Updated as of 05/15/13-1 -

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Updated as of 05/15/13-1 -"

Transcription

1 Updated as of 05/15/ GENERAL OFFICE POLICIES Thank you for choosing the Quiroz Adult Medicine Clinic, PA (QAMC) as your health care provider. The following general office policies are provided to give you a clear understanding of our office protocols and further enhance our professional relationship. Please review and initial each of the following policies and sign at the bottom of the page. HMO REFERRALS: If your insurance policy requires a written authorization or referral for a medical specialist from our office, you must notify the clinic five (5) business days prior to your specialist appointment to ensure that the authorization or referral is received prior to your visit with the specialist. PRE-CERTIFICATION: Some insurance companies require pre-certification for the more expensive radiological procedures. If your insurance requires pre-certification of a non-urgent procedure, the procedure may be delayed. Pre-certification may take up to three (3) business days to obtain due to constraints placed on the clinic by the insurance company. MEDICATION REFILL: When you need a prescription refill, please contact your pharmacy before calling the clinic. The pharmacy will then call the Quiroz Adult Medicine Clinic, PA with the necessary information to fill your prescription. This step ensures that you are prescribed the correct medication, from the correct pharmacy and prevents refill errors. Routine medication refills make take up to 24 hours to approve, but are generally completed by the end of the business day. There may be a delay on a given refill if your insurance company requests additional information regarding the prescription. Holidays and weekends may also delay the fulfillment of a prescription refill; for this reason, please give appropriate advance notice of your refill requests. Routine refills will not be processed after business hours or on weekends. AFTER HOURS CARE: In the case of a non-life-threatening emergency, please contact the office at the main phone number, (210) The answering service will notify the provider on call. If you feel that your situation is life-threatening, please visit the nearest emergency room or urgent care facility to receive immediate medical attention. Please contact QAMC on the following business day to schedule a follow-up appointment regarding this emergency visit. After-hours calls deemed non-urgent may incur a fee. HOSPITAL CARE: If you are admitted to the hospital for any reason, QAMC utilizes the hospital s on-call physician to attend to your needs. The hospitalist is a primary care specialist who has focused their practice on inpatient care, while QAMC has limited its practice to out-patient care. At the time of your admission to and discharge from the hospital, the hospitalist will send the clinic a summary of care. Follow-up care at the clinic is recommended after discharge from the hospital.

2 Updated as of 05/15/ FORMS: Our office charges a minimum of $25.00 for letters and forms from other facilities that need to be completed by your primary care physician. These forms include, but are not limited to the U.S. Department of Labor Family and Medical Leave Act, and school sports physical forms. Please complete all the demographic information before bringing us the form. MEDICAL RECORDS RELEASED TO PATIENT: According to state guidelines, the minimum charge for the release of medical records to a patient is $ FINANCIAL POLICIES Quiroz Adult Medicine Clinic is committed to providing you and your family with the best available health care. The following is provided in an effort to help you understand the policies of the clinic. These policies are in place to help ensure that your receive quality care each time you interact with the staff and providers of the clinic. Please review and initial each of the following policies and sign at the bottom of the page. As the recipient of service, you are ultimately accountable and responsible to make payment for all services rendered to you. By agreeing to accept service, you also accept the responsibility to pay the balance, if any, left over after your insurance company has made payment. You will also be expected to accept full responsibility for all charges incurred for services on days that you cannot produce proof of insurance that certifies your eligibility with the plan. Your insurance policy is a contract between you, your employer and the insurance company. The clinic s relationship is with you, not your insurance company. For this reason, Quiroz Adult Medicine Clinic, PA will not become involved in disputes between you and your insurer regarding deductibles, co-payments, covered charges, secondary insurance, and usual and customary charges. As your medical provider, the clinic will only supply factual information to facilitate claim processing. Fees for services are due at the time the service is rendered. If there is a copayment or unpaid balance, the patient will be asked to render payment prior to the visit. Fees that are determined based on services rendered will be collected at the end of the visit. For your convenience, Quiroz Adult Medicine Clinic, PA accepts cash, checks, money order, Visa, MasterCard and Discover as forms of payment. It is your responsibility to promptly remit to Quiroz Adult Medicine Clinic, PA any payment made directly to you by your insurance company for services billed by the Quiroz Adult Medicine Clinic, PA. If your insurance company does not remit payment within 60 days of service due to incorrect or lack of information supplied by you, the balance for the service will be transferred to you and therefore be due by you, the patient.

3 Updated as of 05/15/ Once your insurance has reimbursed Quiroz Adult Medicine Clinic, PA, we will send you a statement of your responsibility. The bill is payable upon receipt. If the bill is not paid in full within 90 days and you have not contacted Quiroz Adult Medicine Clinic, PA regarding payment, your account will be considered delinquent. As a last resort, we may turn the account over to a collection agency. If so, their fee of 50% of the outstanding balance will be charged to the patient. Secondary insurances will not be billed by this office. This is in order for the staff of Quiroz Adult Medicine Clinic, PA to focus their attention on providing you with the greatest quality care. You are responsible for submitting the claim to your secondary insurance company. If you have Medicare Part B as your primary insurance and Medicare submits your claim to the secondary carrier, you will not be held responsible for this payment. At Quiroz Adult Medicine Clinic, we understand that financial problems may affect timely payment for services rendered. We encourage you to communicate any such problems to the clinic staff, so that we may assist you in keeping your account in good standing. I UNDERSTAND THE ABOVE INFORMATION AND WILL BE RESPONSIBLE FOR MY ACCOUNT. I ACKNOWLEDGE THAT I HAVE READ THE FINANCIAL POLICIES AND AGREE TO TERMS OF PAYMENT DUE.

