assistant/Nurse Practitioner will see the follow ups. Exceptions can only be made depending on individual case basis.