Berta Briones MD 600 Superior Ave- Suite 1300 Cleveland, OH Medicalrejuvenationinstitute.com
|
|
|
- Duane Watkins
- 8 years ago
- Views:
Transcription
1 Berta Briones MD 600 Superior Ave- Suite 1300 Cleveland, OH 44107
2 Notice in Advance of Service to Patient that Service May Not Be Covered By Medicare Medicare will only pay for services that it determines to be reasonable and necessary under section 1862(a) (1) of the Medicare law. If Medicare determined that a particular service, although it would otherwise be covered, is not reasonable and necessary under Medicare program standards, Medicare will deny payment for that service. It is likely that, in your case, Medicare will deny payment for all the blood/diagnostic test ordered by physician and the cost of the supplements, integrative cancer treatments, RE and most of the services provided at the Medical Rejuvenation Institute for the following reasons: 1. The tests and treatments are preventative. 2. The tests and treatments are not reasonable and necessary under Medicare. Disclosure of lack of billing services At this time Dr. Briones at the Medical Rejuvenation Institute does not have Insurance billing services in place. While she is making every attempt to get credentialed, the process takes a long time to complete. While in the past some insurance companies have paid claims submitted late, this is not the case for Medicare anymore. So, billing will not be submitted for services provided during the time the credentialing process takes place. Since Medicare requires an opt- out contract signed by your provider to allow you to pay out of pocket for services that they approve, and such agreement precludes Dr. Briones to work at her current Emergency Room Group practice, you agree not to bill Medicare for the Services provided by Dr. Briones at the Medical Rejuvenation Institute. Physicians Name: Date: Beneficiary Agreement: I have been notified by Dr. Berta Briones and associates that Medicare will likely in my case, deny payment for the services provided at the Medical Rejuvenation Institute. I agree to be personally and fully responsible for payment. Beneficiary Signature and date: Witness Signature and date:
3 Contract to provide services under RE I authorize payment in the amount of : NEO PROGRAM: N=NEUROFEEDBACK, E=PERSONAL TRAINING WITH HBO, POWER PLATE AND Pulsed Electromagnetic Therapy. (Prepaid 10%off) Select one: NEO Recommended ($3096): NEO twice a week * eight weeks. NEO Economy ($1548): NEO once a week * eight weeks NEO sampler ($387): One time session. NEO intensive ($1935): daily NEO for 5 days. Brain Health asessment : $150 Food be my medicine instruction: $100 INDIVIDUAL SESSIONS ONDAMED 1 SESSION: $120 ONDAMED 11 SESSIONS AT 10% OFF if PREPAID : $1200 NEUROFEEDBACK 1 SESSION: $110 NEUROFEEDBACK 11 SESSIONS AT 10% IF PREPAID: $1100 WORK OUT HBO CHAMBER 1 SESSION: $150 WORK OUT HBO CHAMBER 8 SESSION PACK AT 10% PREPAID: $1080 PEMF 1 SESSION: $40 PEMF 8 SESSIONS AT 10% PREPAID DISCOUNT: $320 PERSONAL TRAINING WITH HBO, PP, PEMF: $200 PERSONAL TRAINING 8 SESSIONS PACK AT 10% PREPAID: $1440 TOTAL:
4
5 COMPREHENSIVE PALLIATIVE CARE CANCER CONSULTATION AGREEMENT I authorize payment in the amount of $250/hour for the following professional services, to be provided to the patient named below: Lifestyle and medical history assessment Laboratory interpretation Nutrition analysis Physical exam Prior medical records review Professional recommendations specifically for me in the selected areas: Nutrition: diet, oral and IV supplements Palliative therapies Novel cancer therapies Traditional and non- traditional cancer and complementary treatment Research on your condition as needed Medical clearance for RE Non traditional Medicine disclosure agreement I understand that Dr. Briones at the Medical Rejuvenation Institute will not be billing my insurance company for these services and that I am responsible for payment and for submitting the claim to my insurance company if I desire to do so. I also understand that some or all of these services might not be considered medical necessity by my insurance company and that Dr. Briones does not make any claims that I will be reimbursed for these expenses. Furthermore, Dr. Briones