Forms & Instructions

Please read the following instructions and download appropriate forms.


Appointment Scheduling:

Please call the front office to schedule an appointment at (661) 255-5444. Tell the receptionist the reason you are seeing a neurologist, your symptoms and the name of your Primary Care Provider and/or Provider who is referring you to Dr. Schultz. If you have a referral, have the number ready. Be sure to have your insurance card handy to provide the name of your insurance company, the subscriber number, the group number, and if you are not the subscriber, the name, date of birth and social security number of the subscriber. It is helpful to tell the receptionist whether you have had any diagnostic testing done recently, and where it was done. If you have medical records or test results, bring them with you to your appointment. If you have a prescription for a consultation or test written by another Doctor or Health Care Provider, please fax it to the office. You may fill in your Demographic information using our on-line “PATIENT INFORMATION FORM”, print, sign, and bring it to the office. Completed and signed forms, copies or prescriptions may be faxed to us prior to your appointment at (661) 255-8447. PLEASE DO NOT EMAIL MEDICAL INFORMATION TO US AS WE CANNOT GUARANTEE THE CONFIDENTIALITY AND SECURITY OF INFORMATION SENT BY EMAIL. If you wish to change or cancel an appointment, please call the receptionist during office hours. Appointments cancelled with less than 24 hour notice may result in a cancellation fee.

 

Check-in Requirements:

When you arrive for your appointment we will need to make a copy of your Medicare or Primary and Secondary insurance card(s) and a picture ID. If you have copies of test results, please bring them with you to your appointment and give them to receptionist. You may read our NOTICE OF PRIVACY PRACTICES on-line located here in the new patient forms section or when you arrive at the office. In the office you will be asked to sign a form indicating that it was provided to you. If you want a paper copy to keep, please ask the receptionist. Co-Pays should be paid at the time of your arrival. We accept Visa, Mastercard, Discover, cash or checks made out to “Santa Clarita Neurology Medical Group”. We will be happy to bill your insurance carrier. If there is a deductible or co-insurance for which you are responsible after your insurance pays their portion, we will send you a statement. Payments may also be made on your account with cash, check or a credit card. Credit card payments may be made in the office, over the phone, by mail or on-line.

 

Appointment Arrival Time:

If you are a new patient or are returning after a long absence for a new problem, please arrive at least 20 minutes prior to your scheduled appointment time to allow time for check-in procedures. Dr. Schultz runs very much on time. We respect your time and don’t want to disrupt your schedule or that of the patients who are scheduled after you, so if you are late, we may ask you to reschedule your appointment for another time when you are able to arrive on time.

 

 

Forms and copies may be faxed anytime before your appointment to (661) 255-8447.

If you wish to mail them, please do so at least 5 working days prior to your appointment to ensure that we receive them.

Forms

Authorization for Dr. Schultz to Receive Medical Records From Another Provider

Complete and sign form. Then fax, mail or bring it to the office.

Download Form

 

Authorization for Dr. Schultz to Send Medical Records To Another Provider

Complete and sign form. Then fax, mail or bring it to the office.

Download Form

 

Patient Information Form

Complete and sign form. Then bring it with you to your appointment.

Download Form

 

EEG Instructions

Read when the Doctor orders an EEG to be scheduled here in our office.

Download Form

 

Neurodiagnostic Consent Form

To be signed at the office prior to your having a Nerve Conduction Test, EMG, or BAER test..

Download Form

 

Notice of Privacy Practices

When you arrive in the office you will be given a form to sign indicating that you were provided a copy of this notice to read.

Download Form