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
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1 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 ( ) Mobile Phone ( ) Patient s Employer Employer s Address Suite City State Zip Work Phone ( ) (Only list if you are able to receive phone calls at work). Marital Status: Single Married Separated Divorced Widowed Spouse s Name DOB Social Security # (only necessary if required for insurance claim) Employer s Address Suite City State Zip Code Spouse s Work Phone ( ) (Only list if you are able to receive phone calls at work). Authorization to Release Information for Rheumatology Consultants: (1) Name Relationship to Patient Phone ( ) (2) Name Relationship to Patient Phone ( ) Signature Date
2 Payment Policy The patient is responsible for payment at the time of service, unless prior arrangements have been made. Payments can be made either by cash, check or Visa/Master card. If we participate with your insurance company we will file the claim. All patients with insurance that Dr. Klein and Dr. Howell do not participate with, are responsible for payment at the time of service, unless prior arrangements have been made, or they have obtained an out of network authorization before the time of service. The patient is responsible for any service that is not covered by his/her insurance as well as any co-pays, deductibles, and co-insurance. Co-pays are due at the time of service. We accept co-pays by cash, check or Visa/Master card. All HMO and Managed Care plans require a referral for all services. It is the patient s responsibility to obtain any necessary insurance referrals. If you do not have a referral, your appointment will need to be rescheduled. Each patient is responsible to make sure that lab studies, x-rays and scans are performed at a facility participating with their insurance. If a response to a claim is not received from your insurance company within forty-five (45) days after billing, a statement will be sent to you. If your account becomes delinquent and becomes assigned to a collection agency, you agree to pay 35% collection agency fees, court costs, and attorney fees. A $35.00 returned check fee will be assessed to the account for each check returned to the office as a result of insufficient funds. We require at least a 24 hour notice to cancel an appointment. If you do not call at least 24 hours ahead of time or if you no show for an appointment, you will be charged a $50 fee that must be paid before another appointment is scheduled for you. I hereby authorize Drs. Klein and Howell to furnish information to any insurance company or authorized agency specified concerning my medical care. I hereby assign and transfer any medical benefits due me to Drs. Klein and Howell for the services provided to me by this medical practice. I permit a copy of this authorization to be used in place of the original. Regulations pertaining to Medicare Assignment of Benefits apply, as applicable. I have read, understand and agree to all of the terms described in the Payment Policy above. I understand and agree, accept where applicable under contract, that I am ultimately responsible for the balance on my account for any professional services rendered. DATE SIGNATURE
3 Consent & Assignments Medicare I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Finance Administration or its intermediaries or carriers of any information needed for this or a related Medicare claim (Title XVIII). I permit a copy of this authorization to be used in place of the original and request payment of medical insurance benefits to the party whom accepts assignment. Blue Cross/Blue Shield Of Maryland Dr. Steven Klein and Dr. Mary Howell are participating physicians of Blue Cross/Blue Shield of Maryland, Inc. I authorize release of any medical information necessary to process this claim. I understand that I am responsible for any deductible and/or co-payment. Insurance Assignment I authorize and assign payment directly to the physicians involved in my treatment and authorize release of medical information necessary to process the claim. I further understand I am financially responsible for charges not covered by my insurance. Managed Care I understand that without an authorization/referral form from my HMO/IPA/PPO or MCO I will be financially responsible for charges I incur. ********************************** Ultimately, you are responsible for payment to our physicians for services rendered. If your insurance company does not respond to our claim within 45 days, a statement will be sent to you. Your signature below acknowledges your understanding and your agreement to fulfill all financial obligations. DATE SIGNATURE
4 KLEIN & ASSOCIATES, M.D., P.A. Receipt of Notice of Privacy Practices Written Acknowledgement Form I,, have received a copy of Klein & Associates, M.D., P.A. s Notice of Patient Name Privacy Practices. Signature of Patient Date
5 Current Medication List Please list below, all prescription and over-the-counter medications as well as any supplements you are currently taking. Name: Pharmacy: Drug Allergies: Drug Name Dosage Date Started (if known)
P.S. Please remember to bring your completed forms to your office visit!