4 Updated as of 05/15/ AUTHORIZATION TO RELEASE INFORMATION It is the physician s responsibility to ensure that the physician patient relationship is confidential. The Privacy Statement of Quiroz Adult Medicine Clinic, PA is the basis for how we treat your Protected Health Information (PHI), HIPAA allows physicians to use their professional judgment on disclosing certain PHI to family, friends, etc. without an authorization. Please review and initial each of the following policies and sign at the bottom of the page. I authorize Quiroz Adult Medicine Clinic, PA to release all medical information (including but not limited to: information on psychiatric conditions; sickle-cell anemia; alcohol and drug abuse; and HIV or communicable diseases) requested by my health insurance carrier, Medicare, or any other third party payers. I authorize Quiroz Adult Medicine Clinic, PA to release and receive all medical information to and from my specialty physicians. I authorize Quiroz Adult Medicine Clinic, PA to contact my insurance company or health plan administrator to obtain all pertinent financial information concerning coverage and payments under my policy. I direct the insurance company or health plan administrator to release such information to Quiroz Adult Medicine Clinic, PA. Quiroz Adult Medicine Clinic, PA honors the important role that families, friends, and other loved ones play in supporting our patient s healthcare and treatment. At the same time, the clinic is committed to protecting the patient s privacy as well as complying with state and federal law. Accordingly, disclosure to other people, even family, must remain a decision that rests with the patient. By signing the form below, I authorize the Quiroz Adult Medicine Clinic, PA to disclose the protected health information as described below. The protected health information in my medical records may be released and/or discussed with the following persons (any records excluded from this release will be noted): Exclusions, if any:

5 Updated as of 05/15/ PREVENTIVE CARE VISITS In an effort to best serve you, the following is an explanation of preventive care visits; what they entail, and how they are useful in helping you attain and maintain a high level of health. The preventive exam is also known as a physical. Some insurance companies distinguish the physical exam from the well-woman exam, while others do not. The preventive care visit or physical is a healthy visit. It is a time for you to come to the doctor to: - review your current health status; - discuss strategies to screen for certain health problems that may be silent or underlying; - recommend strategies to improve your current health; - And discuss methods to prevent future injury or illness. Patients will often attend this visit with a list of concerns: various symptoms that have become bothersome or worrisome. In order to provide you with the best care possible, it is impractical to try to address all of the preventive needs and these concerns in the same visit. Additionally, most insurance companies will not cover a preventive visit which is, by definition, a well visit, on the same day as a sick visit because they are, by definition, mutually exclusive. The few companies that will pay for both will expect the patient to be responsible for a second co-payment on the same day. It is for these reasons that the policy of Quiroz Adult Medicine Clinic, PA does not allow for both a preventive visit on the same day as a sick visit. Should you have an appointment scheduled for a well visit and find that you are sick, the providers will address the illness and reschedule the preventive exam. As stated in the financial policy, Quiroz Adult Medicine Clinic, PA will provide the insurance company with information that is factual. If the visit was a preventive visit, the clinic will bill it as such. If concerns regarding symptoms that are possibly an illness are addressed, the office will bill for a routine or sick visit. It is your responsibility to understand your insurance company s policy regarding payment for the well visit as opposed to the sick visit.

6 Updated as of 05/15/ NO-SHOW POLICY Thank you for the confidence you have placed in Quiroz Adult Medicine Clinic, PA for the care of your medical needs. The providers at this clinic will prescribe an individual plan of care for your condition. This treatment plan will require commitments from both yourself and your provider. Once this treatment plan is agreed to, the provider will need to monitor your progress and may require you to schedule regular clinic visits. In order to ensure the availability of appointments for those who require medical services, the clinic has established a no-show policy to protect the time of both yourself and other patients at Quiroz Adult Medicine Clinic, PA. A No-Show appointment occurs when you do not show up for a schedule appointment, arrive after the next appointment has already begun, or you cancel your appointment with less than a business day s notice. If you fail to show up or cancel an appointment, the office will send you a notice informing you of the incident. Monitoring your condition is very important to the successful outcome of your care. It is for this reason that if you fail to show up to the clinic at your appointed time, Quiroz Adult Medicine Clinic, PA may charge a $25 fee for routine office visits and $50 for preventive care or physical exam appointments that are not kept. If this problem persists, you may be discharged from the practice. We ask that if you are unable to make your scheduled appointment, you please call the office at least 24 hours in advance. The staff will make every effort to reschedule your appointment at a time that is convenient for both you and the provider based on the urgency of the appointment.

7 Updated as of 05/15/ TELEPHONE NOTIFICATION OF TEST RESULTS Please note that in the event of an abnormal test result, a message will be left on your answering machine instructing you to contact the office if you cannot be reached. The nature of the test results will not be left on an answering machine or with anyone other than the patient. Please initial ONE of the following regarding your preference concerning normal test results: I authorize the staff at Quiroz Adult Medicine Clinic, PA to leave a message that test results are normal on the answering machine or with whoever answers the phone at the number listed below. Phone number: I prefer to have the staff at Quiroz Adult Medicine Clinic, PA leave a message for me personally to call the office regarding all lab results. In this case, a message will simply request the patient call the clinic regarding the test results. *Please note, normal mammogram results are sent by mail to the patient by the radiologist and are not routinely called. With the exception of mammogram results, if you have not received a call from our office within three (3) business days of the test date, please contact the office to inquire about the results.

Quiroz Adult Medicine Clinic, P.A. General Office Policies

Quiroz Adult Medicine Clinic, P.A. General Office Policies General Office Policies Thank you for choosing Quiroz Adult Medicine Clinic P.A. (QAMC) as your health care provider. The following general office policies are provided to understand our office protocols

More information

OFFICE POLICIES, EFFECTIVE October 19, 2009

OFFICE POLICIES, EFFECTIVE October 19, 2009 Thank you for choosing our office for your medical care. We have written these policies to keep you informed of our current office policies. Please refer to our website for policy updates. OFFICE POLICIES,

More information

Stonebridge Adult Medicine, P.A. Registration Form (Please Print)

Stonebridge Adult Medicine, P.A. Registration Form (Please Print) Stonebridge Adult Medicine, P.A. Registration Form (Please Print) PATIENT INFORMATION Last Name: First Name: Is this your legal name? Yes No If not what is your legal name: Date of Birth: Sex: male female

More information

Welcome Information. Registration: All patients must complete a patient information form before seeing their provider.

