Please fill out your form, PRINT, and FAX it back to us at KCA: 615.550.1819. The SUBMIT button cannot be used due to HIPPA regulations.
No fax? Check out the smart phone app “Genius Scan” to take a pic of your completed forms and fax them. Thank you for your cooperation.
At KCA, we have worked very hard to reduce our wait times, but we need your help.
Please fill out the medical information forms completely so our data entry specialists can start your chart before your first appointment.
Also, please submit your forms via fax: 615.550.1819, snail mail, or in person 48 hours prior to your appointment
Remember have your current insurance card and valid driver’s license with you before you begin completing the forms. Bring your license and insurance card(s) to all of your appointments as well.
Your insurance carrier requires that we collect very specific information, neglecting any of the fields in the forms may prolong our new patient setup.
Thank you for your help, and we look forward to meeting you!
(Give us permission to request your records from your other doctors)
If you would like for us to have your medical records from any of your other providers, please go ahead and give us permission. Without your written approval, we are not able to request information on your behalf. Help us to serve you better by allowing us to access your medical history.
After faxing your written request, it usually takes 36-72 hours for the information to be received. So please complete this form as soon as possible if you wish for our KCA providers to have your information prior to your appointment.
Help us help you get better!
Need a good neurologist? At KCA many of our patients come to us through referrals from other doctors. Although in most cases it is not necessary to have a referral to make an appointment, we wanted to make it as easy as possible for your primary care doctor or any other provider to complete that request.
We request that you submit these forms no later than 48 hours prior to your appointment date and time. This helps us streamline the check-in process and keep our lobby wait times to a minimum.
Thanks for your help!