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Neurology Associates
Enclosed in this packet is the information you need to create the necessary partnership
between us. This packet is designed to assist you in maximizing the benefits of the services
you receive from us.
1) Completed Patient Registration form (enclosed)
2) Completed Patient Medical Information form (enclosed)
For your visit we will need the following information:
Welcome to Neurology Associates... we value your confidence in our ability to address
your specialized health care needs. Neurology Associates offers comprehensive
neurological health care services including expert clinical diagnostics, specialized
neurological testing, and up-to-date treatment of diverse disorders affecting the brain,
spinal cord, peripheral nerves and muscles.
The staff of Neurology Associates is dedicated to providing you with compassionate,
comprehensive specialty care.
6) Copies of pertinent medical records, x-rays and the list of medications
We look forward to being of service to you.
3) Medical insurance cards (New Medicare Card)
Thank you for choosing Neurology Associates.
7) Texas Drivers License or US Photo ID (i.e.. Passport or State ID)
4) Drug Coverage Card
5) Completed Release of Medical Records form
Welcome...
Eric J. Pappert, M.D.
Toan Q. Vu, M.D.
Santiago Restrepo, M.D.
Vikki Alvarez, M.D.
Patrick Grogan, M.D.
Mike Garcia, Ph.D.
255 EAST SONTERRA BOULEVARD SUITES 210 & 211 SAN ANTONIO TX 78258 TEL: 210.656.2333 FAX: 210.656.1333
Neurology Associates
We accept checks, Visa, MasterCard, Discover and American Express. If you have any questions regarding this policy
please call our San Antonio Office: 210-656-2333. lf you have questions regarding the billing process or status, please
call our billing service: 512-282-2455. Your insurance statement for your bill may list the doctor’s name or our central
main billing office San Marcos Neurology Associates, P.A. as the payee.
If you are a member of a Managed Care, PPO, POS, or HMO plan with whom we contract, you will be responsible for only
your co-pay and/or the fulfillment of your deductible, prior to your visit with the doctor. HMO members are responsible
for the receipt of referral forms from their primary care physicians for new and follow-up visits. If you do not have a
referral, you will be responsible for the entire cost of the visit or will have to reschedule the visit when you have a valid
referral.
Thank you for choosing us as your health care providers. We are committed to your treatment being successful. Your
clear understanding of our Financial Policy is important to our professional relationship. All patients must complete our
“Patient Registration Forms” prior to your arrival to our office. You will find this form attached for your convenience. Our
business office policy requires payment at the time of each visit.
IF YOU NEED TO CANCEL A FOLLOW-UP APPOINTMENT: Please notify us at least 24 hours In advance. We will assess a
$50.00 no show fee for failure to present without a 24-hour notice and $75.00 no show fee for Neuropsychological
Assessments appointments.
Medicare patients (who do not have a supplement or secondary insurance) are responsible for their annual deductible
and co-pay at the time of visit. After Medicare pays its component, we will submit the remaining balance on your behalf
to your supplement only twice. Thereafter, you will be responsible for payment of this component.
We will confirm your insurance benefits with us prior to your first visit. New patient, neurology, specialty consultations /
examinations are approximately $250-370. The cost of follow-up visits are $80-200. If you do not have insurance, you
are responsible for payment in full, prior to scheduling your visit with the doctor. We will accept credit cards, check, or
cash to hold your appointment time.
If you have commercial, indemnity policy, you are responsible for payment in full, regardless of your insurance
company’s arbitrary determination of what they consider “usual” and “customary” rates. Insurance is a contract
between you and your insurance company. We are not a party to this contract.
Returned Checks: The office will assess a $50 return check fee for insufficient funds.
Unpaid Balances: Unpaid balances are subject to collection fees and attorney fees.
Forms and Letters: The office will assess a $25 fee for each page of a form or $150 for a letter requiring the attention of
staff or physician (e.g., disability, handicapped sticker, attorney or employer). We charge $25 for copies of medical
records for your use.
