Forms

We specialize in complex patients – patients with neuromuscular diseases, autonomic diseases, Ehlers-Danlos Syndrome and Postural Orthostatic Tachycardia Syndrome.

We screen all our potential patients to ensure that we re the right practice for you. Each patient, no matter whether referred by another provider, needs to compete the screening process.

The Screening Process:

You will start with a screening that includes:

  • A copy of your insurance card,
  • A form explaining what you want to see Dr. Saperstein
  • A link to a survey that goes over your symptoms (This survey takes about 30 minutes to complete, so please set aside time to complete this in one sitting. Without this survey, we cannot appropriately screen your case.)

Once your screening is competed, Dr. Saperstein reviews it. Occasionally, we may request medical records to fully understand your medical picture. We will inform you whether we will accept your case.

The Intake Process:

If, after screening, we determine that you are appropriate for our office, we will send you another Klara message with the intake documents.

These include:

  • Review of and proof of receipt of Privacy Policies
  • Patient Intake and Registration Form
  • Acceptance of Financial and Appointment Policies
  • HIPPA Consent to Share Information (if you want to allow us to speak with a parent, spouse, sibling, etc)
  • Medical Records Requests – records form prior providers you have seen for your medical issues and your Primary Care Provider
  • A picture of your photo identification (if a minor, the parent’s photo ID)

 

PLEASE NOTE:

We require all your forms and information to be completed prior to scheduling the appointment.

 

If your insurance requires prior authorization, we must have that as well in order to schedule your appointment. You are responsible for contacting your PCP or other referring provider to get this.

 

Due to the complex nature of our patients, we must have medical records in time for your appointment.