Patient Information- NATUROPATHIC MEDICINE | Neuron Medical | Thousand Oaks CA | Neuron Medical Corporation

Appointment

What to Bring to the Appointment

Your insurance card
Physician referral forms if required by insurance
A list of current prescriptions and/or over-the-counter medications you are taking, including dose and frequency
Pertinent information about your medical and surgical history
Any recent x-rays or appropriate records you may have

Schedule an Appointment

Patient Forms
NATUROPATHIC MEDICINE

Patient Forms

Click on the following links to download and print our patient forms and send to email neuronoffice@gmail.com,

Or fill online

New Patient Forms – NATUROPATHIC MEDICINE

New Patient Information sheet

New patient information form

New Patient Information sheet Naturopathic Medicine / Dr. Green:

NEW PATIENT Information Form

Neuron Medical Corp.
227 W. Janss Rd. #135
Thousand Oaks, CA 91360
Tel (805) 373-2890
Fax (805) 364-5464
NeuronOffice@gmail.com

The fields marked with * are mandatory

First Name

Middle Name

Last Name

Date of birth

Gender

Marital status

Address

Address (street)

City

State

Zip Code

Phone #

Cell#:

Driver lic. Or ID#

Employer name and address

Work phone #

If student, school name

Referring physician/healthcare providers

RESPONSIBLE PARTY, SIGNIFICANT “OTHER” OR SPOUSE INFORMATION

Name

Relationship to patient

Address (street)

City

State

Zip Code

Phone #’s

Driver License # or ID#

Work #

Employer name/address

Friend or relative not living with you

Phone#

INSURANCE INFORMATION

Medicare # or PPO ID #

Supplemental Plan name or PPO Insurance

Insured’s Name

Relationship to patient

PHARMACY INFORMATION

Preferred Pharmacy:

Address:

Phone#:

I Agree to Terms *:

I hereby assign, transfer and set over to Neuron Medical Corp. all my rights, title and interest to my medical reimbursement benefits under my insurance policy. I authorize the release of any medical information needed to determine these benefits. This authorization shall remain valid until written notice is given by me revoking said authorization. I understand that I am financially responsible for all charges whether they are covered by insurance or not.

A $100 cancellation fee will be charged to all patients who do not cancel their appointment within 24 hours prior to their scheduled appointment.

The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.

Patient’s signature

Date of completion

Arbitration contract - English

Arbitration contract – English

PHYSICIAN-PATIENT ARBITRATION AGREEMENT ENGLISH
PHYSICIAN-PATIENT ARBITRATION AGREEMENT

Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

Article 2: All Claims Must Be Arbitrated: It is the intention of the parties that this agreement shall cover all claims or controversies whether in tort, contract or otherwise, and shall bind all parties whose claims may arise out of or in any way relate to treatment or services provided or not provided by the below identified physician, medical group or association, their partners, associates, associations, corporations, partnerships, employees, agents, clinics, and/or providers (hereinafter collectively referred to as “Physician”) to a patient, including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term “patient” herein shall mean both the mother and the mother’s expected child or children.
Filing by Physician of any action in any court by the physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim. However, following the assertion of any claim against Physician, any fee dispute, whether or not the subject of any existing court action, shall also be resolved by arbitration.

Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing by U.S. mail, postage prepaid, to all parties, describing the claim against Physician, the amount of damages sought, and the names, addresses and telephone numbers of the patient, and (if applicable) his/her attorney. The parties shall thereafter select a neutral arbitrator who was previously a California superior court judge, to preside over the matter. Both parties shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the arbitrator. Patient shall pursue his/her claims with reasonable diligence, and the arbitration shall be governed pursuant to Code of Civil Procedure §§ 1280-1295 and the Federal Arbitration Act (9 U.S.C. §§ 1-4). The parties shall bear their own costs, fees and expenses, along with a pro rata share of the neutral arbitrator’s fees and expenses.

Article 4: Retroactive Effect: The patient intends this agreement to cover all services rendered by Physician not only after the date it is signed (including, but not limited to, emergency treatment), but also before it was signed as well.

Article 5: Revocation: This agreement may be revoked by written notice delivered to Physician within 30 days of signature and if not revoked will govern all medical services received by the patient.

Article 6: Severability Provision: In the event any provision(s) of this Agreement is declared void and/or unenforceable, such provision(s) shall be deemed severed therefrom and the remainder of the Agreement enforced in accordance with California law.

I understand that I have the right to receive a copy of this agreement. By my signature below, I acknowledge that I have received a copy.

NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HA VE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE I OF THIS CONTRACT.

Print Patient’s Name
Date
Print Name and Relationship to Patient (if applicable)
Date
A signed copy of this document should be given to the patient. The original copy will be archived in the patient’s medical file.

Arbitration contract - Spanish

Arbitration contract – Spanish

PHYSICIAN-PATIENT ARBITRATION AGREEMENT SPANISH

ACUERDO DE ARBITRAJE MÉDICO-PACIENTE

Artículo 1: Acuerdo de arbitraje: Se conviene que cualquier disputa relativa a negligencia médica, es decir, a si cualquiera de los servicios médicos
prestados bajo este contrato fueron innecesarios o no autorizados o llevados a cabo de manera impropia, negligente o incompleta, sea determinada
por el sometimiento a arbitraje según lo dispuesto por la ley de California, y no por medio de una demanda o el recurso a un procedimiento judicial
salvo en lo que la ley de California dispone para la revisión judicial de procedimientos arbitrales. Ambas partes, al celebrar este contrato, están
renunciando a su derecho constitucional a que dicha disputa sea decidida en un tribunal frente a un jurado y, en su lugar, están aceptando el uso
de arbitraje.