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

More information

San Antonio Arthritis Care Centers

San Antonio Arthritis Care Centers Thank you for choosing San Antonio Arthritis Care Centers. We look forward to seeing you on: Day: Date: Time: With: Dr. Stolow Dr. Feinstein Dr. Des Rosier At this location: 8527 Village Dr., Suite 104,

More information

Patient Financial Policies

Patient Financial Policies Patient Financial Policies Diabetes & Internal Medicine Associates, PLLC 2302 E. Terry St., Pocatello, ID 82301 208-235-5910 Fax 208-235-5920 Thank you for choosing Diabetes & Internal Medicine Associates,

More information

Cardiology Consultants of Atlanta, P.C. 2801 N. Decatur Rd. Suite 395, Decatur GA, 30033 (404) 298-2220 phone (678) 904-5336 fax

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

More information

When you arrive for your first appointment, please bring the following with you:

When you arrive for your first appointment, please bring the following with you: 115 N. Sumter Street, Suite 400, Sumter, SC 29150 Phone (803) 774-7425 (SICK) / Fax (803) 774-9426 www.cfmsumter.com WELCOME We are honored that you have chosen Carolina Family Medicine of Sumter for your

More information

Pediatric Ophthalmology Date: PLEASE PRINT: PATIENT NAME: Male: Female: AGE: First Middle Last BIRTH DATE: / / HOME PHONE: (

Pediatric Ophthalmology Date: PLEASE PRINT: PATIENT NAME: Male: Female: AGE: First Middle Last BIRTH DATE: / / HOME PHONE: ( Eye Consultants of Atlanta, P.C. Scottish Rite Office 5445 Meridian Mark Road, Suite 220, Atlanta, GA 30342 Phone: (404-255-2419) - Fax (404-255-3101) Zane Pollard, M.D. Marc F. Greenberg, M.D. Mark A.

More information

Dr. H. Lokesh M.D Dr. R. Desai M.D Tarah Savino MMS, P.A. C 4804 Rowan Road New Port Richey, FL 34653 (727) 375 5242 (727) 375 5198 Fax

Dr. H. Lokesh M.D Dr. R. Desai M.D Tarah Savino MMS, P.A. C 4804 Rowan Road New Port Richey, FL 34653 (727) 375 5242 (727) 375 5198 Fax Practice Policies for Patients It is important to read all the enclosed information carefully. Confirmation and Cancellation of Appointments: Our patients are very important to us. Missed appointments

More information

THE WORLD OF PEDIATRICS. Medical Records/Health Information Release (Please fill out and fax or send to your current practice or pediatrician)

THE WORLD OF PEDIATRICS. Medical Records/Health Information Release (Please fill out and fax or send to your current practice or pediatrician) Medical Records/Health Information Release (Please fill out and fax or send to your current practice or pediatrician) Date: To: Fax: Please, release a copy of medical records for the following patient(s):

More information

LAST NAME FIRST NAME MI BIRTHDATE ADDRESS CITY STATE ZIP HOME PHONE# CELL# S.S. # EMAIL ADDRESS

LAST NAME FIRST NAME MI BIRTHDATE ADDRESS CITY STATE ZIP HOME PHONE# CELL# S.S. # EMAIL ADDRESS The more information we know about you and your family, the better medical care we can provide you. None of this information will be released to any person except with your written consent. LAST NAME FIRST

More information

TOTAL WOMEN S HEALTHCARE Robert L. Levy, M.D.

TOTAL WOMEN S HEALTHCARE Robert L. Levy, M.D. TOTAL WOMEN S HEALTHCARE Robert L. Levy, M.D. PATIENT NAME: DOB: FINANCIAL and other OFFICE POLICIES Please be assured that everyone in this practice is dedicated to providing the highest quality medical

More information

Atlanta Diabetes Associates Patient Registration Form. Patient Name: First Middle Last. Address: City: State: Zip Code:

Atlanta Diabetes Associates Patient Registration Form. Patient Name: First Middle Last. Address: City: State: Zip Code: Atlanta Diabetes Associates Patient Registration Form : Chart #: Which Doctor are you seeing today: _ Patient Name: First Middle Last Address: City: State: Zip Code: _ Home Phone: Work Phone: of Birth:

More information

Putnam North Family Medical Center An Affiliate of Advance Pain Management of Oklahoma

Putnam North Family Medical Center An Affiliate of Advance Pain Management of Oklahoma PATIENT INFORMATION AND PRACTICE POLICIES The Putnam North Family Medical Center's commitment to maintaining a broad knowledge and skill base enables your family to benefit from comprehensive and convenient

More information

AUBURN MEMORIAL MEDICAL SERVICES, P.C.

AUBURN MEMORIAL MEDICAL SERVICES, P.C. AUBURN MEMORIAL MEDICAL SERVICES, P.C. Office Policies We would like to thank you for choosing as your medical provider. We have written this policy to keep you informed of our current office policies.

More information

Sincerely yours, Rev. 06.10

Sincerely yours, Rev. 06.10 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

More information

REGISTRATION FORM (Please print)

REGISTRATION FORM (Please print) REGISTRATION FORM (Please print) PATIENT INFORMATION Patient s last name: First: Middle: Mr. Mrs. Miss Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid Is this your legal name? If not so,

More information

Patient Information Form Trinity Wellness Center. Insurance 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

More information

Psychiatric Associates of Atlanta, LLC Twelve Piedmont Center, Suite 410 3495 Piedmont Road, NE Atlanta, GA 30305 404-495-5900 404-495-5901 (fax)

Psychiatric Associates of Atlanta, LLC Twelve Piedmont Center, Suite 410 3495 Piedmont Road, NE Atlanta, GA 30305 404-495-5900 404-495-5901 (fax) PATIENT INFORMATION: Psychiatric Associates of Atlanta, LLC Twelve Piedmont Center, Suite 410 3495 Piedmont Road, NE Atlanta, GA 30305 404-495-5900 404-495-5901 (fax) Last Name: First: MI: Address: City:

More information

OFFICE POLICIES. Please note that NO controlled substance requests can be filled via phone as per DEA regulations. (initial)

OFFICE POLICIES. Please note that NO controlled substance requests can be filled via phone as per DEA regulations. (initial) OFFICE POLICIES Thank you for choosing Spencer Dermatology and Skin Surgery Center for your health care needs. We recognize that you have a choice in health care providers and we appreciate the trust that

More information

Patient Intake Form (Adult)

Patient Intake Form (Adult) Patient Intake Form (Adult) Facility: Clinician: Resilience Counseling & Psychiatric Services Nashville, TN Brandon Teeftaller, APN & Debra Cohen, APN Name: Date of birth: Date of Visit: Referral source:

More information

POS. Point-of-Service. Coverage You Can Trust

POS. Point-of-Service. Coverage You Can Trust POS Point-of-Service Coverage You Can Trust Issued by Capital Advantage Insurance Company, a Capital BlueCross subsidiary. Independent licensees of the Blue Cross and Blue Shield Association. Coverage

More information

PATIENT FINANCIAL RESPONSIBILITY STATEMENT

PATIENT FINANCIAL RESPONSIBILITY STATEMENT PATIENT FINANCIAL RESPONSIBILITY STATEMENT Thank you for choosing Medical Associates Clinic, P.C., as your healthcare provider. The medical services you seek imply an obligation on your part to ensure

More information

WELCOME TO PCCMA. We look forward to being of service to you and helping you to be healthier in the future.

WELCOME TO PCCMA. We look forward to being of service to you and helping you to be healthier in the future. Phone: 717-234-2561 Franklyn J. Myers, III, M.D., F.C.C.P. Alexis B. Aaronson, M.S.N, C.R.N.P. Michele M. Knepper, C.R.N.P. WELCOME TO PCCMA Welcome to our practice. We are specialists in the treatment

More information

Patient Resource Guide for Billing and Insurance Information

Patient Resource Guide for Billing and Insurance Information Patient Resource Guide for Billing and Insurance Information 17 Patient Account Payment Policies July 2012 Update Lexington Clinic Central Business Office Payment Policies Customer service...2 Check-in...2

More information

PRESCRIPTIONS AND REFILLS

PRESCRIPTIONS AND REFILLS 105 W. Stone Drive, Suite 2 Kingsport, TN 37660 Telephone 423 247 7500 Facsimile 423 247 7556 Scott Fowler, MD, FACOOG Chad Jarjoura, MD, FACOG Renda Knapp, MD, FACOG Christopher Mitchell, MD, FACOG Daphne

More information

New Patient Information Form

New Patient Information Form PATIENT INFORMATION New Patient Information Form Patient s Patient s Preferred Name Middle Initial Date of Birth SSN# Primary Language YES NO Email Address Race/Ethnicity Is patient of Hispanic Origin?

More information

Conroe Physician Associates. Patient Consent Form. I fully understand that this is given in advance of any specific diagnosis or treatment.

Conroe Physician Associates. Patient Consent Form. I fully understand that this is given in advance of any specific diagnosis or treatment. Conroe Physician Associates Patient Consent Form Please Read and Sign I, undersigned, hereby consent to the following: Administration and performance of all treatments Administration of any needed anesthetics

More information

Nova Medical & Urgent Care Center, Inc Financial Policy

Nova Medical & Urgent Care Center, Inc Financial Policy Welcome and thank you for choosing Nova Medical & Urgent Care Center, Inc (hereafter referred to as Nova ) for your medical care. We are committed to providing you with the highest quality medical care

More information

Frequently Asked Questions About Your Hospital Bills

Frequently Asked Questions About Your Hospital Bills Frequently Asked Questions About Your Hospital Bills The Registration Process Why do I have to verify my address each time? Though address and telephone numbers remain constant for approximately 70% of

More information

Patient Agreement. Welcome to Community Psychiatry. Treatment - What to Expect. Children and Appointments

Patient Agreement. Welcome to Community Psychiatry. Treatment - What to Expect. Children and Appointments Welcome to Community Psychiatry Our dedicated medical providers and staff are committed to providing the highest quality medical care for each and every patient. Set forth below is our Patient Agreement,

More information

WORKERS COMPENSATION INFORMATION. Soc. Sec.# Address Marital Status: Single Married Divorced Widowed Email: Home Phone: Cell Phone: Work Phone:

WORKERS COMPENSATION INFORMATION. Soc. Sec.# Address Marital Status: Single Married Divorced Widowed Email: Home Phone: Cell Phone: Work Phone: WORKERS COMPENSATION INFORMATION PATIENT INFORMATION Name: Birthdate: Soc. Sec.# Address Marital Status: Single Married Divorced Widowed Email: Home Phone: Cell Phone: Work Phone: Preferred Pharmacy: Tel

More information

Street Address Apt. or Post Office Box. City State Zip. Telephone Primary: ( ) Home Work Cell. Date of Birth / / Social Security # - -

Street Address Apt. or Post Office Box. City State Zip. Telephone Primary: ( ) Home Work Cell. Date of Birth / / Social Security # - - Appointment Information Date: Time: Physician: Patient Information Name: First MI Last Street Address Apt. or Post Office Box City State Zip Telephone Primary: ( ) Home Work Cell Work: ( ) Cell: ( ) Date

More information

PATIENT REGISTRATION Date:

PATIENT REGISTRATION Date: PATIENT REGISTRATION Date: PLEASE PRESENT YOUR DRIVER S LICENSE AND INSURANCE CARDS TO RECEPTION DESK. INSURANCE CO-PAYMENTS ARE EXPECTED BEFORE SERVICES ARE RENDERED. PAYMENT IN FULL IS EXPECTED WHEN

More information

Lake Oswego Eye Clinic 530 First ST, Suite A Lake Oswego, OR 97068 Office: (503) 636-9608 Fax: (503) 636-9600

Lake Oswego Eye Clinic 530 First ST, Suite A Lake Oswego, OR 97068 Office: (503) 636-9608 Fax: (503) 636-9600 PAYMENT AGREEMENT: We accept most insurance plans as a courtesy. We encourage you to familiarize yourself with your individual plan. Insurance coverage is an agreement between patient and insurance company

More information

Is your injury work related? Yes No Is your injury auto accident related? Yes No If so, when was the Date Of Injury:

Is your injury work related? Yes No Is your injury auto accident related? Yes No If so, when was the Date Of Injury: Is your injury work related? Yes No Is your injury auto accident related? Yes No If so, when was the Date Of Injury: PATIENT INFORMATION First Name: Last Name: Date of Birth: Gender: Marital Status: S.S.N.

