NEW PATIENT INFORMATION SHEET
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- Francine Cole
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1 NEW PATIENT INFORMATION SHEET PATIENT NAME BIRTHDATE / / SEX M F HOME ADDRESS STREET APT# CITY STATE ZIP CODE HOME TELEPHONE ( ) SOCIAL SECURITY - - MARITAL STATUS OCCUPATION EMPLOYER WORK PHONE ( ) RACE (OPTIONAL) ASIAN BLACK CAUCASIAN HISPANIC NATIVE AMERICAN OTHER INSURANCE INFORMATION PRIMARY INSURANCE ID# GROUP# NAME OF INSURED RELATION TO PATIENT SOCIAL SECURITY - - D.O.B. / / HOME PHONE ( ) ADDRESS CELL PHONE ( ) EMPLOYER OCCUPATION WORK PHONE ( ) SECONDARY INSURANCE ID# GROUP# NAME OF INSURED RELATION TO PATIENT SOCIAL SECURITY - - D.O.B. / / HOME PHONE ( ) ADDRESS CELL PHONE ( ) EMPLOYER OCCUPATION WORK PHONE ( ) PHARMACY INFORMATION Name Phone ( ) Address City State Zip Code Emergency Contact Relationship Phone( ) How did you learn about Dr. Cohen? Another Patient Yellow Pages ZocDoc Yelp Internet Another Doctor Name of Dr. who referred you to us:
2 Financial Responsibility Patient D.O.B. / / I understand that I am financially responsible for any balance not covered by my insurance carrier, including co-pays, coinsurance, and all amounts applied to deductibles. I authorize the release of any medical information to my insurance company necessary for processing of the claim. I certify that I am eligible participant under my insurance carrier, and authorize payment to the treating physician for services provided directly from my insurance carrier. Financial Policy Thank you for choosing us as your health care provider. Our main concern is that you receive the proper medical care needed to maintain your health. If you have any questions, please do not hesitate to ask our staff and/or doctors. All co-pays and deductibles are due at the time of your visit. Payments for services for cash visits are due IN FULL at the time of visit. We accept cash, checks, all major credit cards and debit cards. We will submit insurance claims on your behalf as a courtesy, if we have a provider contract with your insurance company. You are responsible for any co-payments, co-insurances, deductibles, plus any balance due on non-covered services from you plan. However, it is YOUR responsibility to follow-up with your insurance company in the event that your claim is unpaid. If your insurance company changes, it is YOUR responsibility to notify us and provide a copy of the new insurance card to us immediately. 1. Your insurance policy is a contract between you, your employer and your insurance company. We are not a party to that contract. Our relationship is with you and you are ultimately responsible for any service provided, regardless of your insurance coverage. 2. Not all services are covered by your insurance company. It is your responsibility to know what is covered and what is not. Fees for non-covered services are due at the time service is rendered. 3. Minor Patients -The adult (parent, guardian) accompanying a minor is responsible for the co-payment at time of service. (A Divorce decree/custody papers do not determine which party our office will bill for medical services. They are only binding upon the two parties who made the agreement) -The parent accompanying the child(ren) on the first appointment will be considered the guarantor (responsible party) on the patient s account. The guarantor is responsible for co-payments at time of service. 4. If your insurance company does not pay within 60 days, we reserve the right to begin billing you directly and that you contact your insurance carrier. Accounts will be considered delinquent after 90 days. Delinquent accounts will be placed with a private collections agency. 5. Returned checks will be subject to a $30 fee. 6. WE DO NOT BACK BILL INSURANCE. We have contractual obligations with insurance companies that require us to bill claims within a certain amount of time. If the claims are not billed in that time frame the insurance will not pay.
3 We do understand that temporary hardships may affect timely payment of your balance. We encourage you to communicate any problems so that we can assist you in the management of your account. Non-discrimination Policy Victor E. Cohen s office does not discriminate against any person on the basis of race, color, national origin, sex, religion, age or disability.
4 Victor E. Cohen, M.D. Allergy Asthma Immunology 4445 S. Eastern Avenue Suite A Las Vegas, Nevada (702) Fax (702) PRIVACY NOTICE The following notice describes how your medical information may be used and disclosed, and how you can get access to this information. Please review the information carefully. Your confidential healthcare information may be released to other healthcare professionals for the purpose of providing you with quality healthcare. Your confidential healthcare information may be released to your insurance provider for the purpose of the practice receiving payment for providing you with needed healthcare services. Your confidential healthcare information may be released to public or law enforcement officials in the event of an investigation in which you are a victim of abuse, a crime or domestic violence. Your confidential healthcare information may be released to other healthcare providers in the event you need emergency care. Your confidential healthcare information may be released to a public health organization or federal organization in the event of a communicable disease or to report a defective device or untoward event to a biological product (food or medication). Your confidential healthcare information may not be released for any other purpose than that which is identified in this notice. Your confidential healthcare information may be released only after receiving written authorization from you. You may revoke your permission to release confidential healthcare information at any time. You may be contacted by the practice to remind you of any appointments, healthcare treatment options or other health services that may be of interest to you. You have the right to restrict the use of your confidential healthcare information. However, the practice may chose to refuse your restriction if it is in conflict of providing you with quality healthcare or in the event of an emergency situation.
5 You have the right to receive confidential communication about your health status. * You have the right to review and photocopy any/all portions of your healthcare information. You have the right to make changes to your healthcare information. You have the right to know who has accessed your confidential healthcare information and for what purpose. You have the right to possess a copy of this Privacy Notice upon request. The practice is required by law to protect the privacy of its patients. It will keep confidential any and all patient healthcare information and will provide patients with a list of duties or practices that protect confidential healthcare information. The practice will abide by the terms of this notice. The practice reserves the right to make changes to this notice and continue to maintain the confidentiality of all healthcare information. Patients will receive a mailed copy of any changes to this notice within 60 days of making the changes.
6 Victor E. Cohen, M.D. Allergy Asthma Immunology 4445 S. Eastern Avenue Suite A Las Vegas, Nevada (702) Fax (702) Patient Consent for the Use and Disclosure of Protected Health Information With consent, Victor E. Cohen, M.D. may use and disclose protected health information about me to carry out treatment, payment, and healthcare operations. Please refer to Victor E. Cohen, MD s Notice of Privacy Practices for more complete description of such uses and disclosures. I have the right to review the Notice of Privacy Practices prior to signing this consent; Victor E. Cohen, M.D. reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy practices may be obtained by forwarding a written request to Victor E. Cohen, M.D. s Privacy Officer at 4445 S. Eastern Ave., Suite A, and Las Vegas, NV With my consent, Victor E. Cohen, M.D. s staff may call my home or other designated location and leave a message on my voic or in person in reference to any items that assist the practice in carrying out healthcare operations, such as appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory results among others. With my consent, Victor E. Cohen, M.D. s staff may mail to my home or other designated location any items that assist the practice in carrying out healthcare operations, such as appointment reminder cards, patient statements, insurance information, and letters explaining your account. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. By signing this form, I am consenting to Victor E. Cohen, M.D.s use and disclosure of my Protected Health Information to carry out healthcare operations. I may revoke my consent in writing except to the extent that the practice has a ready made disclosure in reliance upon my prior consent. If I do not sign this consent, Victor E. Cohen, M.D. may decline to provide treatment to me. Signature of Patient or Legal Guardian Print Name Patient Name