may choose modalities not approved by my insurance company and does not make any claims that her recommendations under this agreement will cure my cancer and that my goal in engaging in this relationship is to optimize my functional status and wellbeing while creating an adverse environment for the cancer to thrive. My goal is to feel better and I am free to comply or not with Dr. Briones recommendations. I understand that if I miss my scheduled appointment without proper notice as defined in the cancelation policies, I am responsible for 1 hour of professional services. I am eligible for Medicare Benefits I am not eligible for Medicare Benefits Patient s Name Signature Date
6 PAYMENT: I authorize one of the following payment methods: Check enclosed (payable to Berta Briones MD, INC) ($20 bounce fee) Visa Mastercard American Express (3% cc convenience fee will be added) Card Number Expiration CC Name on the card Relationship to patient Billing address Signature date
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
DVH PLUS with Coverage Schedule CSA58PP
Medico Insurance Company Dental, Vision & Hearing Plan Form A58 DVH PLUS with Coverage Schedule CSA58PP Premium Rates by Mode Monthly Automatic Bank Withdrawal Quarterly Automatic Bank Withdrawal Issue
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
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
Columbia Associates in Psychiatry 2501 N. Glebe Rd Suite 303 Arlington, VA 22207 703-841-1290
Columbia Associates in Psychiatry 2501 N. Glebe Rd Suite 303 Arlington, VA 22207 703-841-1290 Welcome to Columbia Associates in Psychiatry! Thank you for choosing us to take care of your behavioral health
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.
Referring Physician: Type (Circle): Insurance Fitness Work/Comp Personal Injury Auto D/A:
Patient Information Referred By: Referring Physician: Patient Name: Appointment Date: Time: Last First Middle Int. Date of Birth: SS#: Street Address: City/State/Zip: Phone Numbers: Home: Work: Cell: Email:
Coventry Network. Benefit Details. Short Term Medical. Exclusive features include: Why Short-Term Medical (STM)?
Short Term Medical Exclusive features include: Up to $2,000,000 Lifetime Maximum per Covered Person Choice of Coverage Periods of up to 6 months or 11 months (Coverage periods of greater than 6 months
READ ONLY COPIES (These forms to be completed in the doctor s office at time of visit)
Qing Tai, M.D., Ph.D. Center for Pain Management and Rehabilitation, LLC Board Certified Pain Management 635 East Main Street, Bridgewater NJ 08807 Physical Medicine and Rehabilitation Phone: (908) 231-1131
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
Practice Name: Brief overview of your intended scope of practice at Anna Jaques Hospital:
Medical Staff Application for Initial Appointment Supplemental Page Introduction (to be presented to the Credential Committee): Practice Name: Brief overview of your intended scope of practice at Anna
1. First MI Last Preferred Email. 2. First MI Last Preferred Email. 3. First MI Last Preferred Email. 4. First MI Last Preferred Email
Group Membership Application Hospital/Institution Name Address City State/Province Zip/Postal Code Contact Name Title Phone Members All new members and existing members who are renewing* their membership
APRN/PA Pediatric Updates in Clinical Practice
APRN/PA Pediatric Updates in Clinical Practice Monday, May 11, 2015 Considine Professional Building Auditorium 215 W. Bowery Street Akron, OH 44308 Conference Information Who Should Attend Nurse Practitioners,
PATIENT INFORMATION. Patient: S.S.# Address: D.O.B. Home Phone: Bus Phone: Male Female. Emergency contact: Relation to Patient: PH#
Massage 258 West 91 st Street, Suite 1-B Physical THERAPY EXPERTS, PLLC WELCOME 212-875-8345 T PLEASE FILL IN FORM COMPLETELY TO AVOID INSURANCE PAYMENT DELAY! PATIENT INFORMATION Patient: S.S.# Address:
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
Patient Demographic Form
Patient Demographic Form Today s Date This document is part of your permanent record. By law, we are required to collect the following information from every patient treated in our facility. Please assist
