Amy Lindsay Nash, M.D.
Neurology
_________________________________________________________________________________________________
18220 Tomball Parkway, Suite 280
Houston, TX 77070
Tel: 832-237-1000
What to Bring to Your Appointment:
Your insurance card
A list of your current medications including the dose and frequency
Any pertinent information about your medical or surgical history
Any records, report, xrays or films that pertain to your current problem – if you have been seen
in a doctor’s office or hospital for the same reason you are coming to see us, please have all
records sent to us PRIOR to your visit
Physician referral forms if required by your insurance
Patient information forms which are provided here on our website
(filling these out ahead of time will help us check you in much more quickly)
Amy Lindsay Nash, M.D.
Neurology
_________________________________________________________________________________________________
18220 Tomball Parkway, Suite 280
Houston, TX 77070
Tel: 832-237-1000
Release of Medical Records
Date:
Attention:
Address:
Phone:
Fax:
I, the undersigned, hereby authorize you to release the checked information listed
below:
__ Copy of entire medical chart
__ Most recent labs and/or Xray reports
__ All labs and/or Xray reports
__ Other diagnostic reports, specifically ____________________
__ Other, specifically _____________________
From the Medical Record of Patient:
Patient Date of Birth:
Patient Social Security Number:
Please fax or mail the above information to: Amy Lindsay Nash, M.D.
18220 Tomball Parkway, Suite 280
Houston, TX 77070
Tel: 832-237-1000
Fax: 832-237-1003
I understand that my records are confidential and cannot be disclosed without my written authorization,
except as otherwise provided by law. I also understand that I may revoke this authorization at any time except
to the extent that has been taken in compliance on it and that in any event this authorization expires
automatically as described below. This must be done in writing if before 90 days.
______________________________________ ___________
Signature of patient or authorized representative Date
Amy Lindsay Nash, M.D.
Neurology
_________________________________________________________________________________________________
18220 Tomball Parkway, Suite 280
Houston, TX 77070
Tel: 832-237-1000
Patient Consent for the Disclosure of Information
I have read the NOTICE OF PRIVACY PRACTICES and have had any questions answered
by this office. I understand that by signing this form I consent to the following:
a. Sharing Information for Purposes of Treatment: You will share my information
with all members of my treatment team, both within this office and with other
providers (personal and institutional) in order to provide me with quality care and
the educational/wellness programs specified in my insurance plan;
b. Sharing Information for Purposes of Payment: You will share all necessary
information with my insurer(s), payor (s), governmental entities (such as
Medicare, Medicaid, etc.) and their representatives (including, but not limited to
benefit determination and utilization review) as well as your representatives
involved in the billing process (including, but not limited to claims representatives,
data warehouses, billing companies.)
c. Sharing of Information for Purposes of Operations: You will share all
information necessary for ongoing operations of this office, including (but not
limited to) the credentialing processes, peer review, accreditation and
compliance with all federal and state laws.
My consent is freely given. I understand that I may remove this consent at any time if
that revocation is in writing, but any disclosures given in reliance on this prior consent
will be permissible.
___________________________________ ____________________
Patient’s Name (Printed) Date
___________________________________
Patient’s Signature (or guardian, if a minor)
Amy Lindsay Nash, M.D.
Neurology
_____________________________________________________________________________
18220 Tomball Parkway, Suite 280
Houston, TX 77070
Tel: 832-237-1000
CONSENT FOR CARE AND TREATMENT
Patient Name (Please Print) ____________________________________________________
I, the undersigned, do hereby agree and give my consent for Amy Lindsay Nash, M.D. dba Amy Lindsay,
M.D.,
P.A. to furnish medical care and treatment to __________________________, considered necessary and
proper in diagnosing or treating my/his/her physical and mental condition.
_________________________________ ______________________________
Patient/Guardian Signature Date
Amy Lindsay Nash, M.D.
Neurology
_____________________________________________________________________________
18220 Tomball Parkway, Suite 280
Houston, TX 77070
Tel: 832-237-1000
Authorization and Assignment of Benefits for Insurance
Authorization to pay benefits to physician: I hereby authorize payment of
medical/surgical benefits directly to Amy Lindsay, M.D., P.A.
_____________________________________________________________________________
Patient Signature Date
Signature to release information to my insurance company and my attorney:
_____________________________________________________________________________
Patient Signature Date
In order to continue efficient service to our patients, we request that office visits be paid at the time of service
Amy Lindsay Nash, M.D.
