Ty K. Swartzlander, M.D N. Congress Ave * Suite 320 * Boynton Beach, FL * Telephone (561) * Fax (888)
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1 1880 N. Congress Ave * Suite 320 * Boynton Beach, FL * Telephone ( * Fax ( "#$%$&'(#*+,%(-.-/+0,1%&$'.'$+2%,-345#%2','64..+0,74#'7%89-"-$'(:5&/%&+ Directions to the office The office is located on the corner of Gateway Blvd and N. Congress Ave, just north of the Boynton Beach Mall F rom I-95: Take Gateway Blvd exit and turn west Travel 1.3 miles until you see the Renaissance commons on the left. Enter the Renaissance commons. You will see a clock tower straight ahead with two large buildings on either side and several restaurants at the base of each building. Go right, to the West building, the one with the Bonefish Grille at the bottom. If possible, park on the west side of the building. The west entrance to the building is next to Lemon Grass Asian Bistro. Take the west elevators to the 3 rd floor. Go right to Suite N. Congress Ave * Suite 320 * Boynton Beach, FL * Phone ( * Fax (
2 1880 N. Congress Ave * Suite 320 * Boynton Beach, FL * Telephone ( * Fax ( "#$%$&'(#*+,%(-.-/+0,1%&$'.'$+2%,-345#%2','64..+0,74#'7%89-"-$'(:5&/%&+ Name: Street Address: City: State: Zip: Home phone number: Cell phone number: address (we do not give it out: Birthdate: Social Security Number: Referred to practice by: Employer: Occupation: Work phone: Extension: Marital Status: Married Single Divorced Widowed Spouse/Next of Kin: Phone #: Nearest Friend/Relative: Phone #: Relationship: Pharmacy: Phone #: Name of Primary Care Provider: Primary Insurance: PPO HMO PPS Indemnity Phone #: Subscriber: Spouse Self Dependent Secondary Insurance: PPO HMO PPS Indemnity Phone #: Subscriber: Spouse Self Dependent As a courtesy to our patients, our office will submit all charges incurred to your insurance company on record. It is the sole responsibility of the patient to notify our office, in writing, of any changes to their insurance policy. Any account balance remaining after sixty (60 day period shall become the responsibility of the patient. I certify that the above information is correct and further authorize the release of any medical information to your furnishing the service, or authorize the physician to submit a claim for me. I also agree that should this account be referred to any agency or attorney for collection, I will be responsible for all collection fees, attorney fees and court costs. There will be a minimum charge of $50.00 for all balances sent to collections. I am also aware that payment is expected when services are rendered, unless prior arrangements have been made. Signature: Date: 1880 N. Congress Ave * Suite 320 * Boynton Beach, FL * Phone ( * Fax (
3 1880 N. Congress Ave * Suite 320 * Boynton Beach, FL * Telephone ( * Fax ( "#$%$&'(#*+,%(-.-/+0,1%&$'.'$+2%,-345#%2','64..+0,74#'7%89-"-$'(:5&/%&+ Contact Authorization and Preferences I, authorize Dr. Ty K. Swartzlander, or his office staff, to notify me of my diagnostic or lab results. Please check one or more of the following options: Phone Number: Alternate Phone Number: Leave a message with my results at my phone number designated above if I am not available. Leave a message containing my results with anyone answering my phone. I authorize another person to accept results for me. Name of person: Relationship: I authorize you to me with test results or other correspondence at the following address; Other: Speak with me only. Do N O T call me with any results. I will call the office if I want test results. Signature: Date: 1880 N. Congress Ave * Suite 320 * Boynton Beach, FL * Phone ( * Fax (