Dear Patient: Please print the following forms and complete them as accurately as possible and bring them with you to your office visit. If you have any questions about the forms you can call my office
Last Name First Name MI. Sex (circle): Male Female Date of Birth SS# Marital Status (circle): Married Single Divorced Widowed Separated
Patient Information Last Name First Name MI Sex (circle): Male Female Date of Birth SS# Marital Status (circle): Married Single Divorced Widowed Separated Race (circle): Black White Asian Other Ethnicity
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.
California Pain Consultants - PATIENT REGISTRATION FORM
Patient Information California Pain Consultants - PATIENT REGISTRATION FORM First name: Last name: Middle Initial: Address: City, State, Zip Home phone :( ) -Work phone: ( ) -_Cell: ( ) - Birth Date: Age:
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
Faculty Group Practice Patient Demographic Form
Name (Last, First, MI) Faculty Group Practice Patient Demographic Form Today s Patient Information Street Address City State Zip Home Phone SSN of Birth Gender Male Female Work Phone Cell Phone Marital
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
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:
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
FAMILY PRACTICE PATIENT REGISTRATION FORM
FAMILY PRACTICE PATIENT REGISTRATION FORM **Today s Date: Clinic Name: Healthy Texan Pediatrics and Family Medicine PATIENT INFORMATION: (Please use full legal name, no nicknames) *Last Name: _ *First
Name Last) (First) ( (M.I.) Birth Date Social Security Age Sex: Home Address. City State Zip. Complaint/ Area to be treated Email Address
PLEASE PRINT CLEARLY : NEW PATIENT FORM Name Last) (First) ( (M.I.) Birth Social Security Age Sex: M / F Home Address City State Zip Complaint/ Area to be treated Email Address Home Phone ( ) Drivers Lic
Your appointment is scheduled for at with Dr. Your arrival time is.
Dear : We appreciate your selection of our office for your complete eye care. Your appointment is scheduled for at with Dr. Your arrival time is. First visits usually take approximately one and a half
Wayne Physical Medicine & Rehabilitation Associates 401 Hamburg Turnpike, Suite 105 Wayne, NJ 07470
PLEASE FILL OUT THIS SHEET COMPLETELY AND CORRECTLY. PLEASE PROVIDE ALL INSURANCE CARDS TO THE RECEPTIONIST TO COPY. Name Social Security # Address City, State & Zip Code Home Phone No. ( ) Cell Phone
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11120 New Hampshire Ave., Suite 411 Silver Spring MD 20904 Office (301)754-0505 Fax (301)754-0509
PATIENT REGISTRATION FORM (PLEASE PRINT) PATIENT S LAST FIRST MIDDLE DATE OF BIRTH / / AGE: SEX: M F SOCIAL SECURITY # STREET ADDRESS APT # CITY STATE ZIP HOME CELL EMAIL MARITAL STATUS: SINGLE / MARRIED
Advanced Solutions Pain Management
Joseph Ho, M.D. Sabrina Shue, M.D. Patient Information Name: M F Age: Last, First, Middle (Circle One) DOB: SSN: Single Married Divorced Separated Widowed Address: City: State: Zip: Home Phone: Cell: Work:
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
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Faculty Group Practice Patient Demographic Form
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Thank you for your cooperation.
