ࡱ> ceb ZbjbjWW .^55hTT8\V*,A8::::::$ #^EZZZ^Z8Z8{p@0$01$p1$1$\ S^^ZZZZ1$T t: NEUROPSYCHOLOGY CONSULT fax SHEET GAINESVILLE-OCALA TO: Clinical Psychology Associates of North Central Florida CPANCF.COM MEMORY-DISORDER-CLINIC.COM FAX 352 371-1730 ph. 352 336-2888 FORENSICNEUROPSYCHOLOGY.COM PEDIATRICNEUROPSYCHOLOGY.COM Date_________ Doctors Office: ______________________________ PHONE _______ FAX________ Pt. Name ____________________________ DOB ___________ TEL __________ Pt Address_____________________________________________________________ Primary Insurance ___________________________ Contact Number ____________ Contract Number ___________________ Policy Number _______________________ _____Assessment  FORMCHECKBOX Legal Involvement  FORMCHECKBOX  Possible Dementia  FORMCHECKBOX  Chronic Pain  FORMCHECKBOX  Dementia vs. Depression  FORMCHECKBOX  ADHD  FORMCHECKBOX  ADHD  FORMCHECKBOX  General psychotherapy  FORMCHECKBOX  Learning Disorder  FORMCHECKBOX  Addiction treatment  FORMCHECKBOX  Early / Mild Cognitive Impairment  FORMCHECKBOX  Psycho-oncology  FORMCHECKBOX  Pre-surgical Evaluation Deep Brain Stim.  FORMCHECKBOX  Post DBS Eval  FORMCHECKBOX Other ________________  FORMCHECKBOX  Pre-surgical eval other _____________________  FORMCHECKBOX  Concussion/Head Injury  FORMCHECKBOX  Possible Toxic/Medication Effects  FORMCHECKBOX  Possible Anoxic/Hypoxic  FORMCHECKBOX  Post Stroke  FORMCHECKBOX  MS  FORMCHECKBOX  Seizure Disorder  FORMCHECKBOX  Chronic Pain Evaluation  FORMCHECKBOX  Possible Addiction  FORMCHECKBOX  Possible Exaggeration/Malingering OTHER OR BRIEF REASON FOR CONSULT: Instructions: FAX sheet to number above with neurological evaluation if available. Have patient sign release to your office from us and include confidential psychological neuropsychological report and progress notes as the information to be released. Ideally, fax that with the consult request and it will make it easy for us to let you know if the patient did not show, did not have the right insurance, or was referred elsewhere due to wait times, etc. Check all the above that apply. We now serve preschool children through adults. We are not on any managed care panels. Medicaid does not allow billing by independent psychologists, so we cannot accept Medicaid programs. We ARE NOT IN-NETWORK for any insurance plans, but can facilitate referrals for services located in our offices through an alliance with Comprehensive MedPsych Systems for patients who have Medicare or who cannot afford to go out-of-network for BCBS plans. BCBS and most insurance does not cover Learning Disability Assessment, or that portion of the assessment considered for learning disability. Due to changes in the PIP law Auto accident or litigation cases must be referred for neuropsychological IME by their attorney. NEUROPSYCHOLOGY CONSULT SHEET PAGE 2 Clinical Psychology Associates of North Central Florida CPANCF.COM MEMORY-DISORDER-CLINIC.COM FAX 352 371-1730 FORENSICNEUROPSYCHOLOGY.COM PEDIATRICNEUROPSYCHOLOGY.COM Pt. Name ____________________________ StudyWhen PerReported