HMO insurances and patients under 18 years old are required to have a referral from their Primary Care Physician (PCP) to schedule with our office.  Have your PCP fax the referral to our office and we will call you to schedule your appointment. 


Otherwise, patients should complete this Self-referral Form before calling us to schedule an appointment.


Please print and bring the following completed forms to your first patient visit.  You will also need your insurance card and will be asked to pay your co-payment before your office visit.



New Patient Forms To Be Filled Out and Brought to Your First Visit


 1.  Click and print New Patient Form Packet

 2.  Review our HIPAA Notice of Privacy Practices.


 3.  Complete optional forms below that apply to your visit:


 a) Headache/Migraine: print and fill out the following additional form only if you are being seen for headache or migraine issues New Patient Headache Questionnaire.


 b)  Auto Accident Claim: print and complete the following additional forms only if you are being seen for issues related to an auto accident claim New Patient Auto Paperwork.
    
4.  Complete all forms and bring them to your first office visit. 


Steps to Follow for New Patients to Transfer Health Records to First Coast Neurosciences


1.  Click and print this form: Release of Records

2.  Fill out, sign and fax to your existing physician or medical office.

3.  Instruct them to fax your health records to (904) 730-3688. 

Now Offering Affordable Neurology Services for Self-pay Patients

Patient Forms

The FCN Wellness Plan provides affordable access to FCN health care and is designed for individuals where one or more of the following applies:


    *  You have no health care insurance
    *  You are not on Medicare or Tricare
    *  You have insurance but does not cover FCN providers
    *  You have an insurance plan that is not accepted at FCN


For a nominal $49 annual membership fee, you can save 15-35% off of the regular self-pay costs.  Enrollment is easy: you can sign up on the same day of service and save enough to cover the annual fee in addition to extra savings.  Click FCN Wellness Plan for more information.

Other Patient Forms

 

We require that all new patients to our practice come prepared for their initial appointment. Please be sure to bring current medication lists, any recent imaging and/or testing performed (MRI's, CT Scans, lab work, X-rays, etc.), along with all current insurance information. Copay's, coinsurance, and deductibles will be due at time of service for your scheduled visit.

We also encourage family members and caregivers to attend appointments. We believe it is essential that patients have the support and understanding of those around them in treating their neurological condition.

Now accepting

payments online!

Enter your account number:
Patient Web Portal

1. Petition to waive missed appointment fee.  Complete this form and mail or fax it to our office.

Appointments

Mon-Thur from 8am-4:30pm
Fri 8am-3:30pm

Call today for your appointment (904)-730-3689