BILLING INFORMATION AND ASSIGNMENT OF BENEFITS
BILLING INFORMATION AND ASSIGNMENT OF BENEFITS Facility: Northpoint Radiation Center Pro Physicians Clinic PA Physician: Timothy D. Nichols, M.D. PA, Board Certified Radiation Oncology Wilhelm J. Lubbe,
HEALTH CARE DENTAL CARE
UNIVERSITY OF DAYTON MEDICARE SUPPLEMENT PLAN OPEN ENROLLMENT HEALTH CARE DENTAL CARE 2016 Office of Human Resources 300 College Park Dayton, OH 45469-1614 Phone 937-229-2541 Fax 937-229-2009 O65 1 Health
Certified Healthcare Auditor [CHA]
![Certified Healthcare Auditor [CHA]](/thumbs/39/18984739.jpg "Certified Healthcare Auditor [CHA]")
Presents Certified Healthcare Auditor [CHA] Advanced Training & Certification Become a Certified Healthcare Auditor (CHA) A comprehensive distance learning course for providers, compliance officer and
City of Portland HEALTH EXPENSE REIMBURSEMENT ACCOUNT
EXHIBIT C City of Portland HEALTH EXPENSE REIMBURSEMENT ACCOUNT S U M M A R Y P L A N D E S C R I P T I O N Effective January, 2016 City of Portland Health Expense Reimbursement Account Summary Plan Description
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,
OUTLINE OF MEDICARE SUPPLEMENT COVERAGE
OUTLINE OF MEDICARE SUPPLEMENT COVERAGE Tufts Medicare Preferred Supplement Core Tufts Medicare Preferred Supplement One Outline of Medicare Supplement Coverage Cover Page: Benefit Plans Medicare Supplement
PATIENT INFORMATION EMERGENCY CONTACT LAST FIRST RELATIONSHIP REFERRAL SOURCE DOCTOR / REFERRING CLINICIAN: FAMILY MEMBER/FRIEND: INSURANCE:
PATIENT INFORMATION LAST FIRST MI GENDER M F BIRTHDATE MO./ DAY/ YEAR SS# - - ADDRESS CITY ST ZIP PHONE (CELL) PHONE (HOME) EMAIL MARITAL STATUS EMPLOYER ADDRESS OCCUPATION WORK PHONE EXT WHO IS YOUR PRIMARY
Michael F. Cantwell MD, MPH Rising Phoenix Integrative Medicine Center Patient Information
Patient Information 1. NAME OF PATIENT: a. NAME OF SPOUSE/SIGNIFICANT OTHER: b. IF MINOR/CHILD: 1. NAME OF MOTHER: 2. NAME OF FATHER: 3. NAMES/AGES OF SIBLINGS: c. NAMES OF OTHER SIGNIFICANT FAMILY MEMBERS:
I authorize the Center for ADHD, Inc./R. Timothy Brown, M.D. to evaluate and treat.
CENTER FOR ADHD, INC. AND R. TIMOTHY BROWN, M.D., LLC Consent to Evaluate and Treat Patient: Age: Date of Birth: Female Male Black Hispanic White Other Address: City, State, Zip Code: Home Phone: Business/Cell
MIGUEL GONZALEZ, MD, FCCP, FACP 303 S. Moorpark Rd. Thousand Oaks, Ca 91361 805-497-7508 Phone 805-495-6834 Fax PATIENT INFORMATION
MIGUEL GONZALEZ, MD, FCCP, FACP 303 S. Moorpark Rd. Thousand Oaks, Ca 91361 805-497-7508 Phone 805-495-6834 Fax PATIENT INFORMATION DATE: REFERRED BY: NAME: SEX: M / F MARITAL STATUS: BIRTHDATE: DRIVERS
STATE OF MAINE RADIOLOGIC TECHNOLOGY BOARD OF EXAMINERS APPLICATION FOR LICENSURE. Radiologic Technologist
STATE OF MAINE RADIOLOGIC TECHNOLOGY BOARD OF EXAMINERS APPLICATION FOR LICENSURE Radiologic Technologist Department of Professional and Financial Regulation Office of Professional and Occupational Regulation
Southern Oregon Alternative Medicine INTAKE FORM
Southern Oregon Alternative Medicine INTAKE FORM Please complete the information so we can better serve you. Date: Patient: (Last) (First) (MI) Mailing Address: Physical Address: City: ZIP: State: Home
Select travelinsuranceselect.com
Travel Insurance Select travelinsuranceselect.com A flexible travel insurance plan with your choice of options and services Now with Security Evacuation Option Trip Cancellation and Interruption Coverage
How To Get A Physical Therapy At West Point Physical Therapy Center
Palmdale (Main) 1115 West Ave. M-14 Palmdale, CA 93551 (661)265-0060 To our workers compensation patients: Cathedral City 68-845 Perez Rd., Ste. H6-H7 Cathedral City, Ca 92234 (760)328-0292 California
Patient History Information
Date: Body Technic Systems, Inc. 33790 Bainbridge Rd. Ste. 205 Solon, Ohio 44139 440-248-9255 phone 440-248-3608 fax Patient History Information Name: Date of birth: Address: City: State: Zip: Home phone:
Medicare Supplement plans at a glance
Medicare Supplement plans at a glance Medicare Supplement plan information is effective as of January 1, 2013 S2468_12_249A CMS Accepted 09032012 blueshieldca.com/findamedicareplan Use this brochure to:
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.