Findings CT Brain  FORMTEXT       MRI Brain  FORMTEXT       MRA Brain  FORMTEXT       PET Brain  FORMTEXT       SPECT Brain  FORMTEXT       EEG  FORMTEXT       EMG FORMTEXT       Carotid Artery Scan FORMTEXT       Spinal Tap FORMTEXT       BAER FORMTEXT       VEP FORMTEXT        FORMTEXT        FORMTEXT       Other results or findings: When possible have patient sign and date the following: I ____________________________, authorize release o#45;Wrtu}! . / 0 ? @ Q {  - 6 C Y Z ˽ˍˍˁ˅ˁˁ˅yuyiyjhy*CJUaJhy*hy*CJaJhKhBhWsh&h Hh&56B* CJphh HhK56B* phh Hh&56B* phh Hh,56B* phh,h Hh,5B* phh>5B* phh Hh&5B* phh HhB5B* ph)56u! 0 |  [ ) n  \ ) X gdy*^gd&gd&     ) * 8 9 : ; R V W X f g h m n o } ~  ٻ٩ٌٞفoف]ف#jJhy*hy*CJUaJ#jhy*hy*CJUaJhKh,CJaJ#j`hy*hy*CJUaJhKhKCJaJ#jhy*hy*CJUaJ#jvhy*hy*CJUaJhy*hKCJaJhy*CJaJjhy*CJUaJ#jhy*hy*CJUaJ$        6 8 : ; I J K [ \ ] k ϪϪt#jhy*hy*CJUaJ#jhy*hy*CJUaJ#jhy*hy*CJUaJhKCJaJ#j4hy*hy*CJUaJhKh,CJaJhKhKCJaJ#jhy*hy*CJUaJjhy*CJUaJhy*CJaJ'k l m n  $ ( ) * 8 9 : ; Q W X Y ٱٍٟ΅zh]hKhKCJaJ#jhy*hy*CJUaJhy*h,CJaJhBCJaJ#jfhy*hy*CJUaJ#jhy*hy*CJUaJ#j|hy*hy*CJUaJhy*hy*CJaJhKh,CJaJhy*CJaJjhy*CJUaJ#jhy*hy*CJUaJ$Y g h i j  67EFGuc#j hy*hy*CJUaJ#j hy*hy*CJUaJ#j& hy*hy*CJUaJ#jhy*hy*CJUaJ#j:hy*hy*CJUaJ#jhy*hy*CJUaJhKhKCJaJjhy*CJUaJ#jNhy*hy*CJUaJhy*CJaJ& 6[jkz{|>gd&gdBGHZ[\jklmikmryz{{{o{{{gh,CJaJhqR;hqR;5CJaJhqR;CJaJhqR;hB5CJaJhy*hBCJaJhy*hKCJaJhy*h,CJaJhBhKhqR;hBCJaJ#j hy*hy*CJUaJjhy*CJUaJhKh,CJaJhKhKCJaJhy*CJaJ&z|>^Z\` ǼpXC)j hUjh&5CJU\aJ.jhUjh&5CJU\aJmHnHu)j hUjh&5CJU\aJ#jhUjh&5CJU\aJhUjh&CJ\aJhUjh&5CJ\aJh&5CJ\aJh Hh&CJaJh&h Hh Hh&56B* CJphh Hh&56B* phh Hh&B* phh&CJaJ\`lx$Ifgd&l gd&F3333$Ifgd&l kd $$Iflo\ q"\d t0q"644 lalp(ytUj3kdG $$IflM\ q"\d t0q"644 lalp(ytUj$Ifgd&l .03kd $$IflJ\ q"\d t0q"644 lalp(ytUj$Ifgd&l  *,0FLNbdfprv,.0:<@JȼȧȼȒȼ}ȼhȼ)j>hUjh&5CJU\aJ)jhUjh&5CJU\aJ)jhUjh&5CJU\aJ)jchUjh&5CJU\aJhUjh&CJ\aJhUjh&5CJ\aJ#jhUjh&5CJU\aJ.jhUjh&5CJU\aJmHnHu(02FHJLt$Ifgd&l tvxF3333$Ifgd&l kd$$IflM\ q"\d t0q"644 lalp(ytUj3kd"$$IflJ\ q"\d t0q"644 lalp(ytUj$Ifgd&l 3kdk$$IflM\ q"\d t0q"644 lalp(ytUj$Ifgd&l >$Ifgd&l >@BJLNF3333$Ifgd&l kd$$IflM\ q"\d t0q"644 lalp(ytUjJNPdfhrtx"&(<>@JLPZ}r]r)jbhUjh&5CJU\aJhUjh&CJaJ)jhUjh&5CJU\aJ)jhUjh&5CJU\aJhUjh&CJ\aJ.jhUjh&5CJU\aJmHnHu)jhUjh&5CJU\aJ#jhUjh&5CJU\aJhUjh&5CJ\aJ$Nvxz3kd$$IflJ\ q"\d t0q"644 lalp(ytUj$Ifgd&l 3kdF$$IflM\ q"\d t0q"644 lalp(ytUj$Ifgd&l 3kd$$IflJ\ q"\d t0q"644 lalp(ytUj$Ifgd&l "$&NP3kd$$IflM\ q"\d t0q"644 lalp(ytUj$Ifgd&l PRZ\^$Ifgd&l Z^`tvx$&DXgZhZ~vnbn`nUhBhqR;CJaJUh>hqR;5CJaJhqR;CJaJh&CJaJhqR;h&CJaJ)j=hUjh&5CJU\aJ)jhUjh&5CJU\aJ.jhUjh&5CJU\aJmHnHu)jhUjh&5CJU\aJ#jhUjh&5CJU\aJhUjh&5CJ\aJF3333$Ifgd&l kd!$$IflJ\ q"\d t0q"644 lalp(ytUj3kdj$$Ifl\ q"\d t0q"644 lalp(ytUj$Ifgd&l $3..gd&kd$$Ifl\ q"\d t0q"644 lalp(ytUj$Ifgd&l $&(ZhZjZkZmZnZpZqZsZtZuZvZwZxZyZzZ{Z|Z}Z~ZZZZZf confidential psychological and other protected health information concerning this referral from the referral source to Clinical Psychology Associates of North Central Florida (CPANCF) and/or Comprehensive MedPsych Systems (CMPS) and for CPANCF and/or CMPS to contact me at the following number:____________________________. I understand CPANCF and CMPS are independent entities and that each is solely responsible for any services they provide. This release for establishing referral shall expire in 3 months from date of signature. Signature_________________________________ Date_________________     hZiZkZlZnZoZqZrZtZZZZhBhqR;CJaJh&hUjjhUjU ,1h/ =!"