Signature:__________________________________________________________
Printed Name:______________________________________________________
FINANCIAL INFORMATION
Neurology Associates
HIPAA NOTICE OF PRIVACY PRACTICES
NEUROLOGY ASSOCIATES
Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a
possible victim of abuse, neglect, or domestic violence or the possible victim of airier crimes. This information will be disclosed only
to the extent necessary to prevent a serious threat to your health or safety or that of others.
TYPICAL USES AND DISCLOSURES OF HEALTH INFORMATION
Required by Law: We may use or disclose your health information when we are required to do so by law (Court or administrative
orders, subpoena, discovery request, or other lawful process). We will use and disclose your information when requested by
national security, intelligence, other State and Federal officials, and/or if you are an inmate or otherwise under the custody of law
enforcement.
We will keep your health information confidential, using it only for the following purposes:
Disclosure: We may disclose and/or share your healthcare information with other health care professionals who provide treatment
and/or service to you. These professionals will have a privacy and confidentiality policy like this one. Your health information may
also be disclosed to your family, friends, and/or other persons you choose to involve in you care only if you agree that we may do so.
Healthcare Operations: We will use and disclose your health information to keep our practice operable. Examples of personnel
who may have access to this information include, but are not limited to our medical records staff, outside health or management
reviewers, and individuals performing similar activities.
Treatment: We may use your health information to provide you with our professional services. We have established “minimum
necessary or need to know” standards that limit various staff members access to your health information according to their primary
job functions. Every staff member is required to sign our confidentiality statement.
Payment: We may use and disclose your health information to seek payment for services we provide to you. This disclosure
involves our business office staff and may include insurance organizations or other businesses that may become involved in the
process of mailing statements and/or collecting unpaid balances.
Emergencies: We may use or disclose your health information to notify or assist in the notification of a family member or anyone
responsible for your care in case of an emergency involving your care, your location, your general condition or death. If at all
possible, we will provide you with an opportunity to object to this use or disclosure. Under emergency conditions or if you are
incapacitated, we will use our professional judgment to disclose only that information directly relevant to your care. We will also
use our professional judgment to make reasonable inferences of your best interest by allowing someone to pick up files,
prescriptions, x-rays, or other similar forms of health information and/or supplies unless you have advised us otherwise.
It is our right to change our privacy practices provided law permits the changes. Before we make a significant change, this Notice will
be amended to reflect the changes, and we will make the new Notice available upon request. We reserve the right to make any
changes in our privacy practices, and the new terms of our Notice effective for all health information maintained, created, and/or
received by us before the date changes were made. You may request a copy of our Privacy Notice at any time by contacting our
Privacy Officer, Janis Adkins. Information on contacting us can be found at the end of this Notice.
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU
CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THIS FORM DOES NOT CONSTITUTE LEGAL
ADVICE, AND IT COVERS ONLY FEDERAL, NOT STATE, LAW.
State and Federal laws require us to maintain the privacy of your information and to inform you about our privacy practices by
providing you with this Notice. We must follow the privacy practices as described below. This Notice will take effect on April 14,
2003 and will remain in effect until it is amended by us.
Neurology Associates
HIPAA NOTICE OF PRIVACY PRACTICES
NEUROLOGY ASSOCIATES - continued
Amendment: You have the right to amend your healthcare information if you feel it is inaccurate or incomplete. Your request must
be in writing and must include an explanation of why the information should be amended. Under certain circumstances, your
request may be denied.
Access: Upon written request, you have the right to inspect and get copies of your health information (and that of an individual for
whom you are a legal guardian). There will be some limited exceptions. If you wish to examine your health information, you will
need to complete and submit an appropriate request form. Contact our Privacy Officer for a copy of the Request Form. You may
also request access by sending us a letter to the address at the end of this Notice. Once approved, an appointment can be made to
review your records. Copies, if requested, will be $25 for the first 20 pages and 15¢ for each page thereafter and the staff time
charged will be $75 per hour including the time required to locate and copy your health information. If you want the copies mailed
to you, postage will also be charged. If you prefer a summary or an explanation of your health information, we will provide it for a
fee. Please contact our Privacy Officer for a fee and/or for an explanation of our fee structure.
