Well Care Neurology, LLC

Vikas Agrawal, MD
944 N. Broadway Suite 106 1665 Grand Concourse Suite A
Yonkers, NY 10701 Bronx, NY 10452
Phone 914-920-3535 Fax 718-294-4700

REGISTRATION FORM
Today’s date:
PATIENT INFORMATION
Patient’s last name: First: Middle: q Mr. q Miss Marital status (circle one)
q Mrs. q Ms. Single / Mar / Div / Sep / Wid

Email Address: Birth date: Age: Sex:

/ / qM qF

Street Address: Home phone no.: Cell phone no.:

( ) ( )

City: State: ZIP Code: Social Security No.:

Primary Physician: Physician Number:

Pharmacy Name: Pharmacy Phone Number or Street Location:

IN CASE OF EMERGENCY
Name of Local Friend or Relative: Relationship to Patient: Phone No.:

( )

INSURANCE INFORMATION
Primary Insurance:

Co-
Subscriber’s name: Subscriber’s S.S. no.: Birth date: Group no.: Policy no.:
payment:
/ / $

Patient’s relationship to subscriber: q Self q Spouse q Child q Other

Name of secondary insurance (if applicable): Subscriber’s name: Group no.: Policy no.:

Patient’s relationship to subscriber: q Self q Spouse q Child q Other

Insurance:
I request that payment of authorized Insurance Benefits be made on my behalf to Vikas Agrawal MD or Well Care Neurology LLC for services
furnished to me. I authorize any holder of my medical information about me to release to the above Insurance Company(s) and its agents any
information needed to determine these benefits or the benefits payable for received services.

Consent for Treatment

I understand that diagnosis and treatment of me by any physician provider or staff member may be conditioned upon my consent as
evidenced by my signature on this document. I have the right to revoke this in writing at any time to the extent ant action has been taken in
reliance upon this consent.

The above information is true to the best of my knowledge.

Patient/Guardian signature Date

 Well Care Neurology, LLC
Vikas Agrawal, MD
944 N. Broadway Suite 106 1665 Grand Concourse Suite A
Yonkers, NY 10701 Bronx NY 10452
Phone 914-920-3535 Fax 718-294-4700

Consent to use and Disclosure of Protected Health Information:

Use and disclosure of your protected health information

Your protected health information will be used by Well Care Neurology, PLLC or disclosed to
others for the purposes of treatment, obtaining payment or supporting day to day health care
operations of the practice.

Notice of privacy practices

You should review the notice of Privacy Practices for a more complete description of how your
protected heath information may be used or disclosed. You may review the notice prior to
signing this consent.

Requesting a restriction on use or disclosure of your information

You may request a restriction on use or disclosure of your protected health information. Well
Care Neurology, PLLC may or may not agree to restrict the use agrees to your request, the
restriction will be binding on the practice. Use or disclosure of protected information in violation
of an agreed upon restriction will be violation of federal privacy standards

Revocation of consent
You may revoke this consent to the use and disclosure of your protected health information. You
must revoke this consent in writing. Any use or disclosures that has already occurred prior to the
date on which your revocation of consent is received will not be affected.

Reservation of right to change privacy practices

Well Care Neurology, PLLC reserves the right to modify the privacy practices outlined in the
notice. We will provide you with a revised notice on your next office visit.

I have reviewed this consent form and give my permission to Well Care Neurology, PLLC to use
and disclose my health information in accordance with it.

Signature________________________ Name____________________ Date___________