#$% vDeCheck24tDeCheck1vDeCheck18tDeCheck2vDeCheck19tDeCheck3vDeCheck20tDeCheck4vDeCheck21tDeCheck5vDeCheck22tDeCheck6tDeCheck7vDeCheck23tDeCheck8tDeCheck9vDeCheck10vDeCheck11vDeCheck12vDeCheck13vDeCheck14vDeCheck15vDeCheck16vDeCheck17$$Ifl!vh#v#v#v\#vd:V lo t0q"6555\5dalp(ytUjvDText70$$Ifl!vh#v#v#v\#vd:V lM t0q"6555\5dalp(ytUjvDText71$$Ifl!vh#v#v#v\#vd:V lJ t0q"6555\5dalp(ytUjvDText72$$Ifl!vh#v#v#v\#vd:V lM t0q"6555\5dalp(ytUjvDText73$$Ifl!vh#v#v#v\#vd:V lJ t0q"6555\5dalp(ytUjvDText74$$Ifl!vh#v#v#v\#vd:V lM t0q"6555\5dalp(ytUjvDText75$$Ifl!vh#v#v#v\#vd:V lM t0q"6555\5dalp(ytUjvDText76$$Ifl!vh#v#v#v\#vd:V lJ t0q"6555\5dalp(ytUjvDText77$$Ifl!vh#v#v#v\#vd:V lM t0q"6555\5dalp(ytUjvDText78$$Ifl!vh#v#v#v\#vd:V lJ t0q"6555\5dalp(ytUjvDText79$$Ifl!vh#v#v#v\#vd:V lM t0q"6555\5dalp(ytUjvDText80$$Ifl!vh#v#v#v\#vd:V lJ t0q"6555\5dalp(ytUjvDText81$$Ifl!vh#v#v#v\#vd:V l t0q"6555\5dalp(ytUjvDText82$$Ifl!vh#v#v#v\#vd:V l t0q"6555\5dalp(ytUj^ 2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH @`@ NormalCJ_HaJmH sH tH DA D Default Paragraph FontRi@R  Table Normal4 l4a (k (No List j@j & Table Grid7:V04@4 &Header  !4 @4 &Footer  !PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3N)cbJ uV4(Tn 7_?m-ٛ{UBwznʜ"Z xJZp; {/<P;,)''KQk5qpN8KGbe Sd̛\17 pa>SR! 3K4'+rzQ TTIIvt]Kc⫲K#v5+|D~O@%\w_nN[L9KqgVhn R!y+Un;*&/HrT >>\ t=.Tġ S; Z~!P9giCڧ!# B,;X=ۻ,I2UWV9$lk=Aj;{AP79|s*Y;̠[MCۿhf]o{oY=1kyVV5E8Vk+֜\80X4D)!!?*|fv u"xA@T_q64)kڬuV7 t '%;i9s9x,ڎ-45xd8?ǘd/Y|t &LILJ`& -Gt/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!0C)theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] ^  k Y Gz JZhZZ !'. 0t>NP$Z "#$%&()*+ )9Wgn~:J\l)9Xh 6F[k    & 2 8 I U [ n z %/;AHTZamsG G G G G G G G G G G G G G G G G G G G G G G G FFFFFFFFFFFFF8@0(  B S  ?%Check24Check1Check18Check2Check19Check3Check20Check4Check21Check5Check22Check6Check7Check23Check8Check9Check10Check11Check12Check13Check14Check15Check16Check17Text70Text71Text72Text73Text74Text75Text76Text77Text78Text79Text80Text81Text82 *Xo;]*Y 7\  ' J o 0Ib  !"#$:hKm:iGl  9 \ &B[t  9*urn:schemas-microsoft-com:office:smarttagsplace h\#4 hjkmnpqst5^f}n hjkmnpqst33333#4 ,,g#4 ,,ghijklmnopqrstT:Jy*qR;Ws",&q[ &Uj Hq>KBhj@4444@{@ @@UnknownG*Ax Times New Roman5Symbol3. *Cx ArialA$BCambria Math"qh{fi"q%24``3QHP ?,2!xx NEUROPSYCHOLOGY CONSULT SHEETErnest J. Bordini, Ph.D.drejbOh+'0 (4 T ` lx NEUROPSYCHOLOGY CONSULT SHEETErnest J. Bordini, Ph.D.Normaldrejb7Microsoft Office Word@[@T@@0՜.+,0l   $ N4 Clinical Psychology Associates of N.C. Florida, PA` NEUROPSYCHOLOGY CONSULT SHEET Title  !"#$%&'()*+,-./123456789:;<=>@ABCDEFGHIJKLMNOPQSTUVWXY[\]^_`adRoot Entry Fy@0fData 01Table?1$WordDocument.^SummaryInformation(RDocumentSummaryInformation8ZCompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q