7 Victor E. Cohen, M.D. Allergy Asthma Immunology 4445 S. Eastern Avenue Suite A Las Vegas, Nevada (702) Fax (702) THE FOLLOWING MEDICATIONS SHOULD BE DISCOUNTINUED SEVEN DAYS PRIOR TO ALLERGY TESTING: Any cough or cold preparations: Examples: Nyquil, Dayquil, Theraflu Any sleeping medications: Including over the count, prescribed and holistic Examples: Tylenol PM, Excedrin PM, Nytol, Sominex, Melatonin Antihistamines: This is a list on many antihistamines; there are many different names for store brand antihistamines. Look with caution for the word: allergy or sinus on the box. ASTELIN NASAL SPRAY ACTIFED ALLEGRA ATARAX BENADRYL CHLORPHENIRAMINE CLARITIN, CLARINEX CONTAC DIMETAPP DRISTAN DRIXORAL HYDROXYZINE DYMISTA NASAL SPRAY PHENERGAN RYNATAN SINE-AID SINEQUAN (DOXYPIN) SUDAFED PLUS (PLAIN SUDAFED IS OK) TAVIST D TRIAMINIC TYLENOL SINUS (PLAIN TYLENOL OK) ZYRTEC XYZAL ZANTAC
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Welcome to RehabXperience. Thank you so much for choosing us. We recognize that you have a choice of physical therapy centers and greatly appreciate you for choosing us as your outpatient physical therapy
Patient Information Form Trinity Wellness Center. Insurance Information
Patient Information Form Trinity Wellness Center Last Name, First Name, MI* Date of Birth* / / Social Security # -- -- Sex* : Female / Male Student Status (circle one): Full-time / Part-time / not a student
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REHAB XCEL, LLC. NEW PATIENT INFORMATION
REHAB XCEL, LLC. NEW PATIENT INFORMATION DATE: NAME: LAST: FIRST: MID: MAIL ADDRESS: HOME PHONE: CELL PHONE: WORK PHONE: DATE OF BIRTH: SS# SEX: M OR F EMERGENCY CONTACT: PHONE: MARITAL STATUS: M OR S
Patient s Last Name First MI. Social Security # Date of Birth. Age Sex M F Family Referring Doctor Doctor. Home Address Apt # City State Zip
Klein & Associates, M.D., P.A. Registration Form Patient s Last Name First MI Social Security # Date of Birth Age Sex M F Family Referring Doctor Doctor Home Address Apt # City State Zip Home Phone ( )
Cardiology Consultants of Atlanta, P.C. 2801 N. Decatur Rd. Suite 395, Decatur GA, 30033 (404) 298-2220 phone (678) 904-5336 fax
OFFICE POLICIES AND PROCEDURES Thank you for choosing Cardiology Consultants of Atlanta for your cardiovascular care. We realize that you have a choice in medical providers and are pleased that you have
Flyer Internet Source (Please circle one): Office Webpage Google Facebook Other Insurance Please Specify. Last Name First Name M.I.
Welcome and Thank you for choosing us as your oral care provider! To help us meet all your dental needs, please fill out this form completely. If you have any questions or need assistance, please ask us
Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,,
Medical History Existing or Relevant Previous Conditions Allergies Yes No Dizzy Spells Yes No MRSA Yes No Anemia Yes No Emphysema/Bronchitis Yes No Multiple Sclerosis Yes No Anxiety Yes No Fibromyalgia
Medicine and Reconstructive Surgery of the Foot and Ankle Board Certified in Foot and Ankle Surgery
Medicine and Reconstructive Surgery of the Foot and Ankle Board Certified in Foot and Ankle Surgery PATIENT INFORMATION Title First Name MI Last Name Address Apt# City State Zip Code County Home Ph. (
You are scheduled to see Dr. Kennard: at. On the day of your visit, he will be located at: (Directions are enclosed)
Your dermatologist has referred you for treatment of your skin condition. We would like to take this opportunity to welcome you and give you information that will make your appointment with us go smoothly.