Finance Department. Ambulance Billing Frequently Asked Questions
Ambulance Billing Frequently Asked Questions Question 1 Whom can I call to discuss my ambulance bill? If you were transported by a City of Houston Fire Department ambulance to a hospital prior to May 25,
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
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
Provider Appeals and Billing Disputes
Provider Appeals and Billing Disputes UniCare Billing Dispute Internal Review Process A claim appeal is a formal written request from a physician or provider for reconsideration of a claim already processed
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
THINK PHYSICAL THERAPY PATIENT INFORMATION Please present your insurance card(s) for copying. Patient Name: Sex: Date of Birth: Age:
THINK PHYSICAL THERAPY PATIENT INFORMATION Please present your insurance card(s) for copying. Patient Name: Sex: Date of Birth: Age: Social Security Number: Employment Status: Marital Status: Emp Unemp
Outline of Medicare Supplement Coverage TUFTS MEDICARE PREFERRED SUPPLEMENT PLANS 2015
TUFTS MEDICARE PREFERRED SUPPLEMENT PLANS 2015 Outline of Medicare Supplement Coverage Tufts Medicare Preferred Supplement Core Tufts Medicare Preferred Supplement One Effective January 1, 2015 December
CERTIFIED PSYCHIATRIC NURSE SPECIALIST PROVIDER FILE APPLICATION
CERTIFIED PSYCHIATRIC NURSE SPECIALIST PROVIDER FILE APPLICATION Date of Request / / Name Telephone # ( ) National Provider Identifier (NPI) # Federal Tax ID # Medicare # Office Location (Street Address):
How To Opt Out Of Medicare
DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services NEW products from the Medicare Learning Network (MLN) Transitional Care Management Services, Fact Sheet, ICN 908682, Downloadable
Regence Bridge. Medicare Supplement (Medigap) Plans
DECISION GUIDE Regence Bridge Medicare Supplement (Medigap) Plans Regence BlueCross BlueShield of Utah is an Independent Licensee of the Blue Cross and Blue Shield Association 09708rep07356-ut UT Learn
I recommend that you inform your medical doctor (s) and other licensed healthcare practitioners that you are receiving nutrition services.
To: (name of client) Welcome! I am a Certified Nutrition Educator who provides nutrition services. Please note: I am not a licensed physician. The idea behind nutrition is that: when properly grown and
Stay. connected protected. with the AB Service Agreement. AdvancedBionics.com
Stay connected protected with the AB Service Agreement AdvancedBionics.com Stay connected protected with the AB Service Agreement As your partner in hearing, Advanced Bionics wants to help you to avoid
X Guarantor/Parent/Guardian Signature
Patient Name: Last First Address City State Zip Phone# (C) (H) (W) Date of Birth Social Security# (REQUIRED FOR BILLING) If Patient is a Minor, a Parent s Name & Social Security# are Required Emergency
Blue Cross Blue Shield of Michigan
Medicare Plus Blue Home infusion therapy Applies to: Medicare Plus Blue PPO SM Medicare Plus Blue Group PPO SM X Both Home infusion therapy Home infusion therapy is the continuous, slow administration
Updated as of 05/15/13-1 -
Updated as of 05/15/13-1 - 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
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
BluePerks Discount Program. Savings on non-covered services and more
BluePerks Discount Program Savings on non-covered services and more Complement health plan coverage in new ways. These days, more and more people whether treating a recurring sports injury, relieving stress
:: Member Services Agreement ::
:: Member Services Agreement :: Member Services Agreement Welcome to Nextera Healthcare s direct primary care program for individuals, families and businesses. A monthly membership program centered on
Single Married Divorced Widowed Student Minor African American Asian Caucasian Hispanic Other:
At both New Tampa Foot & Ankle AND South Tampa Foot & Ankle, we are committed to getting you back on your feet free of pain and injury so that you can get back to your activities and back into life! We
AFLAC MEDICARE SUPPLEMENT
AFLAC MEDICARE SUPPLEMENT You lead a strong, active, healthy life Make sure a gap in your Medicare coverage doesn t slow you down. GEORGIA 2013 A19MS75GA RC(7/13) Aflac Medicare Supplement Insurance Policy
Combined Client Agreement, Authorization for Release of Personal Health Information & Notice of Privacy Practices
Page 1 of 7 Senior LinkAge Line /RxConnect and State Health Insurance Assistance Program (SHIP) Combined Client Agreement, Authorization for Release of Personal Health Information & Notice of Privacy Practices
UNIFORM HEALTH CARRIER EXTERNAL REVIEW MODEL ACT
Model Regulation Service April 2010 UNIFORM HEALTH CARRIER EXTERNAL REVIEW MODEL ACT Table of Contents Section 1. Title Section 2. Purpose and Intent Section 3. Definitions Section 4. Applicability and
MEDICARE SUPPLEMENT APPLICATION - NEVADA Please complete entire application.
MEDICARE SUPPLEMENT APPLICATION - NEVADA Please complete entire application. Select a plan: Plan A Plan B Plan F Plan I Plan J Section 1 Applicant Information This complete original application will be
RECERTIFICATION INFORMATION
RECERTIFICATION INFORMATION The World s Largest Fitness and Telefitness Educator www.afaa.com PERSONAL CONTINUING EDUCATION LOG This chart is provided so that you may keep a log of all continuing education
NOTICE TO RETIREES. Benefits Eligibility: Guaranteed Acceptance No Waiting Period 30-Day Review
NOTICE TO RETIREES Benefits Eligibility: Guaranteed Acceptance No Waiting Period 30-Day Review Rates: Retiree: $138.00 Retiree and spouse: $276.00 To Enroll: Call 1-800-634-0168 Or complete and return
The Center for ADHD, Inc.
Consent to Evaluate and Treat Date: Patient: Age: Date of Birth Female Male Black Hispanic White Other Address: City, State, Zip Code: Home Phone: Work/Cell: Person(s) Responsible for Payment: Address
Chiro & Podiatry Plus Chiropractic With the ChooseHealthy program, you have access ccess to a wide variety of complementary health care programs. ograms. Utilize a nationwide alternative health care network
Hospitalization and preventive care paid at 100%; other basic benefits paid at 50% 50% Skilled Nursing Facility. coinsurance.
Sentinel Security Life Insurance Company Administrative Office P.O. Box 16960, Clearwater, FL 33766-6960 (888) 510-0668 Outline of Medicare Supplement Coverage Cover Page Benefit Plans A, B, C #, D #,
*6816* 6816 HARTFORD HOSPITAL DIALYSIS PATIENT/DIALYSIS TREATMENT FACILITY AGREEMENT
This is a contract between two parties, who are YOU, the DIALYSIS PATIENT, and US, your DIALYSIS TREATMENT FACILITY. You probably think it is unusual, and perhaps unnecessary, to have such a contract.
