- Your insurance card
- Your photo ID
- Physician referral or copy of Authorization
- A list of medications you are taking, prescribed or over the counter
- Any recent lab or block work results
- Any recent X-rays or MRI results
- A list of questions you would like to ask the Doctor.
- Any names and contact information for person(s) you want us to release medical information to
- Name and Phone number of the Pharmacy that you wish to use
- To keep scheduled appointments
- To be honest with the doctors and health care workers
- To understand that no one has all the answers
- To follow the treatment plan agreed upon
- To bring actual bottles of any medication you are currently taking
- To know what medications have been used unsuccesfully on you in the past
- To know what allergies you have
- To understand the requirements of your own health insurance
- To know how your pharmacy plan works, is it mail-away or local.
New Patient Forms
Download and print our forms
If this is your first visit, you will be asked to complete a short registration form and a consult form. You may download and complete these forms in the convenience of your home then bring them with you to your appointment.
Insurance and Billing Questions
We are a Medicare provider and a PROMED of Pomona Valley provider. We accept most major insurance plans and provide insurance billing. Patients are responsible for anything not covered by insurance.
AMERICAN POSTAL WORKERS UNION
BEECH STREET PPO
BLUE CROSS OF CALIFORNIA PPO
BLUE CROSS OUT OF STATE PPO
BLUE SHIELD PPO
BLUE SHIELD OUT OF STATE PPO
BLUE CARD PROGRAM
BLUE CROSS/BLUE SHIELD PPO
CALIFORNIA IRON WORKERS PPO
CARPENTERS HEALTH AND WELFARE
FIRST HEALTH NETWORK PPO
GREATWEST HEALTCARE PPO
Records Release Authorization form.
To request medical records we require a completed Medical Records Release Authorization form.
For your convenience, this form is available here to download and fill out before visiting our office. Please print and complete this form and return it to our office in person or by fax. You may also choose to email it to firstname.lastname@example.org
Recommended Web Resources
BRAIN BASICS – KNOW YOUR BRAIN:
HEAD INJURY: (Traumatic Brain Injury)
GENETIC TESTING GUIDE:
Enter A Search Term: Genetic Testing Guide
NEUROPATHY (NERVE DISORDER):
PRECIPTION DRUG INFORMATION:
TRUSTED HEALTH INFORMATION FOR YOU:
NOTICE OF PATIENT INFORMATION PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO INFORMATION. PLEASE REVIEW IT CAREFULLY.
The Neurology Group LEGAL DUTY
The Neurology Group is required by law to protect the privacy of your personal health information, provide this notice about our information practices and follow the information practices that are described herein.
USES AND DISCLOSURES OF HEALTH INFORMATION
The Neurology Group uses your personal health information primarily for treatment; obtaining payment for treatment; conducting internal administrative activities and evaluating the quality of care that we provide. For example, The Neurology Group may use your personal health information to contact you to provide appointment reminders, or information about treatment alternatives or other health related benefits that could be of interest to you.
The Neurology Group may also use or disclose your personal health information without prior authorization for public health purposes, for auditing purposes, and for emergencies. We also provide information when required by law.
In any other situation, The Neurology Group policy is to obtain your written authorization before disclosing your personal health information. If you provide us with a written authorization to release your information for any reason, you may later revoke that authorization to stop future disclosures at any time.
The Neurology Group may change its policy at any time. When changes are made, a new Notice of Information Practices will be posted in the waiting room and patient exam areas and will be provided to you on your next visit. You may also request an updated copy of our Notice of Information Practices at any time.
PATIENT’S INDIVIDUAL RIGHTS
You have the right to review or obtain a copy of your personal health information at any time. You have the right to request that we correct any inaccurate or incomplete information in your records. You also have the right to request a list of instances where we have disclosed your personal health information for reasons other than treatment, payment or other related administrative purposes.
You may also request in writing that we not use or disclose your personal health information for treatment, payment and administrative purposes except when specifically authorized by you, when required by law or in emergency circumstances. The Neurology Group will consider all such requests on a case by case basis, but the practice is not legally required to accept them.
CONCERNS AND COMPLAINTS
If you are concerned that The Neurology Group may have violated your privacy rights or if you disagree with any decisions we have made regarding access or disclosure of your personal health information, please contact our practice manager at the address listed below. You may also send a written complaint to the US Department of Health and Human Services.
For further information on The Neurology Group health information practices or if you have a complaint, please contact the following person:
630 N. 13th Ave. Suite B
Upland, Ca. 91786