For your convenience, we have included our most popular forms for you to download and print (via PDF) to expedite any administrative tasks for our records and to facilitate your appointment. For new patients, the RNA scheduler will direct you to other forms you may need in addition to the obvious ones listed under New Patient Forms.

Our forms are clearly titled for their usage, however, the HIPAA forms may need some explanation.

RNA HIPAA Notice - This is the actual HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) notice that we are required by law to give you access. You may read it online as our Privacy Notice or you may download an actual copy of the notice to read. We require that you sign a HIPAA Release that states you have read it and it will be archive in your permanent file at RNA.

RNA HIPAA Disclosure and Medical Records Release - This form states that you have read the RNA HIPAA Notice and understand how seriously we take your privacy, but are obligated to release medical information under certain legal conditions as described therein. Sometimes you may wish to have only certain parts (or medical conditions) of your medical records to be released to only certain physicians or people. If you want to restrict this information, this disclosure form allows you to list what information and to whom it may be released.

You will need Acrobat Reader to view the file. Acrobat Reader is free and can be obtained from the Adobe site.

New Patient Forms

(see below for New Child Patient Forms)

New Adult Patient Registration
(PDF / Online)

HIPAA Notice (Privacy Policy)
(PDF / Online)

Acknowlegement of Receipt of Notice of Privacy Practices
(PDF / Online)

Authorization to Release Health Information (HIPAA Release)
(PDF / Online)

Medical Records Release
(PDF / Online)

Patient Forms

Headache Diary
(PDF)

Sleep Diary
(PDF)

Sleep Study Information
(PDF)

Sleep Study Questionnaire
(PDF / Online)

Comment or Complaint
(PDF / Online)

Narcotic Contract
(PDF / Online)

Child Neurology Forms

New Child Patient Profile
(PDF / Online)

New Child Patient Registration (Patients of Dr. Milowic only)
(PDF)

HIPAA Acknowledgement
(PDF)

Guardian Release Form
(PDF / Online)

Child Headache Calendar
(PDF)

Sleep Diary
(PDF)

Neuro-ophthalmology Forms

Patient History Form
(PDF / Online)

You can download copies of these forms to use at your convenience. You will need Acrobat Reader to view the file. Acrobat Reader is free and can be obtained from the Adobe site.

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