4 1880 N. Congress Ave * Suite 320 * Boynton Beach, FL * Telephone ( * Fax ( "#$%$&'(#*+,%(-.-/+0,1%&$'.'$+2%,-345#%2','64..+0,74#'7%89-"-$'(:5&/%&+ No Malpractice Acknowledgement Form Under Florida law, physicians are generally required to carry medical malpractice insurance or otherwise demonstrate financial responsibility to cover potential claims for medical malpractice. YOUR DOCTOR HAS DECIDED NOT TO CARRY MEDICAL MALPRACTICE INSURANCE. This is permitted under Florida law subject to certain conditions. The following notice is provided pursuant to Florida law. Please understand that Dr. Ty K. Swartzlander has elected not to carry medical malpractice insurance. In accordance with F.S (5(g 1 and (5(g1, he must provide this notice in writing to you as a patient. Please sign below acknowledging you understand he does not carry medical malpractice insurance. I, understand that I will be provided services by Ty K. Swartzlander, M.D. and that he has chosen not to carry medical malpractice insurance. I would still like to receive medical services provided by Dr. Swartzlander. Thank you, Signature: Date: (Signature of Parent or Legal Guardian if above named patient is a minor and indicate relationship below Parent or Legal Guardian, please print your name: Relationship to patient: 1880 N. Congress Ave * Suite 320 * Boynton Beach, FL * Phone ( * Fax (
5 1880 N. Congress Ave * Suite 320 * Boynton Beach, FL * Telephone ( * Fax ( "#$%$&'(#*+,%(-.-/+0,1%&$'.'$+2%,-345#%2','64..+0,74#'7%89-"-$'(:5&/%&+ Consent for use and disclosure of health information Patient Name: Address: Phone Number: Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations. Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain. You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting: Contact Person: Ty K. Swartzlander, M.D. Telephone: Fax: Address: 1880 N. Congress Ave, Suite 320, Boynton Beach, FL Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this consent will not affect any action we took in reliance on this consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent. Authorization I,, have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities, and health care operations. Signature: Date: If a personal representative on behalf of the patient signed this Consent, complete the following: _ Relationship to patient: Y O U A R E E N T I T L E D T O A C OPY O F T H IS C O NSE N T A F T E R Y O U SI G N I T N. Congress Ave * Suite 320 * Boynton Beach, FL * Phone ( * Fax (
6 1880 N. Congress Ave * Suite 320 * Boynton Beach, FL * Telephone ( * Fax ( "#$%$&'(#*+,%(-.-/+0,1%&$'.'$+2%,-345#%2','64..+0,74#'7%89-"-$'(:5&/%&+ Receipt of Notice of Privacy Practices W ritten Acknowledgement Form I,, have read and/or received a copy of Ty K. Swartzlander, (Patient Name Notice of Privacy Practices. Signature of Patient: Date: For Office Use ONLY Below this Line We attempted to obtain written acknowledgment of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained for one or more of the following reasons: Individual refused to sign Communication barriers prohibited obtaining acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (please specify: 1880 N. Congress Ave * Suite 320 * Boynton Beach, FL * Phone ( * Fax (
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Anthony N. Dardano, D.O., P.A., F.A.C.S. AESTHETIC AND RECONSTRUCTIVE PLASTIC SURGERY Diplomate of the American Board of Plastic Surgery Diplomate of the American Board of Surgery 951 N.W. 13 th Street,
Jodi L. Ceballos, Psy.D. Clinical Psychologist
Hello, my name is Dr. Jodi Ceballos and I am a Licensed who recently relocated to Del Rio. I offer psychological and psycho-educational testing services, as well as individual, couples, and family therapy
LAS VEGAS PAIN INSTITUTE & MEDICAL CENTER, L.L.C.
LAST NAME: FIRST NAME: DOB: / / AGE: MARITAL STATUS: SEX: M F SSN: - - HOME#: CELL#: WORK#: STREET ADDRESS: CITY: STATE: ZIP: EMPLOYER NAME & ADDRESS: SPOUSE S NAME: DOB: / / SSN: - - WORK#: EMPLOYER NAME
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:
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
Mother Stepmother Guardian. Your Child. Father Stepfather Guardian. Parent s Marital Status. Primary Dental Insurance. How Did You Hear About Us?
