The following forms can be sign online:
The following forms can be printed out as a PDF:
The office has a 15 minute grace period policy. If you arrive more than 15 minutes after the scheduled time of your appointment, we may require you to reschedule in order to avoid delaying other patients’ appointments. Exceptions may be made at our discretion, depending upon the circumstances and time constraints.
Please make sure you always have your actual insurance card (no temporary or print outs will be accepted), and picture ID at the time of your appointment. Failure to provide these documents may result in your appointment being canceled, rescheduled, or you may pay at the time of service.
Patients should inform the office of any change in information such as insurance, address and telephone numbers, etc. Failure to provide accurate insurance and demographic information may result in your appointment being rescheduled or payment due at time of service.
We apologize for any inconvenience.
South Coast Neurology is solely credentialed with Medicare as Non-par members.
Payment in full is due prior to service rendered. Regarding insurance carriers we are not contracted with, we will provide you all necessary billing paperwork to help you file a claim.
South Coast Neurology fee structure is similar to other neurologic practices in Southern California. Our charges for each patient visit, take into account time spent directly with you, and the additional time needed to consult, review records, labs, and other tests. Supplemental charges may be made for complex care which requires additional consult, completion of medical forms, or written correspondence/letters outside the scope of a standard evaluation and management service. If you have any questions or concerns regarding our charges, please free to contact us.
PAYMENT TYPES ACCEPTED: Cash, Check, Visa, MasterCard, and AMEX
A finance charge of $15.00 will be assessed beginning 90 days after the initial billing date. Interest will be assessed at 18% per annum calculated on all amounts due after 90 days. We understand financial hardship and are always willing to set up a payment plan to prevent delinquent accounts. In the event it is necessary to refer your account to an attorney for collections, you will be responsible for all charges accrued; i.e. attorney’s fees, court costs, expenses, etc.
Your First Visit
On the first visit you will be required to complete the following forms (Patient Registration Form, Financial Agreement, Disclosure Authorization Form, Patient Questionnaire, E-prescribe Consent, HIPPA, Agreement for Controlled Substance Prescriptions). If you have any health records from previous physicians, please bring them with you. You may print and fill out the forms in advance to save time.
Please also bring a list of any medications you are currently taking. We suggest that all new patients plan to arrive 15 minutes before their appointment time to allow for processing.
All existing patients are required to fill out the Patient Questionnaire; you may print out the form prior to your appointment to expedite your visit. Please also bring a list of any medications you are currently taking.
All patients are required to fill out a new patient registration form at the beginning of the year and whenever any of your information changes. All the forms can be printed out and completed prior to the visit for faster service.
There is a 48 hours processing time for prescription requests. Please call ahead of time before running out of your prescription. Any incomplete information may cause a delay on your request.
Frequently Asked Questions (FAQ)
How can I get a copy of my medical record?
If you desire your own copy, you must provide the office a written request for your medical records or fill out the patient medical records request form. Any incomplete information may cause a delay in your request. Your request may take up to thirty days to complete. Your request will incur the following fees: our office charges a reasonable, cost based fee for providing patients with copies of their records. The fees will only include the cost of supplies for and the labor of copying, postage if the individual has requested that the information be mailed, and cost for preparing an explanation or summary of the information if agreed to by the individual. See 45 CFR 164.524.
How can I request for my medical record to be forwarded to another physician?
We will make a single copy to send to another physician’s office at no charge to you. You must provide the office a written request or fill out the medical records request form. Please include the physician’s name, address, telephone number and fax number. Any incomplete information may cause a delay on your request.