More information

PATIENT REGISTRATION FORM

PATIENT REGISTRATION FORM Phone: 831-708-2919 Fax: 831-708-2937 PATIENT REGISTRATION FORM Who may we thank for referring you to us? Name (First, Mid Int. Last) Address City State Zip Code Home Phone w/ area code Email Cell Phone

More information

Welcome To Our Physical Therapy Department

Welcome To Our Physical Therapy Department Welcome To Our Physical Therapy Department Our entire staff is dedicated to providing our patients with the best possible care and service while keeping the costs to you from increasing at an unreasonable

More information

Signature: Date: Witness:

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

More information

Cultural Vistas Inbound Frequently Asked Claim Questions (FAQ) (For New J-1 Visa Holders in the U.S.A. as of 5-1-2012)

Cultural Vistas Inbound Frequently Asked Claim Questions (FAQ) (For New J-1 Visa Holders in the U.S.A. as of 5-1-2012) Specializing in international health insurance for groups. TOLL FREE: 866-433-7462 (within USA) Phone: 607-272-2707 (collect from overseas) FAX: 607-272-2703 EMAIL: claims@iees.com WEB: www.iees.com PO

More information

PLEASE BRING THE FOLLOWING WITH YOU TO YOUR APPOINTMENT:

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

More information

Physician s Practice Organization D/b/a Doctors Park Family Medicine Patient Information Brochure. To Our Patients

Physician s Practice Organization D/b/a Doctors Park Family Medicine Patient Information Brochure. To Our Patients Physician s Practice Organization D/b/a Doctors Park Family Medicine Patient Information Brochure To Our Patients Thank you for choosing Doctors Park Family Medicine as the healthcare provider for you

More information

PATIENT FINANCIAL POLICIES Effective Date: June 1, 2015

PATIENT FINANCIAL POLICIES Effective Date: June 1, 2015 Cardiovascular Specialists of Central Maryland A Community Specialty Practice of Johns Hopkins Medicine 10710 Charter Drive, Suite 400 Columbia MD 21044 PATIENT FINANCIAL POLICIES Effective Date: June

More information

PATIENT REGISTRATION Date:

PATIENT REGISTRATION Date: PATIENT REGISTRATION Date: PLEASE PRESENT YOUR DRIVER S LICENSE AND INSURANCE CARDS TO RECEPTION DESK. INSURANCE CO-PAYMENTS ARE EXPECTED BEFORE SERVICES ARE RENDERED. PAYMENT IN FULL IS EXPECTED WHEN

More information

Clifford A. Selsky, PhD, M.D. Fouad Hajjar, M.D. Ada de la Osa, ARNP-BC Shari Feinberg, CPON, CPOP Kourtnie Ramirez, MSN, CPNP

Clifford A. Selsky, PhD, M.D. Fouad Hajjar, M.D. Ada de la Osa, ARNP-BC Shari Feinberg, CPON, CPOP Kourtnie Ramirez, MSN, CPNP Clifford A. Selsky, PhD, M.D. Fouad Hajjar, M.D. Ada de la Osa, ARNP-BC Shari Feinberg, CPON, CPOP Kourtnie Ramirez, MSN, CPNP 2501 N. Orange Ave. Suite 589 Orlando, Florida 32804-3520 Phone: 407-303-2080

More information

NAME (Last, First, Middle Initial) BIRTHDATE SS # GENDER MALE FEMALE. May we contact you at work? Yes No

NAME (Last, First, Middle Initial) BIRTHDATE SS # GENDER MALE FEMALE. May we contact you at work? Yes No 2680 S Val Vista Dr, Ste 131 Bldg 6 PATIENT ENROLLMENT INFORMATION NAME (Last, First, Middle Initial) BIRTHDATE SS # GENDER MALE FEMALE ADDRESS CITY, STATE, ZIP PRIMARY PHONE - May we leave a detailed

More information

PATIENT DEMOGRAPHIC INFORMATION FORM

PATIENT DEMOGRAPHIC INFORMATION FORM If you did not complete these forms in advance and bring them with your initial appointment today, then please complete them, and sign them now. Our office does not receive email from patients. We do use

More information

PATIENT REGISTRATION (Please Print) Social Security # Address City State Zip. Address

PATIENT REGISTRATION (Please Print) Social Security # Address City State Zip.  Address PATIENT REGISTRATION (Please Print) Date Name (Last) (First) (MI) Clinician Social Security # Address City State Zip Email Address Home Phone ( ) Mobile/Alt. Phone ( ) Work Phone ( ) PLEASE IDENTIFY WHICH

More information

David A. Wang, MD Primary Care Sports Medicine Physician PRINT NAME: ADDRESS: DOB: AGE: SEX: SS# HOME: MOBILE PHONE: WORK: FAX:

David A. Wang, MD Primary Care Sports Medicine Physician PRINT NAME: ADDRESS: DOB: AGE: SEX: SS# HOME: MOBILE PHONE: WORK: FAX: David A. Wang, MD Primary Care Sports Medicine Physician PRINT NAME: ADDRESS: DOB: AGE: SEX: SS# HOME: MOBILE PHONE: WORK: FAX: INSURANCE INFORMATION Did you injure yourself at work or is this injury a

