Nephrology Consultants of Georgia, P.C.

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1 New Patient O (Check One) Established Patient O Name: (Last) _ (First) (MI) Address: City State Zip D.O.B. SSNO Address Ethnicity: O Hispanic or Latino O Not Hispanic or Latino O Patient Refused Preferred Language: Sex: O Male O Female Marital Status: O Single O Married O Divorced O Widowed Race: O American Indian or Alaska Native O Asian O Black or African American O Native Hawaiian or Pacific Islander O White or Caucasian O Hispanic or Latino Contact Info: (Home) (Cell) (Work) Employer: Occupation: Spouses Name: D.O.B. SSNO Spouse s Employer: Work Number: Emergency Contact: Relation: Home: Cell: Work: _ Referring MD: Phone No. Address: Primary Care Physician: Phone No. Address: Primary Insurance Carrier: Referral Required : Yes No ID # Grp # Grp Name: Insured s Name Insured s D.O.B. Secondary Insurance Carrier: Mcare Supplement: Yes No ID # Grp # Grp Name: Insured s Name Insured s D.O.B. By signing below, I hereby authorize you to release any pertinent information or necessary information to my referring and/or primary care physician, facilities I am referred to for testing ordered by my physician and physicians I request. Any other parties requiring information may do so only if this office receives a release of information request signed by me. Signature Date

2 Authorization for Release of Patient Information I,, hereby authorize Dr. Cooper Shore Bahrami Jones Madani 275 Collier Rd, Suite Hwy. 54 West, Suite 500 Atlanta, GA Fayetteville, GA Phone: Phone: Fax: Fax To obtain/release all medical records to/from: Facility/Physician: Address: Phone: _ Fax: Patient s Name: Patient s Representative: Patient s Social Security Number: Patient s Date of Birth: Signature of Patient or Patient s Representative Date Witness

3 Jerry D. Cooper, M.D. Sheldon M. Shore, M.D. David Bahrami, M.D. Edrea G. Jones, M.D. Kamyar Madani, M.D. It is very important that you arrive by the time given to you when you made the appointment in order to process your new patient paperwork. Please bring the following with you to your appointment: 1. Your insurance card(s) and co-payment 2. Photo ID 3. Your referral if required by your insurance company. 4. All current medications. Please bring medications in the actual bottles in which they were purchased. When you arrive, we will need a urine specimen, so please do not eliminate just prior to your visit. Thank you. If you have any questions please feel free to call us. We look forward to serving you. Piedmont Fayette Hospital East Entrance 1265 Hwy 54 West, Suite 500, Fayetteville, GA Phone: Fax: Physicians Piedmont Hospital 275 Collier Rd. N.W., Suite 290, Atlanta, GA Phone: Fax: If you prefer to contact the office by Please visit our website:

4 NEPHROLOGY CONSULTANTS OF GEORGIA, P.C. FINANCIAL POLICY We are committed to meeting your healthcare needs. In order to keep financial arrangements as simple and cost effective as possible, we have implemented the following guidelines: 1. You are ultimately responsible for payment of charges for services you receive from our office. Any check payment dishonored by your bank will result in a $30.00 return check charge being added to your account. 2. All co-payments are collected at the time you check-in. 3. It is your responsibility to provide us with your current address, telephone number and insurance information at each visit. 4. It is your responsibility to contact your insurance carrier to confirm that our physicians participate in your plan. If you see a doctor that is not currently on your plan, you will be responsible for payment in full. 5. If your plan requires a referral, it is your responsibility to obtain this authorization prior to being seen by the doctor. If we are required to obtain the referral for you, please notify our office 72 hours prior to your visit so that we have ample time to acquire this information from your insurance company. 6. All medical records requests MUST be in writing and received in our office a minimum of 72 hours prior to the date needed. We will require the complete name and address where the records are to be mailed. There is a copying fee of.97 cents per page for all records. This is payable in advance. 7. This practice accepts, Visa, MasterCard, American Express as well as checks, cash and debit cards. 8. A $50.00 fee will be charged if you fail to cancel/reschedule your appointment within 3 business days. If you do not inform us of any special requirements in your insurance contract, such as referrals or pre-authorization for treatment, and we subsequently order services that are not covered, we will have no choice but to bill you directly for those charges. In the event that services are provided and your insurance coverage is not in effect on that day, or if your contract contains a pre-existing clause, your insurance carrier will probably deny payment for services rendered. Please remember that you, the patient, are ultimately responsible for payment. I have read and understand the office policy stated above and agree to accept financial responsibility as described. Patient Name Signature Date

5 TO ALL OUR PATIENTS: We are dedicated to ensure your privacy. Please review the following questions and inform the front desk of any changes that may apply to you: Do we have permission to leave a message on the phone number(s) you have provided us? Yes No Please list your cell phone Do we have permission to text appointment reminders to you on your cell phone? (Verizon Plans Only) Yes No Do we have permission to appointment reminders? Yes No Please list your address May we discuss your medical information with family and friends? If yes, please provide their names and relationship to you: Thank you for your cooperation. Name: _ Date: This authorization will automatically expire 1 year from the date signed unless it is terminated prior to that date.

6 Receipt of Notice of Privacy Practices Written Acknowledgement Form I, have reviewed a copy of Nephrology (Print Patient Name) Consultants Georgia, P.C. s Notice of Privacy Practices. Signature of Patient Date Effective Date of this Notice: April 14, 2003

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