PRIOR TO YOUR INITIAL VISIT:
We request paperwork prior to SCHEDULING your first visit. Please send in all paperwork via fax (949) 354-0612 or email to firstname.lastname@example.org:
Please fill out all forms in BLACK ink ONLY.
-- Completed New Patient Questionnaire
-- For ADHD/ADD Evaluations: Vanderbilt Forms from Parents and Teachers
-- For Headache evaluations: completed Headache Diary
-- For Concussion patients: ImPACT Demographics Sheet
-- Copy of your insurance card (front and back)
-- Previous Consultation Reports and School (IEP) Reports
-- Outside records of any EEG, blood work, or neuroimaging reports
-- Neurological imaging (digital images CD if available)
FREQUENTLY ASKED QUESTIONS:
What types of insurance do you accept?
We are currently an "in-network" provider for only Aetna PPO, Anthem Blue Cross PPO, Blue Shield of California PPO (EXCEPT Exclusive plans or XEK plans), Cigna PPO, United PPO, Monarch HealthCare HMO, and Mission Hospital Allied Physicians HMO.
We are currently an "out-of-network" provider for all other HMO, PPO and EPO plans. Therefore, we will not bill your insurance at this time. At the time of your visit, you will receive a “superbill” to submit to your insurance company. You will be required to provide our office payment at the time of your appointment, and then you can submit the “superbill” and receipt to your insurance company. Most patients with PPO plans can expect to receive 60 to 70% reimbursement. For additional information, you may contact your insurance company prior to the appointment for more information about “out-of-network” coverage, deductibles and other limitations.
My current insurance plan is Aetna PPO, Anthem Blue Cross PPO, Blue Shield of California PPO, Cigna PPO, United PPO, Monarch HealthCare HMO, or MHAP HMO.
How does that work for me?
For PPO patients, you do not need an authorization. For HMO patients, you will need an authorization from your primary care provider prior to scheduling an appointment. Your insurance company requires us to collect co-payments, coinsurance, and/or deductible amounts at the time of service. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Any outstanding balance on your account, after adjusting for all of your insurance's responsibilities, will be billed to you. If your insurance changes, please notify us prior to your next visit so we can make the appropriate changes to help you receive your maximum benefits.
Our office will take care of billing insurance as well as any test and follow-up authorizations which may be required.
How much do the appointments cost for “out-of-network” patients?
Typical initial Autism consultations (99245 & 96112) are 60 minutes and the fee is $385.
Typical initial General Neurology Consultations (99245) are 60 minutes and the fee is $385.
Follow-up appointments (99215) are 30 minutes and the fee is $165.
Can I e-mail Dr. Przeklasa Auth?
Yes; however, only non-urgent/non-emergency questions and concerns should be addressed over email. Or you can email her assistant at email@example.com.
What should I do if there is an after-hours emergency?
Dr. Przeklasa Auth (or a covering pediatric neurologist) is available 24 hours a day for urgent matters. However, if your concern is an emergency, you should call 911 or seek immediate medical attention.
How do I get a medication refill?
Dr. Przeklasa Auth will always prescribe enough medication to last until the recommended follow-up appointment. However, if a medication refill is needed prior to your follow-up appointment, have your pharmacy fax a refill request to the office. Please allow 48 hours for regular refill requests and 72 hours for controlled substance refill requests. Any prescription, including Controlled Substance medication changes or prescriptions requested in between visits, will be subject to a $25 charge.
School, Camp, Medication and IHSS Forms:
Please bring your forms to us as soon as you receive them. Be sure to fill in your CHILD'S NAME and DATE OF BIRTH along with all the portions designated to be filled out by Parent PRIOR to submitting your form to us.
If you are bringing a form with you to your appointment, in most cases, we will be able to complete your form before you leave. There are times when our office is extremely busy, and you may be asked to leave the form with us for a few days.
If you are dropping off, faxing or emailing a form to us, please allow 3 to 5 business days to complete. We will call you when your form is ready to be picked up. There is a $25 Form fee.