National Security: The health information of Armed Forces personnel may be disclosed to military authorities under certain
circumstances. If the information is required for lawful intelligence, counterintelligence or other national security activities, we
may disclose it to authorized federal officials.
YOUR PRIVACY RIGHTS AS OUR PATIENT
Public Health Responsibilities: We will disclose your healthcare information to report problems with products, reactions to
medications, produce recalls, disease/infection exposure, and to prevent and control disease, injury and/or disability.
Non-routine Disclosures: You have the right to receive a list of non-routine disclosures we have made of your health care
information (When we make a routine disclosure of you information to a professional for treatment and/or payment purposes, we
do not keep a record of routine disclosures; therefore, these are not available). You have the right to a list of instances in which we,
or our business associates, disclosed information for reasons other than treatment, payment, or healthcare operations. You can
request non-routine disclosures going back 6 years starting on April 14, 2003. Information prior to that date would not have to be
released (Example: If you request information on May 15, 2004, the disclosure period would start on April 14, 2003 up to May 15,
2004. Disclosures prior to April 14, 2003, do not have to be made available).
Marketing Health Related Services: We will not use your health information for marketing purposes unless we have your written
authorization to do so.
Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your health information.
We do not have to agree to these additional restrictions, but if we do, we will abide by our agreement (Except in emergencies).
Please contact our Privacy Officer if you want to further restrict access to your health care information. This request must be
submitted in writing.
QUESTIONS AND COMPLAINTS
Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders including,
but not limited to voicemail messages, postcards, or letters.
Phone Number: (210)656-2333
You have the right to file a complaint with us if you feel we have not complied with our Privacy Policies. Your complaint should be
directed to our Privacy Officer. If you feel we may have violated your privacy rights or if you disagree with a decision we made
regarding your access to your health information, you can complain to us in writing. Please request a complaint form from our
Privacy Officer. We support your right to the privacy of your information and will not retaliate in any way if you choose to file a
complaint with us or with the U.S. Department of Health and Human Services.
HIPAA Notice of Privacy Practices—This form does not constitute legal advice, and it covers only federal, not state, law.
HOW TO CONTACT US
Practice Name: Neurology Associates
$50 for Missed Appointments, Physician Letters, Prior Authorizations for Medications, and Phone
Consultations.
$25/per page for any documents requiring the physician’s signature (examples, FMLA, Disability
Forms, Life Insurance, etc) and Refills Outside Clinic Hours (Monday through Thursday 9am to 4pm and
Friday 9am to 12noon).
Please note the following charges that will be applied to your account for the respective services
not paid for by Medicare or your private insurance:
$75 for all Toxin Prior Authorizations (Botox, Dysport, Myobloc and Xeomin).
Patient Name: __________________________________________________________________
I acknowledge the receipt of this document and have been provided with a copy:
Signature: _____________________________________________________________________
RECORDING DEVICES: TO ENSURE CONFIDENTIALITY AND PRIVACY, ANY TYPE OF
ELECTRONIC RECORDING IS STRICTLY PROHIBITED WITHIN THE OFFICE.
$75 for Missed Neuropsychological Assessment Appointments.
Dear Neurology Associates Patients,
We are committed to providing you with the highest level of medical care. We understand that in today's
healthcare environment you may require the assistance of our office with items that are not part of
covered services by Medicare or your private insurance.
In order to provide these non-covered services, we have added multiple staff members to our offices.
As a result, we need to institute a charge for these non-covered services, in order to cover these added
personnel costs.
Neurology Associates
Eric J. Pappert, M.D.
Toan Q. Vu, M.D.
Santiago Restrepo, M.D.
Vikki Alvarez, M.D.
Patrick Grogan, M.D.
Mike Garcia, Ph.D.
255 EAST SONTERRA BOULEVARD SUITES 210 & 211 SAN ANTONIO TX 78258 TEL: 210.656.2333 FAX: 210.656.1333
Neurology Associates
Witness Signature
Patient Signature
______________________________________________________________________
______________________________________________________________________
Date:_________________
I have been informed that Neurology Associates DOES NOT accept Worker’s
Compensation insurance cases.