More information

Keweenaw Holistic Family Medicine Patient Registration Form

Keweenaw Holistic Family Medicine Patient Registration Form Keweenaw Holistic Family Medicine Patient Registration Form How did you first learn of our Clinic? Circle one: Attended Lecture Internet KHFM website Newspaper Sign in window Yellow Pages Physician Friend

More information

Patient Account Services. Patient Reference & Frequently Asked Questions. Admissions

Patient Account Services. Patient Reference & Frequently Asked Questions. Admissions Patient Account Services Patient Reference & Frequently Asked Questions Admissions Each time you present for a new medical service, a new account number will be assigned. You will be asked to pay any patient

More information

Medical and Rx Claims Procedures

Medical and Rx Claims Procedures This section of the Stryker Benefits Summary describes the procedures for filing a claim for medical and prescription drug benefits and how to appeal denied claims. Medical and Rx Benefits In-Network Providers

More information

ACCESSIBILITY OF SERVICES

ACCESSIBILITY OF SERVICES ACCESSIBILITY OF SERVICES ACCESSIBILITY TO CARE STANDARDS Molina Healthcare is committed to timely access to care for all members. The Access to Care Standards below are to be observed by all Providers/Practitioners.

More information

Michigan Avenue Immediate Care Administrative Policies

Michigan Avenue Immediate Care Administrative Policies Michigan Avenue Immediate Care Administrative Policies IMPORTANT FOLLOW UP INFORMATION/INSTRUCTIONS I. If your symptoms persist, or worsen, follow up with: 1. A primary care physician, including a physician

More information

Cornerstone Clinical Services, P.C. Please complete ALL sections

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

More information

PATIENT S NAME: DOB: PHONE: (HOME) (WORK) (CELL) (EMERGENCY) PATIENT SS#: PATIENT DRIVER LIC# PATIENT S/GUARDIAN S EMPLOYER: SCHOOL: CONTACT: GRADE:

PATIENT S NAME: DOB: PHONE: (HOME) (WORK) (CELL) (EMERGENCY) PATIENT SS#: PATIENT DRIVER LIC# PATIENT S/GUARDIAN S EMPLOYER: SCHOOL: CONTACT: GRADE: FAMILY PSYCHOLOGY ASSOCIATES NEW PATIENT INFORMATION SHEET PATIENT S NAME: DOB: ADDRESS: (street) (apt#) (city) (zip) PHONE: (HOME) (WORK) (CELL) (EMERGENCY) PATIENT SS#: PATIENT DRIVER LIC# PATIENT S/GUARDIAN

More information

* Do you wish to receive our monthly newsletter? Yes No Marital Status: Single Married Legally Separated Divorced Other Employer Name: (If applicable)

* Do you wish to receive our monthly newsletter? Yes No Marital Status: Single Married Legally Separated Divorced Other Employer Name: (If applicable) Doctor: Patient Name: Address: State: Date of Birth: Home Phone: Work Phone: Zip: Patient Demographics Maiden Name: City: Social Security Number: Cell Phone: Email Address: * Do you wish to receive our

More information

Patient Registration Please Print Patient Name Last First Middle

Patient Registration Please Print Patient Name Last First Middle Patient Registration Please Print Patient Name Last First Middle Address City Zip Home Phone Work Ext Cell Birthdate - - Social Security # - - Gender Marital Status Employer Referred by_emergency Contact

More information

Frequently Asked Billing Questions

Frequently Asked Billing Questions Frequently Asked Billing Questions How will I be billed? Mayo Clinic Health System will send you a billing statement with your charges. Provider charges for clinic and hospital services will be billed

More information

Understanding Your Medical Bill

Understanding Your Medical Bill Understanding Your Medical Bill THANK YOU for choosing University of Maryland Medical Center (UMMC) as your healthcare provider. We are committed to providing excellence in the delivery of healthcare.

More information

~* ~ Welcome to Behavioral Health Associates ~ * ~

~* ~ Welcome to Behavioral Health Associates ~ * ~ ~* ~ Welcome to Behavioral Health Associates ~ * ~ Please keep this packet for your records Our mission is to help individuals, couples, and families with their behavioral health goals. Thank you for choosing

More information

155 McDonald Drive SW Shirley E. Charette, MS, PA-C

155 McDonald Drive SW Shirley E. Charette, MS, PA-C LAKELAND FAMILY MEDICINE Dennis J. Charette, M.D. 155 McDonald Drive SW Shirley E. Charette, MS, PA-C Carri A. Meiler, MS, PA-C Phone: 330-308-8999 Fax: 330-308-8016 www.lakelandfamilymedicine.com PATIENT

More information

Date of Birth: Phone # Home Cell Work (please circle) Alternate Phone # Home Cell Work (please circle) Home Address. Insurance Billing Address:

Date of Birth: Phone # Home Cell Work (please circle) Alternate Phone # Home Cell Work (please circle) Home Address. Insurance Billing Address: Patient Demographics Name: _ of Birth: SS# Phone # Home Cell Work (please circle) Alternate Phone # Home Cell Work (please circle) Email: _ Home Address Insurance Information Insurance Provider: Group

More information

Office Policies Dear Patient: We would like to take the opportunity to explain the policies of our office. Please take notice of the following:

Office Policies Dear Patient: We would like to take the opportunity to explain the policies of our office. Please take notice of the following: Office Policies Dear Patient: We would like to take the opportunity to explain the policies of our office. Please take notice of the following: Please contact our answering service after hours for EMERGENCY

More information

How to Use Your International Student Insurance Plan For the Students of. Presented by

How to Use Your International Student Insurance Plan For the Students of. Presented by How to Use Your International Student Insurance Plan For the Students of Presented by YOUR INSURANCE ID CARD Your ID cards will be sent to you after the start of Fall term (or Spring if you are newly enrolled).