Initial Preventive Physical Examination
Initial Preventive Physical Examination Overview The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 expanded Medicare's coverage of preventive services. Central to the Centers
Colorado s premier provider of safe, comprehensive and coordinated complementary and alternative medicine therapy
Colorado s premier provider of safe, comprehensive and coordinated complementary and alternative medicine therapy THE CENTER FOR INTEGRATIVE MEDICINE UNIVERSITY OF COLORADO HOSPITAL SERVICES PROVIDED:
Basic Benefits Skilled Nursing Facility Coinsurance Part A Deductible
MUTUAL OF OMAHA INSURANCE COMPANY OUTLINE OF MEDICARE SUPPLEMENT COVERAGE - COVER PAGE 1 STANDARDIZED BENEFIT PLAN A AND SELECT BENEFIT PLANS B, C, D, E, F AND G These charts show the benefits included
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
Personal Comp Plan Maryland. More to feel good about.
Personal Comp Plan Maryland More to feel good about. Why You Should Choose a Personal Comp Plan from CareFirst BlueCross BlueShield For the cost of many of the things you buy each day, you can have security
Facts About Dentists and Insurance
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
Albany Medical College presents. Saturday, May 2, 2015 7:30 AM 4:30 PM
Albany Medical College presents AMC Pulmonary and Symposium Saturday, May 2, 2015 7:30 AM 4:30 PM Hudson Valley Community College Bulmer Telecommunications Center 80 Vandenburgh Ave. Troy, New York Sponsored
Airport Way Dental Care
Airport Way Dental Care A Family Dental Practice Committed to Wellness Welcome to our dental office! Our goal and commitment is to provide our patients with the highest quality dental care through education,
NOTICE OF PRIVACY POLICY. Effective:, 2013
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY. NOTICE OF PRIVACY POLICY Effective:, 2013 The
Basic, including 100% 50% Skilled Nursing Facility. Skilled Nursing. Part A Deductible. Part A Deductible. Part B Excess (100%) Foreign Travel
UNITED OF OMAHA LIFE INSURANCE COMPANY A Mutual of Omaha Company OUTLINE OF MEDICARE SUPPLEMENT COVERAGE COVER PAGE STANDARDIZED BENEFIT PLAN A AND SELECT BENEFIT PLANS F AND G Benefit Chart of Medicare
SDC-League Health Fund
SDC-League Health Fund 1501 Broadway, 17 th Floor New York, NY 10036 Tel: 212-869-8129 Fax: 212-302-6195 E-mail: health@sdcweb.org NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION
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
Diabetes Self Management Training Insulin Pump Follow Up
701 East Marshall Street, West Chester, PA 19380 www.chestercountyhospital.org 610.431.5000 Diabetes Self Management Training Insulin Pump Follow Up Patient Name: Visit Date: Time: To prepare for your
Advances in Headache Management
8:00am 5:30pm Hilton Garden Inn-Levis Commons 6165 Levis Commons Blvd, Perrysburg, OH 43551 INTRODUCTION Headache disorders are highly prevalent and often disabling. More than 70% of Americans seek medical
Complete the enrollment form on the reverse side to join Onyx 360 today.
