Advanced Neurological
Evaluation and Treatment Center, PC
Dr. Alexander Feldman, M.D
Brandon Schreiber, PA-C
Svetlana Belykh, M.A, M.S., LPC, NCC
1721 E 19th Ave Suite 510
Denver, CO 80218
P. 303-863-0501 F. 303-863-0497
PATIENT REGISTRATION
Patient’s Name (Last, First, Middle) ________________________________________________
Street Address _________________________________________________________________
City/State/Zip _________________________________
Date of Birth ____________________________
Soc. Sec. # _______-_______-________
Marital Status ______
Gender M__F__
Home Phone ___________________
Cell Phone _______________________
Work Phone _______________________
E-Mail Address___________________________
Employer ________________________________________ Occupation ___________________
Employer’s Address ___________________________ City/State/Zip______________________
How did you hear about us? _ Friend _ Family member _ Internet _ Advertisement _ Physician
Referring Physician ___________________________________ Phone ____________________
Primary Care Physician ________________________________ Phone ____________________
Name /Address of Your Pharmacy _________________________________________________
INSURANCE INFORMATION
PRIMARY Ins Co ________________________________________________________________
Address _________________________________________City/State/Zip __________________
Subscriber’s SS# _______-_______-________
Subscriber’s DOB ____________________
Subscriber’s Name ____________________________ Relationship to Subscriber ____________
Policy/ID # ________________ Group# ___________ Phone#____________________________
SECONDARY Ins Co _____________________________________________________________
Address _________________________________________City/State/Zip __________________
Policy/ID # ________________ Group# ___________ Phone#____________________________
AUTHORIZATION FOR RELEASE OF INFORMATION & AUTHORIZATION TO PAY PROVIDER
I hereby authorize ANETC to treat the patient identified above. I acknowledge that I am responsible to pay all charges for all treatments
administered by the physician to the patient identified above. I understand that insurance may not pay for all charges, and I understand that I
am obligated to pay for all charges not paid by insurance. I also agree to pay reasonable attorney fees if my account is turned over to an
attorney or collection agency. CO PAYMENT IS DUE AT THE TIME OF SERVICE.
I hereby authorize my insurance benefits to be paid directly to the physician and I am financially responsible for non covered services. I also
authorize the physician to release any information required in the processing of this claim and all future claims.
Signature__________________________________________ Date _______________________
Advanced Neurological
Evaluation and Treatment Center, PC
Dr. Alexander Feldman, M.D
Brandon Schreiber, PA-C
Svetlana Belykh, M.A, M.S., LPC, NCC
1721 E 19th Ave Suite 510
Denver, CO 80218
P. 303-863-0501 F. 303-863-0497
PATIENT HISTORY
The following questionnaire is intended to help us better evaluate and treat your neurological problems.
Please fill out the form as complete as possible.
Patient’s Name: ________________________________________
Date of Evaluation: ____________________ Age: _________
DOB: ________________________
___Right handed
___Left handed
Referring Physician / PCP: _______________________________________________________________
Please describe the reason you are seeing the neurologist today: ________________________________
_____________________________________________________________________________________
Please describe in detail the symptoms you are having. Exactly when did your problem begin?
What might have caused the problem to begin, for example, medical condition, stress, accident? Please
include details concerning any past diagnostic tests, treatments, and responses to any past treatments.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Have you had a MRI or CT? __________________ Body part imaged/Date ________________________
What makes your condition worse or better? ________________________________________________
How often do you have this problem and how long does it last? _________________________________
How is this problem affecting your life? What can you not do that you used to be able to do?
_____________________________________________________________________________________
Please list any current or past medical problems. _____________________________________________
_____________________________________________________________________________________
Please list reasons for any overnight hospital stays, emergency room visits or urgent care visits.
_____________________________________________________________________________________
Please list any prior surgeries: ____________________________________________________________
Please list any family members’ medical problems:
___ High Blood Pressure
___ Diabetes
___ Heart Disease
___ Stroke
___ Migraines
___ Seizures ___ Parkinson’s
___ Dementia
___ Aneurisms
___ Cancer
Please list any social habits:
Level of education:
___ High School
Marital Status: ___ Single
What are your:
___ Alcohol
___Married
__Height_______________
___Tobacco
___ Illegal Drugs
___College
___Graduate
___Children
___Occupation
__Weight_______________
Advanced Neurological
Evaluation and Treatment Center, PC
Dr. Alexander Feldman, M.D
Brandon Schreiber, PA-C
Svetlana Belykh, M.A, M.S., LPC, NCC
1721 E 19th Ave Suite 510
Denver, CO 80218
P. 303-863-0501 F. 303-863-0497
Please list current prescription medications and dosages, including birth control pills, supplements:
_________________________
__________________________
_______________________
_________________________
__________________________
_______________________
_________________________
__________________________
_______________________
Review of Systems:
Constitutional symptoms:
___ Fever/chills
___ Fatigue
___ Night Sweats
___ Cancer
Cardiovascular:
___ Chest pain
___ Shortness of breath
___ Irregular heartbeat
Respiratory:
Gastrointestinal:
___ Coughing
___ Blood in stool
___ Runny nose
___ Nausea/vomiting
___ Wheezing/asthma ___ Diarrhea/constipation
Eyes:
___ Light sensitivity
___ Loss of vision
___ Double vision
___ Eye pain
Ears, nose, throat and mouth:
___ Head trauma
___ Positional dizziness
___ Tinnitus
Skin / breast:
___ Rashes
___ Lesions
___ Moles
Genitourinary:
___ Frequency
___ Retention
___ Libido
___ Loss of bladder control
Hematologic/Lymphatic:
___ Easy bruising
___ Bleeding problems
___ Taken Coumadin
Endocrine:
___ Diabetes
___ Hypothyroid
___ Weight changes
___ Taken Coumadin
Allergies:
___ Drug
___ Seasonal
___ Contact
___ Foods
Musculoskeletal: ___ Numbness
___ Burning pain
___ Tingling
___ Weakness
___ Neck pain ___ Back pain ___ Joint pain ___ Radiating pain down legs or hands
Neurological/ Psychological: ___ Headaches ___ Shaking/tremor ___ Memory loss ___ Past meningitis
___ Seizures ___ Severe accidents
___ Balance problems
___ Stroke
___ Loss of consciousness ___ Sleep Disturbance
Do you: ___ Get lost often
___ Forget meetings
___ Forget where you are
___ Memory problems
___ Forget time & day
Does it seem that you: ___ Can’t think as quickly as before
___ Are more easily distracted
___ Have trouble with “common sense”
___ Find it hard to think clearly
___ Can’t concentrate
Have you had trouble: ___ Remembering the right word when talking
___ Understanding others
___ Telling right from left ___ Getting dressed ___ With your speech
___ Following conversation ___ With reading
___ With writing
Have you had problems with: ___ Sadness or depression
___ Worry or guilt
___ Change in your attitude
___ Stress, tension or anxiety
___ Anger or keeping your temper
___ Last of interest
Anything else you feel is important for us to know? __________________________________________
_____________________________________________________________________________________
Advanced Neurological
Evaluation and Treatment Center, PC
Dr. Alexander Feldman, M.D
Brandon Schreiber, PA-C
Svetlana Belykh, M.A, M.S., LPC, NCC
1721 E 19th Ave Suite 510
Denver, CO 80218
P. 303-863-0501 F. 303-863-0497
NO SHOW/LATE CANCELLATION POLICY
Welcome to Advanced Neurological Evaluation and Treatment Center, PC.
It is our philosophy and commitment to deliver high quality care to our patients. Our staff will do all that
they can to give you the best treatment available.
In order for you to obtain optimal benefit from your treatment program, it is essential for you to
promptly attend each scheduled appointment.
This policy has been established to help us serve you better.
A “no show” is missing a scheduled appointment. A “late cancellation” is canceling an appointment
without calling us to cancel 24 hours in advance of an office visit and/or a procedure. Please
communicate cancellations during our business hours, 8 AM to 5 PM, for emergencies we do have an
answering service.
We understand that situations such as medical emergencies occasionally arise when an appointment
cannot be kept and adequate notice is not possible. These situations will be considered on a case by
case basis.
A charge of $50.00 will be assessed for each no show or late cancellation
office visit appointment if less than 24 hours notice is given.
A charge of $150.00 will be assessed for each no show or late cancellation
test and / or procedure appointment if less than 24 hours notice is given.
If you are more than 15 minutes late, you will be asked to reschedule.
If your appointment is not confirmed by 12 PM the day before you will be seem only if the providers are
available.
After 2 "NO SHOWS" appointments, you will be dismissed from our practice by certified letter.
Please understand that insurance companies consider this charge to be entirely the patient’s
responsibility.
I certify that I have read and understood the above policy.
_________________________________________
Patient or Legal Representative Signature
_________________________________________
Print Name
_____________
Date
Advanced Neurological
Evaluation and Treatment Center, PC
1721 E 19th Ave Suite 510
Denver, CO 80218
P. 303-863-0501 F. 303-863-0497
Dr. Alexander Feldman, M.D
Brandon Schreiber, PA-C
Svetlana Belykh, M.A, M.S., LPC, NCC
AUTHORIZATION TO RELEASE MEDICAL INFORMATION
Patient’s Name (Last, First, Middle) ____________________________________________________
Street Address ________________________________________________________________________
City/State/Zip ____________________________________
Date of Birth _____________________________
Home Phone ______________________
Work Phone _______________________
I authorize the release of the following protected health information to:
Name (Title) __________________________________________________________________________
Street Address ________________________________________________________________________
City/State/Zip _____________________________________
Phone ___________________________
I request the release of the specific categories of information that I have initialed below:
_____ Acquired immunodeficiency syndrome (AIDS)/human immunodeficiency virus (HIV) infection
_____ Diagnosis and/or treatment relating to drug or alcohol abuse
_____ Diagnosis and/or treatment relating to mental health conditions
_____ Confidential details of:
__
__
__
__
Psychotherapy Notes (Psychiatrist, Psychologist, Mental Health Clinical Nurse Specialist)
Social Work Counseling/Therapy
__ Discharge Summary
__ Lab Reports
Operative Reports __ Pathology Reports __ Imaging Reports __ Orders/Progress Notes
H&P and Consultation(s)
__ Other: _________________________________________
The purpose of this disclosure is:
__ Medical Care __ Legal Matter __ Insurance __ Personal
__ Other (please specify) ____________
I understand that:
• By signing this form, I am authorizing the use or disclosure of protected health information as indicated above.
• I may refuse to sign this authorization, which will not affect my treatment or payment for health care.
• I may revoke this authorization at any time before the information I have requested is released by providing written notice of
revocation as specified in the Notice of Privacy Practices.
• If the receiving party is not subject to medical records privacy laws, the information may be re-disclosed by the recipient and
may no longer be protected by federal or state law. Advanced Neurological Evaluation and Treatment Center shall not be
held liable for any consequences resulting from re-disclosure.
• This Authorization expires on ____ /____ / ____ {if date not completed / one year after signed}
Signature__________________________________________
Date ___________________________