More information

Faculty Group Practice Patient Demographic Form

Faculty Group Practice Patient Demographic Form Name (Last, First, MI) Faculty Group Practice Patient Demographic Form Today s Date Patient Information Street Address City State Zip Home Phone Work Phone Cell Phone ( ) Preferred ( ) Preferred ( ) Preferred

More information

Who to call for an emergency: Name: Relationship: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) -

Who to call for an emergency: Name: Relationship: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - 4425 Ponce de Leon Blvd., Suite 115 Email:info@ Dr. Mercedes Gonzalez, Pediatric Dermatologist Patient Information: Patient Name: Social Security Number: / / Date of Birth: / / Sex: M / F (Circle one)

More information

Sample Patient Payment Policy

Sample Patient Payment Policy Sample Patient Payment Policy Thank you for choosing our practice! We are committed to the success of your medical treatment and care. Please understand that payment of your bill is part of this treatment

More information

The Fort Christian Psychiatric Center

The Fort Christian Psychiatric Center Shaw Wendi Fortuchang, MD, FAPA 110 North Park Drive, Fayetteville, GA 30214 (Phone) 770-376-6726 (Fax) 770-376-6727 DISCLAIMER: A doctor-patient, provider-patient, or therapist-patient relationship is

More information

105 W. Stone Drive, Suite 2B Kingsport, TN 37660 Telephone 423.247.7500 Facsimile 423.247.7556

105 W. Stone Drive, Suite 2B Kingsport, TN 37660 Telephone 423.247.7500 Facsimile 423.247.7556 105 W. Stone Drive, Suite 2B Kingsport, TN 37660 Telephone 423.247.7500 Facsimile 423.247.7556 Scott Fowler, MD, FACOOG Chad Jarjoura, MD, FACOG Renda Knapp, MD, FACOG Christopher Mitchell, MD, FACOG Daphne

More information

All routine calls will be be returned within 24 24 hours, in in the order in in which they were received.

All routine calls will be be returned within 24 24 hours, in in the order in in which they were received. Office Policies We would like to to take the opportunity to to explain the policies of of our office. Please take notice of of include fever, changes with r surgical incision or or increased pain, NO medication

More information

CENTENNIAL MEDICAL GROUP & CENTENNIAL SURGERY CENTER New Patient Paperwork

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

More information

OFFICE POLICIES AND PROCEDURES

OFFICE POLICIES AND PROCEDURES David Fivenson, MD, Dermatology, PLLC 3001 Miller Road, Ann Arbor, MI 48103 Phone: 734-222-9630 Fax: 734-222-9631 email: fivensondermatology@comcast.net OFFICE POLICIES AND PROCEDURES Thank you for choosing

More information

Medical History Questionnaire

Medical History Questionnaire Medical History Questionnaire Name: Date: Allergies (including latex): List all medications that you are currently taking, either prescription or non- prescription. Please specify dosage and length of

More information

Patient Financial Policy

Patient Financial Policy Patient Financial Policy We want you to concentrate on feeling better instead of worrying about how you're going to pay your bill. Please review this Patient Financial Policy for answers to commonly asked

More information

CENTER FOR INTEGRATIVE PSYCHOTHERAPY, P.C, 1251 S.

CENTER FOR INTEGRATIVE PSYCHOTHERAPY, P.C, 1251 S. CENTER FOR INTEGRATIVE PSYCHOTHERAPY, P.C, 1251 S. Cedar Crest Blvd., Suite 211D Allentown, PA 18103 Telephone: 610-432-5066 Fax: 610-432-0973 www.cip-cbt.com AGREEMENT OF PAYMENT I,, agree that I am fully

More information

How to Use Your International Student Insurance Plan For the Students of. Presented by

How to Use Your International Student Insurance Plan For the Students of. Presented by How to Use Your International Student Insurance Plan For the Students of Presented by YOUR INSURANCE ID CARD Your ID cards will be emailed to you after the start of your session. If you have enrolled dependents,

More information

Name: Location: Phone:

Name: Location: Phone: Welcome to our practice. Please complete all sections below. The signature of the patient, the custodial parent, or the legally responsible party is required. Please print all information. PATIENT INFORMATION:

More information

What is HCC Life Short Term Medical (HCC Life STM ) What are my coverage options with HCC Life STM?

What is HCC Life Short Term Medical (HCC Life STM ) What are my coverage options with HCC Life STM? What is HCC Life Short Term Medical (HCC Life STM ) HCC Life STM provides affordable temporary health insurance to protect you and your family. You should consider purchasing HCC Life STM if you are concerned

More information

Brain & Spine Center of Texas, L.L.P. Dallas Minimally Invasive Spine

Brain & Spine Center of Texas, L.L.P. Dallas Minimally Invasive Spine Please print clearly so that we can process your information quickly and efficiently. Thank you! Name (First, M.I., Last) Date of Birth Social Security # Male / Female Race Ethnicity (Latino / Non Latino)

More information

Provider Reference Manual Introduction and Overview of Medical Provider Networks (MPNs)

Provider Reference Manual Introduction and Overview of Medical Provider Networks (MPNs) Provider Reference Manual Introduction and Overview of Medical Provider Networks (MPNs) To meet the requirements of SB899, First Health has designed this manual for The First Health Network providers participating

More information

Beth Cerrito, Ph.D. Licensed Clinical Psychologist 1357 Monroe Avenue Phone: (585) 442-9601 Rochester, NY 14618 Fax: (585) 442-9606

Beth Cerrito, Ph.D. Licensed Clinical Psychologist 1357 Monroe Avenue Phone: (585) 442-9601 Rochester, NY 14618 Fax: (585) 442-9606 Beth Cerrito, Ph.D. Licensed Clinical Psychologist 1357 Monroe Avenue Phone: (585) 442-9601 Rochester, NY 14618 Fax: (585) 442-9606 CONSENT FOR EVALUATION AND TREATMENT Welcome to my practice. This document

More information

STATEMENT OF PRIVACY PRACTICES

STATEMENT OF PRIVACY PRACTICES STATEMENT OF PRIVACY PRACTICES We, at Seattle Smile Works, are dedicated to protect the privacy rights of our patients and the confidential information entrusted to us. The commitment of each employee

More information

Stonebriar Psychiatric Services, P.A. Policies

Stonebriar Psychiatric Services, P.A. Policies OFFICE HOURS: Stonebriar Psychiatric Services, P.A. Policies Monday through Thursday, 8:00 a.m. to 4:00 p.m. The office is closed major holidays and the week between Christmas Eve and New Year s. APPOINTMENTS:

More information

Litchfield Family Practice Center FAQ s

Litchfield Family Practice Center FAQ s Litchfield Family Practice Center FAQ s 1. How long will it take to see my doctor? Each provider has their own staff that manages appointments. Making appointments as far in advance as foreseeable is the

More information

Welcome to Cool Springs EyeCare and Donelson EyeCare!

