Los Altos Neurology | SimplePractice

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Administrative

Determination of Care

I understand that completing this form does not establish a patient-physician relationship. Information provided will be reviewed solely to determine whether my care needs fall within the scope of Los Altos Neurology.

Referring Physician (if applicable):

If self-referred, please include the name of your primary care physician (if available).

Email Consent

I consent to receiving email communications from Los Altos Neurology regarding my inquiry, including information about out-of-network services, fees, and practice policies.

Billing & Payment

Billing Disclosure

I understand that Los Altos Neurology is an out-of-network practice and that services are provided on a self-pay basis, with fees based on time spent. Current rates will be shared prior to scheduling. Payment is due at the time of service. A detailed statement may be provided for patients seeking out-of-network reimbursement; however, submission of claims is the patient’s responsibility. Los Altos Neurology has opted out of Medicare, and services are not billable to Medicare.

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.