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PATIENT FORMS 2018-05-02T15:56:39+00:00

The following forms are needed for your first appointment. To save time, feel free to fill them out at home and bring them with you to your first appointment. If you prefer not to fill them out in advance, please come 15 minutes early to your first appointment and we will provide these forms for you to complete before your appointment.

The following forms are needed for your first appointment. To save time, feel free to fill them out at home and bring them with you to your first appointment. If you prefer not to fill them out in advance, please come 15 minutes early to your first appointment and we will provide these forms for you to complete before your appointment.

Portland Cognitive and Behavioral Neurology is in full compliance with the Health Insurance Portability Accountability Act (HIPAA). Therefore, we are required by law to share our privacy practices with you. Please review the notice of Privacy Practices document HERE and sign the acknowledgement form included in the medical forms below.

Portland Cognitive and Behavioral Neurology is not an in-network provider for any insurance plan. The medicare opt-out contract that we are required to sign with patients is included in the forms below.

PATIENT FORMS

PCBN Registration Form.pdf
PCBN Medical History Form.pdf
PCBN Authorization to Obtain Medical Records.pdf
PCBN Authorization to Release Medical Records.pdf
PCBN Notice of Privacy Practices Acknowledgement.pdf
PCBN Medicare Opt-out Contract.pdf

Portland Cognitive and Behavioral Neurology is in full compliance with the Health Insurance Portability Accountability act (HIPAA). Therefore, we are required by law to share our privacy practices with you. Please review the notice of Privacy Practices document HERE  and sign the acknowledgement form included in the medical forms below.

Portland Cognitive and Behavioral Neurology is not an in-network provider for any insurance plan. The medicare opt-out contract that we are required to sign with patients is included in the forms below.

PATIENT FORMS