Complete the enrollment form on the reverse side to join Onyx 360 today. Oncology Nurse Advocates are available Monday through Friday, from 9 am to 8 pm Eastern Standard Time at 1-855-ONYX-360 (1-855-669-9360)
Regence Bridge. Medicare Supplement (Medigap) Plans
DECISION GUIDE Regence Bridge Medicare Supplement (Medigap) Plans Regence BlueShield serves select counties in the state of Washington and is an Independent Licensee of the Blue Cross and Blue Shield Association
MANDATORY CUSTOMER CREDIT APPLICATION
MANDATORY CUSTOMER CREDIT APPLICATION Dupal Enterprises LLC Telephone» 718-388-8130 67 Metropolitan Ave Fax back to» 718-388-7008 Brooklyn, NY 11249 *Business Information* Ownership Sole Proprietorship
Consent Forms. The UltraWellness Center YOUR KEY TO LIFELONG HEALTH AND VITALITY
The UltraWellness Center YOUR KEY TO LIFELONG HEALTH AND VITALITY Consent Forms 55 Pittsfield Road, Suite 9 Lenox Commons Lenox, MA 01240 Phone (413) 637-9991 Fax (413) 637-9995 www.ultrawellnesscenter.com
Upcoming Distance Learning Opportunity from the Texas Hospital Association
Upcoming Distance Learning Opportunity from the Texas Hospital Association Thriving in the P4P Environment: Strategies for Meeting the Challenges of POA/PQRI/P4P/P4R Lessons Learned: Case Studies in POA
NEW YORK STATE EXTERNAL APPEAL
NEW YORK STATE EXTERNAL APPEAL You have the right to appeal to the Department of Financial Services (DFS) when your insurer or HMO denies health care services as not medically necessary, experimental/investigational
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
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
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
Physical Therapy Services Medical History Form
Physical Therapy Services Medical History Form Last Name First Name DOB Age Diagnosis: Physician: Check Yes or No. If yes, please explain in the space provided. Yes No Are you pregnant? Yes No Currently
HIPAA PRIVACY RULE: PATIENT REQUESTS TO RESTRICT USES/DISCLOSURES OF PROTECTED HEALTH INFORMATION
HIPAA PRIVACY RULE: PATIENT REQUESTS TO RESTRICT USES/DISCLOSURES OF PROTECTED HEALTH INFORMATION POLICY: A. USC Obligations If Patient Requests Restrictions on Uses and Disclosures of Protected Health
PRIMARY CARE PHYSICIAN (PCP) (if different from Referring Physician) COMPLETE NAME AND ADDRESS:
Northern New Jersey Eye Institute P.A. Charles J. Crane, M.D. Bernard C. Spier, M.D. Allison B. Gunzburg, M.D. Adria Burrows, M.D. Carmen H. Gonzalez, M.D. Maureen C. Considine, O.D. Bruce Goldstein, O.D.
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
Nephrology Associates New Patient Registration Forms
Registration Information Authorization form: Last First Middle Address: City: State: Zip: DOB: / / - - Home # ( ) - - Cell # ( ) - - Email Address: Alternate Contact Information Phone Number Relationship
MEDICARE PARTICIPATING PHYSICIAN OR SUPPLIER AGREEMENT
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE PARTICIPATING PHYSICIAN OR SUPPLIER AGREEMENT FORM APPROVED OMB NO. 0938-0373 Name(s) and Address of Participant*
APPLICATION FOR REGISTRATION:
APPLICATION FOR REGISTRATION: POSTGRADUATE EDUCATION - 2015 CANADIAN MEDICAL SCHOOL GRADUATES MATCHED TO AN ONTARIO RESIDENCY PROGRAM Dear Applicant: The College is pleased to provide this application
Dear Doctor: Chair T. Bryson Struse, DO Marana, AZ. Vice Chair James C. Clouse, DO Clinton, MO. Secretary Treasurer Paul Chase, DO Cherry Hill, NJ
Chair T. Bryson Struse, DO Marana, AZ Vice Chair James C. Clouse, DO Clinton, MO Secretary Treasurer Paul Chase, DO Cherry Hill, NJ Member Mark DiMarcangelo, DO Somers Point, NJ Certification Manager Jennifer
Houston IVF. Timothy N. Hickman, M.D. Medical Director. Laurie J. McKenzie, M.D. Director of Oncofertility
Houston IVF Leaders in Fertility Research and Care 929 Gessner Suite 2300 Houston Texas 77024 6550 Fannin Suite 901 Smith Tower Houston Texas 77030 713.465.1211 Fax: 713.550.1475 www.houstonivf.net Timothy
QUESTIONS FOR YOUR LUNG CANCER CARE TEAM
What should I ask my doctor? Thinking about lung cancer brings up many questions. Sometimes it is difficult to keep all of your questions straight. Many patients have topics in mind they want to discuss
M&O Lead Generation Programs
M&O Lead Generation Programs Direct Mail Looking for a low cost way to connect with prospects? M&O s direct mail program allows you to access the mailers and list from a variety of vendors in one convenient
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
medicare Outline of Coverage
2015 medicare SUPPLEMENT Outline of Coverage Benefit Chart of Medicare Supplement Plans sold on or after June 1, 2010 This chart shows the benefits included in each of the standard Medicare supplement
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