Registration Forms (Please leave NO blanks, if something does not apply write N/A and if unknown write unknown)
Registration Forms (Please leave NO blanks, if something does not apply write N/A and if unknown write unknown) Patient Name: Date of Birth Mailing Address: City: State Zip: Apt/Ste/Unit/Bldg Primary Number:
Patient Information. Last First MI (Preferred Name) Male Female Married Single Child. City State Zip Code Emergency Contact/Relation Phone
LEWIS C. COLE DMD Family and Cosmetic Dentistry 525 ENERGY CENTER BLVD SUITE 1603 NORTHPORT, AL 35473 PHONE 205.344.6900 FAX 205.344.6910 www.lewiscoledentistry.com Patient Name: Patient Information Date:
INTEGRITY WELLNESS CENTER NOTICE OF PRIVACY PRACTICES
INTEGRITY WELLNESS CENTER NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YU CAN GET ACCESS TO THIS INFORMATION- PLEASE REVIEW IT CAREFULLY
Cornerstone Clinical Services, P.C. Please complete ALL sections
Cornerstone Clinical Services, P.C. Please complete ALL sections Patient Information Patient s full name Age DOB M / F Marital: S M D W Mailing Address City State Zip Employer Name & Address Home Phone
Healthy Living Clinic, LLC Phone:(321) 549-2273/ FAX:(321) 549-2066
IDENTIFYING INFORMATION Patient Enrollment Form PATIENT NAME: SEX: MALE FEMALE DOB: / / SS# -- -- MO DAY YEAR CONTACT HOME PHONE: EMAIL: WORK PHONE: Preferred method of communication Email Mail Home Phone
Orthodontics on Silver Lake, P.A. Stephanie E. Steckel, D.D.S., M.S. Welcome To Our Office -Please Print-
HEALTH HISTORY Orthodontics on Silver Lake, P.A. Stephanie E. Steckel, D.D.S., M.S. Welcome To Our Office -Please Print- Date: 20 Date of Birth: Patient s name: First Middle Last Name Patient Prefers to
North Country Holistic Care Center PATIENT REGISTRATION FORM. Patient Information. Name: Address: City: State: Zip: Email
PATIENT REGISTRATION FORM Patient Information Name: Address: City: State: Zip: Telephone #: Home: Cell: Email Date of Birth: Age: Sex: M F Social Security #: - - Referred by: Employment Information Employer:
489 Union Avenue Bridgewater, NJ 08807 Tel (732) 356-9950 Fax (732) 356-9959
489 Union Avenue Bridgewater, NJ 08807 Tel (732) 356-9950 Fax (732) 356-9959 LOUIS J. ARNO, M.D, FACP, FCCP NEHAL L. MEHTA, MD, FCCP,D-ABSM PRASHANT B. PATEL, MD Dear Patient: Welcome to Respacare! We
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PATIENT REGISTRATION DATE: ADULT PATIENT CHILD PATIENT Name Address City State Zip Email Landline Cell Phone Do you work? Where? Work Phone Date of Birth Social Security # Single Married Divorced Widowed
Welcome Information. Registration: All patients must complete a patient information form before seeing their provider.
Welcome Information Thank you for choosing our practice to take care of your health care needs! We know that you have a choice in selecting your medical care and we strive to provide you with the best
HANSEN-COHEN ASSOCIATES IN PSYCHOLOGY
HΨC HANSEN-COHEN ASSOCIATES IN PSYCHOLOGY 5237 SUMMERLIN COMMONS BLVD, SUITE 116 FORT MYERS, FLORIDA 33907 PHONE: 239.274.PSYC (7792) FAX: 239.247.5344 Informed Consent for Financial Responsibility & Psychological
Physical Occupational and Speech Therapy Patient Information Sheet
Physical Occupational and Speech Therapy Patient Information Sheet FIRST NAME: MI: LAST NAME: ADDRESS: HOME PHONE: WORK PHONE: MALE FEMALE CELLPHONE: DOB: SS# EMERGENCY CONTACT: PHONE: RELATIONSHIP: PRIMARY
Know What s in the Medicine You Take:
1 Know What s in the Medicine You Take: Active Ingredients in OTC Pain Relievers, Antihistamines, Decongestants and Cough Medicines Single Ingredient Brand Names Pain relievers Acetaminophen Tylenol:,
PLEASE BRING THE FOLLOWING WITH YOU TO YOUR APPOINTMENT:
To Our New Patient: Our primary concern is providing you with excellent eye care. Your understanding of our policies and your cooperation with our procedures enables us to provide this care. Complete eye