Patient Forms

What to bring to Your Appointment 

1. Print complete, and bring the three (3) patient forms listed below:

  • List of medications you are taking including over the counter medication, vitamins, and herbs.
  • List of allergies
  • Insurance information and photo ID

2. If you have had an MRI or Cat Scan, please bring the studies with you or arrange for the facility to deliver them to the office before your appointment.

Payment and Insurance

Neurology, PA has a knowledgeable staff to assist you in filing your insurance.  While we are contracted with many insurance plans,  we are not contracted with all plans.  If we are NOT contracted with your insurance plan, it is possible that your out of pocket co-payment, co-insurance, or general out of pocket expenses will be higher than if you were to be treated by an in-network (contracted) physician.

Please note: if you are covered by a Medicare managed care product (i.e.: United AARP Medicare Complete, Humana, Secure Horizon, Universal, etc.) you will be responsible for any amounts over the Medicare allowable, which are not paid by your insurance carrier.

Your insurance company may require you to pay a co-payment and/or a deductible; this amount is due at the time of your appointment.  We request payment at the time of your appointment for services that are not covered by insurance.  We accept Visa, Master Card, and Discover.

If your insurance plan requires a referral, you, the patient, are responsible for ensuring that a referral has been issued by your referring physician.  If your insurance company requires a referral and one is not obtained, any unpaid balance from the insurance company is the patient’s responsibility.

Question regarding your coverage and benefits should be directed to your employer or insurance company before your appointment.  If you have any questions regarding which insurance plans we accept or any patient billing concerns, please call us at (941) 764-0800.

Patient Forms

Before your appointment, please complete the Patient Information Form, Insurance Authorization Form and the Medical History Form.  Download,  fill and print our forms using the links below:


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