www.hendersonvilledentalspa4kidz.com Your Child First MI Last Preferred Sex Age School Grade Child s Home Address City State/Prov. Zip/P.C. _ Phone Primary Dental Insurance 264 New Shackle Island Rd.,
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PATIENT INFORMATION EMAIL ADDRESS: First Name: Last Name: Middle Initial: Date: / / Address: City: State: Zip: Birth date: / / Age: Male Female S.S. #: - - Home Phone: ( ) - Alternative Phone (Cell, Pager):
Signature: Date: Witness:
: Patient Relationship to Guarantor: of Birth: Sex: M F Social Security Number: Home Address: City: State: Zip Code: Home Telephone:( ) Referred By: Pharmacy of Choice: Pharmacy Address: Pharmacy Phone
License Number: Occupation:
P a g e 1 Today s Appt : Time: Physician: Patient s Name of Birth: Age: Address: Home Phone: Business Phone Cell Phone Sex Social Security: Marital Status License Number: Occupation: Who is your Primary
Anxiety & OCD Treatment Center of Philadelphia
Anxiety & OCD Treatment Center of Philadelphia th 1845 Walnut Street, 15 Floor Philadelphia, PA 19103 Phone: (215) 735-7588 Website: www.ocdphiladelphia.com Authorization to Receive & Release Protected
ADULT MEDICAL SERVICES PC 6645 Main St. Suite A, Williamsville, NY 14221 (716) 276-8726 (Office) (716) 276-8730 (Fax)
I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information
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
Doctors Weight Loss Center of Cary Patient Information Form (please print)
Doctors Weight Loss Center of Cary Patient Information Form (please print) Patient Name: Date: City: State: Zip Code: Home Phone: Cell Phone: Marital Status: Date of Birth: Email: Your Primary Care Provider:
CENTENNIAL MEDICAL GROUP & CENTENNIAL SURGERY CENTER New Patient Paperwork
New Patient Paperwork NAME OF PATIENT ( ) MALE ( ) FEMALE ADDRESS APT CITY STATE ZIP HOME PHONE # CELL PHONE # DATE OF BIRTH AGE SOCIAL SECURITY # MARITAL STATUS E-MAIL ADDERSS OCCUPATION EMPLOYER EMPLOYER
Life Insurance Policy Information. Policyowner(s) (please print clearly) insurance company policy number issue date (00/00/0000)
L I F E S E T T L E M E N T Q U E S T I O N N A I R E (please print clearly) Life Insurance Policy Information insurance company policy number issue date (00/00/0000) face amount total policy loan cash
Life Insurance Policy Information. Policyowner(s)
L I F E S E T T L E M E N T A P P L I C A T I O N Life Insurance Policy Information insurance policy number issue face amount total policy loan cash surrender value annual premium payment next premium
ORANGE COUNTY UROLOGY ASSOCIATES, INC. A M e d i c a l G r o u p
Paul A. Brower, M.D. Don Bui, M.D. Jennifer Gruenenfelder, M.D. Moses M. Kim, M.D. Ph.D. James P. Meaglia, M.D. Leah Nakamura, M.D. Josh M. Randall, M.D Karan J. Singh, M.D. Aaron Spitz, M.D. J. Bradley
WELCOME TO OUR PRACTICE! Giving all patients who enter the practice a healing and loving touch
WELCOME TO OUR PRACTICE! Thank you for choosing our office to serve your eye care needs. Since 1999 Visionary Ophthalmology is dedicated to providing the highest level of care to its patients and community
Advanced Women's HealthCare, SC Registration Form
Patient Full Name Address Advanced Women's HealthCare, SC Registration Form Street Account # Provider Last First Middle Maiden(0ther) Apt/Suite# City State Zip Code Phone # (Please circle preferred contact
Employee Enrollment Application EmployeeElect for 1 50 Employee Small Groups. California
Employee Enrollment Application EmployeeElect for 1 50 Employee Small Groups California Health care plans offered by Anthem Blue Cross. Insurance plans offered by Anthem Blue Cross Life and Health Insurance
Patient or Guardian Signature
Co Payment Policy According to the regulations of individual insurance carriers, patients are responsible for paying co payments at the time of each office visit. PAYMENT POLICY FOR SERVICES RENDERED If