Welcome to Cool Springs EyeCare and Donelson EyeCare! Welcome to Cool Springs EyeCare and Donelson EyeCare! We are looking forward to seeing you and helping you with your eye health and vision. As a comprehensive primary care practice we provide a full range

More information

Dear Parents: Welcome and thank you for choosing Coastal Pediatrics! We appreciate the opportunity to provide your child with the highest quality

Dear Parents: Welcome and thank you for choosing Coastal Pediatrics! We appreciate the opportunity to provide your child with the highest quality Dear Parents: Welcome and thank you for choosing Coastal Pediatrics! We appreciate the opportunity to provide your child with the highest quality pediatric care. Additionally, we promise to offer superior

More information

University Healthcare Administrative Policy

University Healthcare Administrative Policy Page 1 of 6 APPROVED BY: Signatures on File FINANCIAL POLICY (UH) is a not-for profit teaching hospital committed to providing quality health care services. In order to provide necessary medical services

More information

I have received a copy of the Notice of Privacy Practices True Health.

I have received a copy of the Notice of Privacy Practices True Health. Sign-in Time: I have received a copy of the Notice of Privacy Practices True Health. Signature of Patient/Patient Representative Relationship of Patient Representative to Patient 2400 State Road 415 11881-A

More information

FREQUENTLY ASKED QUESTIONS ID CARDS / ELIGIBILITY / ENROLLMENT

FREQUENTLY ASKED QUESTIONS ID CARDS / ELIGIBILITY / ENROLLMENT FREQUENTLY ASKED QUESTIONS ID CARDS / ELIGIBILITY / ENROLLMENT BENEFIT INFORMATION CLAIMS STATUS/INFORMATION GENERAL INFORMATION PROVIDERS THE SIGNATURE 90 ACCOUNT PLAN THE SIGNATURE 80 PLAN USING YOUR

More information

The Healthy Mind PSYCHIATRIC SERVICES

The Healthy Mind PSYCHIATRIC SERVICES The Healthy Mind PSYCHIATRIC SERVICES 900 Straits Tpk Suite D Middlebury, CT 06762 New Patient Registration: Patient s First Name Last Name Patient s Telephone: Home Cell Email: Patient s Date of Birth:

More information

We ask that you allow our office 24-48 hours to respond to telephone messages and callbacks.

We ask that you allow our office 24-48 hours to respond to telephone messages and callbacks. NOTICE OF PRIVACY PRACTICE Associated Physicians Group This notice describes how your medical information may be disclosed and how you can get access to this information. Please review these policies carefully.

More information

Filutowski Cataract & LASIK Institute PATIENT REGISTRATION 3.11

Filutowski Cataract & LASIK Institute PATIENT REGISTRATION 3.11 PATIENT REGISTRATION 3.11 Last Name: First Name: MI: Local Address: City: State: Zip Code: DOB: Sex: Marital Status: Race: SSN [Required for reporting to Agency for Health Care Administration]: Were you

More information

UNDERSTANDING YOUR MEDICAL BILL. Thank you for choosing Your Personal Physicians at:

UNDERSTANDING YOUR MEDICAL BILL. Thank you for choosing Your Personal Physicians at: UNDERSTANDING YOUR MEDICAL BILL Thank you for choosing Your Personal Physicians at: Mercy Medical Center Lutherville Overlea Worthington/Reisterstown Glen Burnie Canton as your healthcare provider. We

More information

Preferred Pharmacy: Phone: Fax:

Preferred Pharmacy: Phone: Fax: PATIENT INFORMATION: TODAY S DATE Last Name: Date of Birth: Sex: Male Female First Name: SS#: Middle Initial: Marital Status: Street Address: City: State: Home Phone: Work Phone: Mobile Phone: Email: Contact

More information

Welcome TO THE PRACTICE

Welcome TO THE PRACTICE Welcome TO THE PRACTICE Patient Information Date Name Birthdate SS# Address City/State Zip Code Driver s License # Name of Employer Check appropriate box Minor Single Married Divorced Widowed Contact Numbers

More information

Underwritten by: HCC Life Insurance Company Billing, Fulfillment, and Customer Service provided by: Agile Health Insurance

Underwritten by: HCC Life Insurance Company Billing, Fulfillment, and Customer Service provided by: Agile Health Insurance Underwritten by: HCC Life Insurance Company Billing, Fulfillment, and Customer Service provided by: Agile Health Insurance Why Choose HCC Flexible Short-Term Medical? There are transitional periods in

More information

Certain exceptions apply to Hospital Inpatient Confinement for childbirth as described below.

Certain exceptions apply to Hospital Inpatient Confinement for childbirth as described below. Tennessee Applicable Policies PRECERTIFICATION Benefits payable for Hospital Inpatient Confinement Charges and confinement charges for services provided in an inpatient confinement facility will be reduced

More information

FLATIRON PEDIATRICS. What You Need to Know about Your Health Plan Coverage and Our Financial Policies EFFECTIVE SEPTEMBER 2014

FLATIRON PEDIATRICS. What You Need to Know about Your Health Plan Coverage and Our Financial Policies EFFECTIVE SEPTEMBER 2014 What You Need to Know about Your Health Plan Coverage and Our Financial Policies EFFECTIVE SEPTEMBER 2014 *Please read & return last page* Introduction We are privileged to have you as our patient, and

More information