Forms/Billing

Forms you will need:

Patient Consent Form

Patient HIPPA Acknowledgement Form

Patients’ Rights Form

Patient History

Financial Policy

Billing:

Below you will find a link to our downloadable patient registration form. Please print and fill it in with your most current insurance information and bring it with you when you visit our clinic. Our billing department will need this information for pre-authorizing any studies or services we provide you.

Patient Registration Form

Our accepted insurance providers:

• BCBS
• Medcost
• Inclusive Health
• Cigna
• Aetna
• Wellpath/Coventry

 For healthcare providers:

If you are a healthcare provider, thank you for your interest in PremierNeuro! Below you will find links to our downloadable referral forms:

Patient Referral Form

MSLT Pre-Study Questionaire

 

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If you have any further questions, please feel free to contact us here.