Neurology
_____________________________________________________________________________
18220 Tomball Parkway, Suite 280
Houston, TX 77070
Tel: 832-237-1000
Patient Name:
_________________________________________________________
Social Security#:
_______________________________________________________
Insurance Company:
___________________________________________________
Release of Information: I hereby authorize Amy Lindsay, M.D., P.A. to release any
or all information acquired in the course of my examination and/or treatment.
I understand this may include the release of any medical or other information required
in the processing of claims for payment. I also authorize the release of information to
another doctor or health care facility to which the patient may be transferred or referred.
Medicare-Patient’s Certification: I certify that the Medicare information given by
me is correct, as this office does accept assignment with Medicare claims for payment. I
understand, due to government regulations, that if Medicare coverage is available to me,
I must inform my physician. I also understand, if in addition to Medicare, I am covered
under an Employer Group Health Insurance, Liability, No-Fault Worker’s Compensation,
or any other insurance which may be responsible for payment, I must inform this office.
I have read and understand the above statement regarding Medicare coverage.
___ Medicare is my primary coverage.
___ Medicare is my secondary coverage.
___ I do not have Medicare/HMO.
___ I do not have Medicaid/HMO.
___ This is NOT a work related condition, injury or symptom.
___ This IS a work related condition, injury or symptom.
___ I understand that payment is required today for all services (copays, deductibles, coinsurance).
Assignment of Benefits: I hereby authorize payment to Amy Lindsay, M.D., P.A. of
the surgical/medical benefits, if any, otherwise payable to me for services I have
received.
Financial Obligation: The undersigned hereby unconditionally guarantees full and
prompt payment of all charges incurred as a result of services rendered to me during
the course of my medical treatment.
___________________________________________
Signature of Insured/Guardian Date Witness Date
Amy Lindsay Nash, M.D.
Neurology
_____________________________________________________________________________
18220 Tomball Parkway, Suite 280
Houston, TX 77070
Tel: 832-237-1000
Please complete all information before seeing the physician. Thank you.
Patient Information
Patient Name: ___________________________________________________________________
Street Address: __________________________________________________________________
City/State/Zip: __________________________________________________________________
Date of Birth: _________ Age: _______ Social Security#: _____________________
Home Phone: _____________ Work Phone: ____________ Cell Phone:______________
Emergency Contact Information
Contact Name: _________________________________________________________________
Relationship: ___________________________________________________________________
Home Phone: ___________________________________________________________________
Work Phone: ____________________________________________________________________
Cell Phone: _____________________________________________________________________
Alternate Contact: _______________________________________________________________
Relationship:____________________________________________________________________
Home Phone: ____________________________________________________________________
Work/Cell Phone:_________________________________________________________________
Insurance Information
Primary Insurance
__ HMO __ PPO __ POS __ Indemnity __ Medicaid __ Medicare __ CPO
Insurance Company: _____________________________________________________________
Insurance Company Address: _____________________________________________________
City/State/Zip: ___________________________________________________________________
Insurance Company Phone Number (on card): _____________________________________
Insured Person: _____________________________
Date of Birth of Insured:_____________ SS# of Insured:________________________
Member ID#: _____________________ Group/Policy#: _______________________________
Secondary Insurance
__ HMO __ PPO __ POS __ Indemnity __ Medicaid __ Medicare __ CPO
Insurance Company: _____________________________________________________________
Insurance Company Address: _____________________________________________________
City/State/Zip: ___________________________________________________________________
Insurance Company Phone Number (on card): _____________________________________
Insured Person: _____________________________
Date of Birth of Insured:_____________ SS# of Insured:________________________
Member ID#: _____________________ Group/Policy#: _______________________________
Employer Information
Name of Employer: _______________________________________________________________
Employer Address: _______________________________________________________________
City/State/Zip: ___________________________________________________________________
Employer Phone Number: _________________________________________________________
Occupation: ______________________________________________________________________
PLEASE ATTACH A COPY OF INSURANCE CARD
Amy Lindsay Nash, M.D.
Neurology
___________________________________________________________________
18220 Tomball Parkway, Suite 280
Houston, TX 77070
Tel: 832-237-1000
Patient Financial and Appointment Responsibility Statement
Payment of your bill is considered part of your treatment. If you have medical insurance, we stand ready to assist you in receiving
your maximum allowable benefits. In order to do this, we need your help by understanding this statement of our Financial Policy.