Artículo 2: Todas las reclamaciones deberán ser sometidas a arbitraje: Es la intención de las partes que este acuerdo cubra todas las
reclamaciones o controversias contractuales, extracontractuales o de cualquier otro tipo, y vinculará a todas las partes cuyas reclamaciones se
deriven o se relacionen de cualquier forma con el tratamiento o los servicios prestados o no prestados al paciente
por el médico, el grupo o asociación médica, sus socios, asociados, asociaciones, corporaciones, entidades sociales, empleados, agentes, clínicas y /o
proveedores identificado/s más abajo (en adelante, agrupados bajo el nombre de “Médico”), incluido el tratamiento o los servicios prestados o no
prestados a cualesquiera cónyuges o herederos e hijos del paciente, nacidos o no nacidos, al tiempo de la aparición de los hechos de los que se deriva
la reclamación. En el caso de una madre embarazada, el término paciente en la presente designará tanto a la madre como al futuro hijo o hijos.
El inicio por parte de un Médico de una acción ante un tribunal para el cobro de honorarios no significará la renuncia al derecho a exigir el
sometimiento a arbitraje de cualquier reclamación por negligencia. Sin embargo, tras la interposición de una demanda contra el Médico, cualquier
disputa por honorarios, esté o no sujeta a un procedimiento judicial, también deberá ser resuelta por arbitraje.

Artículo 3: Procedimiento y ley aplicable: Las peticiones de arbitraje deberán ser comunicadas por escrito a través del correo postal, con el
franqueo pagado, a todas las partes, describiendo la reclamación contra el Médico, la indemnización por daños y perjuicios que se pretende, y los
nombres , direcciones y números de teléfono del paciente y, en su caso, de su abogado. Después de eso, las partes seleccionarán un árbitro de
equidad que haya sido previamente un juez de un tribunal de instancia superior del estado de California, para entienda en la causa. Ambas partes
tendrán el derecho de someter separadamente a arbitraje los temas de responsabilidad e indemnización por daños y perjuicios a petición escrita del
árbitro. El paciente deberá entablar sus reclamaciones con diligencia razonable, y el arbitraje se regirá de acuerdo a los artículos 1280-1295 del
Código de Procedimiento Civil (Code ofCivil Procedure) y a la Ley Federal de Arbitraje (artículos 1 a 4 del Título 9.0 del Código de los Estados
Unidos). Las partes deberán pagar sus propios costos, honorarios y gastos, además de costear una parte proporcional de los honorarios y gastos del
árbitro de equidad.

Artículo 4: Efecto retroactivo: El paciente tiene el propósito de que este acuerdo cubra todos los servicios prestados por el Médico no sólo después
de la fecha de su firma (lo cual incluye, entre otros, el tratamiento de emergencia), sino también antes de que fuera firmado.

Artículo 5: Revocación: Este acuerdo puede ser revocado por notificación escrita entregada al Médico dentro de los 30 días que sig u en a la firma y
si no es revocado regirá todos los servicios médicos recibidos por el paciente.

Artículo 6: Disposición de divisibilidad: En caso de que una o varias disposiciones de este acuerdo sea/n declarada/s nula/s y no exigible/s, tal
disposición o disposiciones deberá/n considerarse nula/s al efecto y el resto del acuerdo será exigible de acuerdo a las normas del estado de
California.
Entiendo que tengo derecho a recibir una copia de este acuerdo. Al firmar abajo, reconozco que he recibido una copia.

ADVERTENCIA: AL FIRMAR ESTE CONTRATO USTED ESTÁ DE ACUERDO CON QUE CUALQUIER PROBLEMA DE NEGLIGENCIA
MÉDICA SEA DECIDIDO POR ARBITRAJE DE EQUIDAD Y ESTÁ RENUNCIANDO A SU DERECHO A UN JURADO O A UN
PROCEDIMIENTO JUDICIAL. VEA EL ARTÍCULO 1 DE ESTE CONTRATO.

Escriba el nombre del paciente en letra de imprenta

(Fecha)

Firma del representante del paciente (si corresponde)

(Fecha)

Escriba con letra de imprenta el nombre y la relación con el paciente

Una copia firmada de este documento deberá ser entregada al paciente. El original será archivado en el expediente médico del paciente.

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CONTACTS

Appointment

What to Bring to the Appointment

Patient Forms
NATUROPATHIC MEDICINE

Patient Forms

Or fill online

New Patient Forms – NATUROPATHIC MEDICINE

RESPONSIBLE PARTY, SIGNIFICANT “OTHER” OR SPOUSE INFORMATION

INSURANCE INFORMATION

PHARMACY INFORMATION

Other Forms and Documents:

CANCELLATION AND NO-SHOW POLICY

Neuron Medical Corporation

Address:

Phone:
(805) 373-2890

Our Email
neuronoffice@gmail.com

Services:

Patient info

LATEST NEWS

The science of OMICm Age with Harvard and TruDiagnostic researchers.

Low Cholesterol: Is There a Neurologic Link?

CONTACTS

Appointment

What to Bring to the Appointment

Patient Forms NATUROPATHIC MEDICINE

Patient Forms

Or fill online

New Patient Forms – NATUROPATHIC MEDICINE

RESPONSIBLE PARTY, SIGNIFICANT “OTHER” OR SPOUSE INFORMATION

INSURANCE INFORMATION

PHARMACY INFORMATION

Other Forms and Documents:

CANCELLATION AND NO-SHOW POLICY

Neuron Medical Corporation

Address:

Phone: (805) 373-2890

Our Email neuronoffice@gmail.com

Services:

Patient info

Patient Forms
NATUROPATHIC MEDICINE

Phone:
(805) 373-2890

Our Email
neuronoffice@gmail.com