I HAVE ALSO RECEIVED A COPY OF NEUROLOGY ASSOCIATES NOTICE OF PRIVACY
PRACTICES.
Print Patient Name
I confirm that my visits with Neurology Associates are not related to ANY work injuries or
illnesses.
______________________________________________________________________
Eric J. Pappert, M.D.
Toan Q. Vu, M.D.
Santiago Restrepo, M.D.
Vikki Alvarez, M.D.
Patrick Grogan, M.D.
Mike Garcia, Ph.D.
255 EAST SONTERRA BOULEVARD SUITES 210 & 211 SAN ANTONIO TX 78258 TEL: 210.656.2333 FAX: 210.656.1333
Neurology Associates
Patient Registration Form
Signature:____________________________________________________________ Date:_______________________________
Patient Name (First, MI, Last): ____________________________________________________________ Date of Birth:__________
Age: _______ Gender: □ M □ F Social Security # _______________________________________________________
Street Address: ___________________________________________________________________________________________
Apartment/Unit: ____________________ City: ________________________________ State:_________ Zip:_________________
Home Phone:: ___________________ Work Phone: __________________ Cell Phone: __________________________________
Email Address: _____________________________________________________________________________________________
Driver’s License Number: __________________ Employer: ___________________ Occupation:____________________________
Employer’s Street Address: ___________________________________________________________________________________
Apartment/Unit: ____________________ City: ________________________________ State:_________ Zip:_________________
Guarantor/Guardian Name (if patient is a minor): _________________________________________________________________
Date of Birth: _____________ Age: ______ Gender: ____________________ Marital Status: _____________________________
Street Address: ___________________________________________________________________________________________
Apartment/Unit: ____________________ City: ________________________________ State:_________ Zip:_________________
Home Phone:: ___________________ Work Phone: __________________ Cell pPhone: __________________________________
Employer: ____________________________________________________ Relationship to Patient: ________________________
Employer’s Street Address: _______________________________ City: _________________ State: ___ Zip: _________________
Spouse Name: _______________________________________ Date of Birth: __________ Social Security #: ________________
Employer: ___________________________ City: _______________ State:____ Zip: __________ Work Phone: ______________
Please list a person living outside your home who should be notified in case of emergency:
Name: _________________________________________________________ Relationship: ______________________________
Home Phone:: ___________________ Work Phone: __________________ Cell Phone: __________________________________
Referring Physician/Primary Care Physician: ____________________________________________________________________
Physician Address: ________________________________________________________________________________________
Unit: ____________________________ City: ________________________________ State:_________ Zip:_________________
Phone Number: ___________________________________________ Fax Number: _____________________________________
Primary Insurance Company Name: ___________________________________________________________________________
Insurance Company Address: _______________________________________________Phone: #____________________________
City;____________________ State: _______ Zip: _________ Name of Insured: ________________________________________
Relationship to Patient:____________________ ID#: __________________________ Group #:___________________________
Secondary Insurance Company Name: _________________________________________________________________________
Insurance Company Address: _______________________________________________Phone: #____________________________
City;____________________ State: _______ Zip: _________ Name of Insured: ________________________________________
Relationship to Patient:____________________ ID#: __________________________ Group #:___________________________
Drug Coverage Insurance Name: ______________________________________________________________________________
Insurance Company Address: _______________________________________________Phone: #____________________________
City;____________________ State: _______ Zip: _________ Name of Insured: ________________________________________
RxBIN #: __________________________ RxPCN #:___________________________ RxGROUP#: __________________________
I agree that (regardless of my insurance policy) I am responsible for the entire balance on my account resulting from professional
services rendered to the patient (or myself). I will be responsible for all payments denied by my HMO, PPO, or insurance company.
I have read the information in the Financial Policy and completed the above answers. To the best of my knowledge this information
is
correct and true. I will notify this office in case of any changes to my health insurance status, or any of the above information.
