Patient Forms

DOWNLOADABLE PATIENT FORMS

For your convenience, The NeuroMedical Center offers all patient forms online, so that you can download and complete them before your next office visit.  We highly recommend completing the forms prior to your scheduled appointment to shorten wait times.  Please bring your completed forms with you to our office at the time of your visit.  All forms and documents available for download are in PDF file format.


NEW PATIENTS

If you are a NEW patient of The NeuroMedical Center Clinic, or it it has been MORE THAN 3 YEARS since your last visit, please click the link bellow to download a printable version of our Patient Registration Packet. You can fill out the form with your keyboard before printing -OR- you can print and fill out the form by hand.   On the day of your appointment, make sure to submit your completed Patient Registration Packet to one of the check-in clerks on the floor where your physician is located.

New Patient Packet
 
UPDATES TO PATIENT PACKET
 
If you have completed the New Patient Registration Packet in the past, but need to make revisions to certain forms in the packet (i.e. change of address) please download the individual forms you need by clicking the links below:

DEPARTMENTS

Neurosurgery 3
Neurosurgery (Drs. Scrantz & Oberlander) 4
Pain Management 3
Neurology 4
Neuropsychology 4

MEDICAL RECORDS REQUESTS

If you need to obtain your medical records for personal use, please print out the Medical Records Request form from the appropriate entity.  Complete all fields, then fax or mail to the number/address listed below.  Our Medical Records clerks are available 8:30am-4:30pm Monday-Friday.  Please allow 3 to 7 business days for the complete processing of your request.  In compliance with state regulations, there will be a cost associated with obtaining your medical records for personal use as outlined at the bottom of the form.

The NeuroMedical Center Clinic
(Medical Records Department located on the 2nd Floor)

The NeuroMedical Center Clinic
Attn: Clinic Medical Records Dept.
10101 Park Rowe Ave, Suite 200
Baton Rouge, LA 70810
Fax: (225) 768-2196

Clinic Release Form Psychotherapy Notes

The Spine Hospital of Louisiana
(Medical Records Department located on the 1st Floor)

The Spine Hospital of Louisiana
Attn: Hospital Medical Records Dept.
10105 Park Rowe Circle., Suite 250
Baton Rouge, LA 70810
Fax: (225) 768-2701

Spine Hospital Release

The NeuroMedical Center Rehabilitation Hospital
(Medical Records Department located on the 5th floor)

The NeuroMedical Center Rehabilitation Hospital
Attn: Hospital Medical Records Dept.
10101 Park Rowe Ave, Suite 500
Baton Rouge, LA 70810
Fax: (225) 906-3837

Rehab Release Form

NOTICE OF PRIVACY PRACTICES

The NeuroMedical Center is required by law to maintain the privacy of Protected Health Information (PHI) and to provide you with an explanation of our privacy practices with regard to that information. You have certain rights – and we have certain legal obligations – regarding the privacy of your PHI.  View our Notice of Privacy Practices for a clear explanation of your rights with regard to your PHI.

The NeuroMedical Center’s Notice of Privacy Practices

MEDICAL APPOINTMENT CANCELLATION/ NO SHOW POLICY

When you schedule an appointment at The NeuroMedical Center Clinic, we set aside enough time to provide you with the highest quality of care. Should you need to cancel or reschedule an appointment, please contact our office as soon as possible, and no later than 24 hours prior to your scheduled appointment. This gives us time to schedule other patients who may be waiting for an appointment.  Please view The NeuroMedical Center Clinic’s Appointment Cancellation / No Show Policy by clicking the link below.

NMC Cancellation / No Show Policy

 


certification of mobility impairment form

This is the form that must be signed by a physician and submitted to the Office of Motor Vehicles (OMV)  if you are seeking to obtain a temporary disability/handicap placard and/or license plate.

Download Mobility Impairment Form