NOTE: Except in emergencies, patients must complete our Information/Insurance form before seeing the physician.
Full payment is due at the time of service unless you are enrolled in an insurance plan to which Amy Lindsay Nash, M.D. dba
Amy Lindsay, M.D., P.A. participates.
Co-payments & deductibles for all insurance plans must be paid in full at the time of service. Failure to pay co-pays will be
reported to your insurance plan and your employer. Co-pays are a condition of your insurance coverage, and you may be subject to
termination of your insurance benefits if you do not pay them.
Method of Payment: Cash, checks and credit card payments are accepted. We also accept several insurance plans; please inquire
with our office for verification of a certain plan.
Patients Without Insurance: Occasionally, our patients may find themselves without health benefits. Our policy is that 100% of all
anticipated charges must be paid at the time service is rendered.
Insurance Coverage - Please understand, as a health care provider and healthcare facility, our relationship is primarily with you,
not your insurance company. As a courtesy and convenience to you, we file insurance claims for all our patients. We cannot bill your
insurance company unless you give us your current and accurate insurance information.
Non-Sufficient Fund Checks written to Amy Lindsay Nash, M.D. dba Amy Lindsay, M.D., P.A. will have a $25.00 fee assessed to
the account. A letter will be sent to the patient requesting the check be made good. If no explanation or payment is received within
14 days, the account will be turned over to an outside collection agency. Subsequent services must be prepaid in cash until the
account is paid in full.
Patient Appointment Responsibility We are a small specialty office and take pride in the fact that we have designed our schedule
to spend the maximum amount of time with you at each visit. If you do now show up for your scheduled appointment, it not only
affects your own medical care, but it also affects the care of patients who have been waiting for appointments. This also impacts our
medical office because we cannot fill an appointment on short notice, and this leaves a gap in our schedule. Therefore, if you do not
call and cancel your appointment within 24 hours in advance, a no-show fee of $50.00 for a regular appointment and $100.00 for a
procedure will be billed directly to you. This charge will not be covered by your insurance.
____________________________________________________________
Patient Signature Date
Note: The original of this document will become a permanent record in your chart
Amy Lindsay Nash, M.D.
Neurology
_____________________________________________________________________________
18220 Tomball Parkway, Suite 280
Houston, TX 77070
Tel: 832-237-1000
Patient Health Questionnaire
*To help us meet your healthcare needs, please complete this entire form. This information is
confidential and will be kept in this office as a record of your medical history
Today’s Date: ______________
Patient Name: _________________________________
Date of Birth: _______________
Name of Primary Doctor: __________________________________________________
Name of Doctor/Health Care Professional Who Recommended that You See a Neurologist:
_______________________________________________________________________
Names of Your Other Doctors: ______________________________________________
Chief Concern:
Please briefly describe the symptoms you are experiencing
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
_______________________________________________________________
Past Medical History:
Do you currently have or have you ever had these health problems in the past? (please circle
all that apply to you):
High Blood Pressure, Diabetes, Heart Disease, High Cholesterol, High Triglycerides,
Thyroid Disease, Arthritis, Cancer, Anemia, Kidney Disease, Stroke, Migraine,
Seizures, Pneumonia, HIV, Sexually Transmitted Disease, Tuberculosis, Polio,
Glaucoma, Asthma, Mitral Valve Prolapse, Hepatitis, Rheumatoid Arthritis, Lupus,
Any other diseases:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
_______________________________________________________________
Past Surgical History:
Please list all previous surgeries and the dates they were performed:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Allergies:
Please list any medication allergies or other allergies we should be aware of:
________________________________________________________________________
Medications:
Name of Medication Dosage (mg) How Many Pills Times Per Day
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
______________________________
Social History:
Who currently lives with you?
________________________________________________________________________
Current occupation:________________________________________________________
Do you exercise?__________________________________________________________
Do you smoke? How many packs per day? ____________________________________
Do you drink alcohol? How many drinks per day? ______________________________
Do you use illicit drugs, what type, how often? _________________________________
Family History:
Please circle any of the listed medical problems that family members currently have or had in
the past:
High Blood Pressure, Diabetes, Heart Disease, Stroke, Epilepsy, Dementia, Thyroid
Disease, Lupus, Arthritis, Rheumatoid Arthritis, Neuropathy, Cancer