Please check the symptoms you are experiencing:
Constitutional q Weight Gain q Weight Loss q Fatigue
q Trouble Sleeping q Sleepiness q Fever
Cardiac q Chest Pain q Palpitations
Cognitive q Forgetfulness q Confusion q Loss of Consciousness
Eyes q Double Vision q Blurry Vision q Trouble Reading
q Loss of Vision
Ears q Trouble Hearing q Ringing in Ears q Vertigo
q Ear Pain q Blisters q Discharge
Respiratory q Cough q Shortness of Breath q Wheezing
Mouth/Throat q Dry Mouth q Trouble Swallowing q Trouble Chewing
q Throat Pain q Blisters q Abnormal Taste
Stomach/Bowel q Nausea q Vomiting q Diarrhea
q Constipation q Bloating q Pain
Bladder/Genital q Frequent Urination q Loss of Urine q Impotence
q Loss of Stool q Urine Retention
Neurological q Headache q Passing Out q Dizziness
q Weakness q Numbness q Tingling
q Shaking q Slowness q Poor Balance
q Twitching q Confusion
Musculoskeletal q Back Pain q Leg Pain q Arm Pain
q Neck Pain q Spasms
Skin q Dryness q Itchiness q Rash
Do You Feel/Have q Down/Sad q Anxious q Nervous
q Suspicious q Hallucinations
Other: ____________________________________________________________________________________________________________
Please indicate whether you have a history of any of the conditions noted below:
q Glasses q Ear/Nose Problems q Thyroid Disease
q Diabetes q Heart Valve Problems q Heart Rhythm Problems
q Seizures q Stomach Ulcers q Liver Problems
q Kidney Problems q Arthritis q Back Trouble
q Rash q Migraine q High Cholesterol
q Drug/Alcohol Abuse q High Blood Pressure q Mental Disease
q Lung Problems q Poor Circulation q Heart Attack/Chest Pain
q Stroke q Eye Problems
q Cancer q If yes what type and treatment: _____________________________________________
List any other medical illnesses not mentioned above: _____________________________________________________________________
__________________________________________________________________________________________________________________
List surgeries:______________________________________________________________________________________________________
Have you smoked in the past: q Yes q No Do you smoke now? q Yes q No Packs/day:________ How many years ?_________
Do you use alcohol: q Yes q No What kind?:________ How much a week?: _____ Did you drink heavily in the past?: q Yes q No
Do you use illegal drugs: q Yes q No What type: ______________________________________________________________________
Past Medical History of Family Members:
Father/Mother:_____________________________________________________________________________________________________
Sister(s) / Brother(s):_________________________________________________________________________________________________
Are you: q Single q Partnered q Married q Divorced q Widowed q Separated Any Children?: q Yes q No Number:___________
Your present and past occupation:___________________________________________________ Highest schooling level:. __________
RELEASE OF MEDICAL RECORDS AND ASSIGNMENT OF BENEFITS: I hereby authorize Neurology Associates to Release my medical records to my Insurance carrier or similar organization for
verification of the validity of my medical c1aim{s). 1 hereby authorize my insurance benefits be paid to San Marcos Neurology Associates P.A.
Print Your Name:___________________________ Birth Date:________ Signature: _____________________________________________
Physician Signature:__________________________________________________________________________ Date: ___/___/____
Neurology Associates
Please “PRINT” your current list of medications
MEDICATION MILLIGRAM # OF PILLS A DAY REASON FOR MEDICATION
List medication allergies: ______________________________________________________________
_____________________________________________________________________________________
Print Your Name:___________________________ Birth Date:_________Signature: _____________________________________________
Neurology Associates
Neurology Associates, P.A. - San Antonio, TX
Neurology Associates
255 E. Sonterra Blvd
Suite 211
San Antonio, TX 78258
TEL: 210.656.2333
Neurology Associates
1604
281
Note: There are three bldgs in Sonterra Medical Park that look identical (Bldg 155, 225 and our Bldg 255).
We are in Bldg 255 in Suites 210 and 211.
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Completed 15 July 2021

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