Please fill out this form completely. Thank You. - Head-Zone

Please fill out this form completely. Thank You.
Date this form is being completed:
Last Name
Date Of Birth
Street Address
/
/
This Form Expires on:
First Name
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/
Middle Initial
Sex
Home Phone
City, State & Zip
PARENT/GUARDIAN # 1 *Please note if “same” as patient’s info above
Full Name
Relation To Patient
Date Of Birth
Home Street Address *
City, State & Zip *
Home Phone Number *
Cell Number
E-Mail Address
Name of Employer
Active Military?
/
(
(
/
Social Security Number
)
)
Work Number
(
-
-
-
-
)
@
Occupation
Is the patient living with this parent/guardian?
PARENT/GUARDIAN # 2 *Please note if “same” as patient’s info above
Full Name
Relation To Patient
Date Of Birth
Home Street Address *
City, State & Zip *
Home Phone Number *
Cell Number
E-Mail Address
Name of Employer
Active Military?
/
(
(
/
Social Security Number
)
)
Work Number
(
)
@
Occupation
Is the patient living with this parent/guardian?
EMERGENCY CONTACT – Please list an individual living locally (other than parents/guardians)
Full Name
Relation To Patient
Phone Number
City Of Residence
(
)
PRIMARY CARE DOCTOR
Full Name
Name of Practice (if any) Phone Number
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)
Fax Number (if known)
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)
Karen Laugel, MD Nicholas Mongillo, MD
Sarah Clark, MHS, PA-C Diana Reichbind, MPH, MHS, PA-C Megan Bromley, MHS, PA-C
HeadZone, LLC Phone (203) 538-5400 Fax (203) 538-5327
2 Ivy Brook Road, Suite 213, Shelton, CT 06484
Name:
Date of Birth:
PATIENT’S HEALTH (Please indicate if “none” at this time)
Allergies
Medication / Food / Other
Reaction
Hospitalizations / Surgeries / Injuries
Specify
Date
Date
Prior History
Date Of Onset
Chronic Headaches: Yes/No
LD/ADD: Yes/No
Seizures: Yes/No
Psychiatric Disorder: Yes/No
Previous Head Trauma:
Other:
Current Medications
Specify
Date Began Taking
Name:
Karen Laugel, MD Nicholas Mongillo, MD
Sarah Clark, MHS, PA-C Diana Reichbind, MPH, MHS, PA-C Megan Bromley, MHS, PA-C
HeadZone, LLC Phone (203) 538-5400 Fax (203) 538-5327
2 Ivy Brook Road, Suite 213, Shelton, CT 06484
* * * * THIS PAGE HAS 2 SECTIONS, PLEASE COMPLETE BOTH SECTIONS * * * *
SECTION ONE – HIPAA (Privacy Act)
I acknowledge that I have received, or have been offered, a copy of HeadZone’s Medical Information Privacy to review, and I have
reviewed it, or have been informed that I have a right to review it, prior to signing this consent.
I hereby consent to the use and disclosure of my personal medical information by HeadZone to carry out treatment, payment, and
health care operations as described in the Notice, which contains a more complete description of the uses and disclosures to which
my child’s personal medical information may be processed in the course of treatment, payment, and health care operations. This
includes communication with my child’s school personnel including the nurse, guidance counselor, school psychologist, teachers,
principal, coaches, and athletic trainers, as well as coaches and athletic trainers from my child’s private teams.
I have been informed that the terms of the Notice may change from time to time, and that I may obtain a copy of the most recent
Notice at the time of any office visit.
I have been informed that I have the right to request that HeadZone restrict how my personal medical information is used or
disclosed to carry out treatment, payment or health care operations, but that HeadZone has the right to refuse to agree to the
requested restrictions. I also have been informed that if HeadZone agrees to a restriction I request, such agreement is legally
binding upon them.
I have been informed that I have the right to revoke this Consent in writing at any time except to the extent HeadZone has taken
action in reliance upon this consent prior to revocation.
Signature:
Date:
SECTION TWO – Insurance Information
Primary Insurance
Subscriber/ID #
Policy Holder
Secondary Insurance
Subscriber/ID #
Policy Holder
I authorize payment of benefits directly to HeadZone. I agree to pay all charges incurred from my child’s care,
including neurocognitive testing which may not be covered by my insurance or may not be reimbursed to the
physician providing care. I assign any insurance benefits to which I may be entitled to the physician providing
the services. I understand that if I have a secondary insurance company that HeadZone participates with, they
will bill that insurance for my family. I understand that I am responsible for any charges not covered by this
assignment. I will be notified by HeadZone for any amounts due not covered by my insurance and will have the
opportunity to pay with cash, check or credit card within 30 days. However, if I do not pay such amounts within 30 days
Karen Laugel, MD Nicholas Mongillo, MD
Sarah Clark, MHS, PA-C Diana Reichbind, MPH, MHS, PA-C Megan Bromley, MHS, PA-C
HeadZone, LLC Phone (203) 538-5400 Fax (203) 538-5327
2 Ivy Brook Road, Suite 213, Shelton, CT 06484
of notice, then I authorize HeadZone to charge such amounts to the credit card that I provided to HeadZone upon
registration. I understand that my credit card information is HIPAA protected.
If I have a deductible plan, then HeadZone will initially submit my bill to my insurer, and my insurer, ASSUMING THAT I
HAVE PAID MY BILL TO HEADZONE, will subtract that amount from my deductible. This will subsequently determine
when my insurance coverage will begin. I understand that I must pay my bill to HeadZone to avoid misrepresenting
information provided to my health insurance company that results in health care benefits being credited to me. I will be
notified by HeadZone for any amounts due not covered by my insurance and will have the opportunity to pay with cash,
check or credit card within 30 days. However, if I do not pay such amounts within 30 days of notice, then I authorize
HeadZone to charge such amounts to the credit card that I provided upon registration. I understand that my credit card
information is HIPAA protected.
If I choose not to provide a credit card on file to guarantee payment, then I know I must pay for my child’s visit
in full at the time of service.
In agreement, please sign below:
Signature:
Date:
Please provide the Receptionist with your health insurance card and a credit card; privacy and security
of all information is HIPAA protected.
Karen Laugel, MD Nicholas Mongillo, MD
Sarah Clark, MHS, PA-C Diana Reichbind, MPH, MHS, PA-C Megan Bromley, MHS, PA-C
HeadZone, LLC Phone (203) 538-5400 Fax (203) 538-5327
2 Ivy Brook Road, Suite 213, Shelton, CT 06484