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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
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
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* Do you wish to receive our monthly newsletter? Yes No Marital Status: Single Married Legally Separated Divorced Other Employer Name: (If applicable)
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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
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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
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THE EYE INSTITUTE. Dear Patient:
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PATIENT FINANCIAL RESPONSIBILITY STATEMENT
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HI *Home Phone: Alternate Phone: Driver License No.: Email Address: INSURANCE COVERAGE & SUBSCRIBER INFORMATION (person that has the insurance policy)
HAWAII PHYSICAL THERAPY INC. -- PATIENT REGISTRATION FORM Please fill out this form to register as a patient of Hawaii Physical Therapy Inc. All fields with an asterisk (*) are REQUIRED. We cannot register
Your appointment is scheduled for:
14090 H.G. Trueman Road, Suite 1400 Solomons, MD 20688 410-610- 2246 Rebecca L Jahed, AuD, FAAA Welcome to Freedom Hearing Center. My name is Dr. Rebecca L. Jahed and I am the President of this private
Welcome to the practice of Paolo Incampo, DMD and Associates
Welcome to the practice of Paolo Incampo, DMD and Associates We have been providing exceptional and comprehensive dental treatment to families of the greater Merrimack Valley community for over a decade.
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Louis J. Avvento, M.D. Alexander Zuhoski, M.D. Deepali Sharma, M.D. Sharon Sparacino, ANP-c, Cynthia Cichanowicz, ANP-c Melanie Acierno, DNP, Denise A. Albano, ANP-c 1333 East Main Street Riverhead, NY
Welcome to North Texas Orthopaedic & Spine 955 Garden Park Dr. Ste. 200 Allen Texas 75013. Today s Date: How did you hear of our practice?
Welcome to North Texas Orthopaedic & Spine 955 Garden Park Dr. Ste. 200 Allen Texas 75013 Name: First Middle Last Today s Date: How did you hear of our practice? Home Address: City: State: Zip: Home Phone:
PRO SPORTS THERAPY, INC. (P.S.T.)
Dear Patient, Thank you for choosing Pro Sports Therapy. Enclosed is the paperwork that you will need to complete and bring with you for your physical therapy evaluation. Please arrive at least 15 minutes
Orthopedic Initial Questionnaire. Date: Weight:
Orthopedic Initial Questionnaire Name: Height: Date: Weight: In order to allow the therapist to have a better understanding of the nature of your injury and evaluate your condition fully, please complete
Patient Registration Form (ecw) (First) (MI) Previous Name. Address
Patient Registration Form (ecw) PATIENT INFORMATION (Please Print) Dr. Miss Mr. Mrs. Ms. Patient's Name (Last) (First) (MI) Previous Name Address City, State ZIP Check the best contact number q Home Phone
PATIENT/PARENT/GUARDIAN SIGNATURE
PATIENT REGISTRATION PATIENT S NAME: SEX MALE FEMALE DOB: SOCIAL SECURITY #: CITY/STATE/ZIP: PHONE # GUARANTOR INFORMATION (if responsible party is not the patient) MOTHER S NAME: DOB: SS#: CITY/STATE/ZIP:
Athens Neuro & Balance Rehabilitation
Acknowledgement of Receipt Of Notice of Privacy Practices Patient Name & Address: I have a received a copy of the Notice of Privacy Practices for the above named practice. Signature For Office Use Only
Patient Registration Form
900 Carillon Parkway Suite 404 St. Petersburg, FL 33716 727-572-1333 727-572-1331 fax www.spencerdermatology.com Patient Registration Form Today s : Name: Suffix First Middle Last of Birth: / / Age: Sex:
The Dermatology & Laser Group of Irvine, A.M.C. 16300 Sand Canyon Avenue, Suite 612 Irvine, CA 92618-3706 Phone# 949-753-1001 Fax# 949-753-1115
16300 Sand Canyon Avenue, Suite 612 Irvine, CA 92618-3706 Phone# 949-753-1001 Fax# 949-753-1115 (Please Print) Today s Date / / PATIENT INFORMATION Name Last First M.I. Maiden Name: SS# Email: Mr. Ms.
Mangione Physical Therapy Please read and complete carefully by printing in ink. Provide all information requested.
Whom may we thank for referring you? Mangione Physical Therapy Please read and complete carefully by printing in ink. Provide all information requested. Name: Date of Birth Age: Address: City: State: Zip: