Dr. Wilbur Kuo & Associates Internal Medicine Patient Information

Transcription

1 Patient Information Today s : Name of Patient: of Birth: Sex: M F Social Security Number: Marital status: single married, spouse s name: Name and ages of children: Street Address:_ City: State: Zip: Preferred Pharmacy (name and city): Preferred Mail-Order Pharmacy (if any): address: Home phone#: Cell phone #: _ Work phone #: Contact Preference: Home phone Cell phone Work phone Patient Portal Language Preference: English Other: Race (per census bureau categorization): Refused White White Hispanic or Latino Black or African American Black Hispanic or Latino American Indian or Alaska Native Native Hawaiian Filipino Chinese Japanese Korean Other Asian Guamanian Tongan Other Pacific Islander Vietnamese Unknown Patient s Employer: Work address: City: State: Zip: How did you hear about our Sykesville office? I was a previous patient at Westminster Internal Medicine Physician referral from Valpak Carroll County Times Family member: Co-worker: Friend: PI Page 1 of 5

2 Primary insurance Do you have insurance? Y N Are you the primary subscriber? Y N If no, then please complete the following for the primary subscriber: Name of subscriber: Sex: M F Street address: City: State: Zip: Social Security Number: of birth: Phone #: address: Employer: Relationship to patient: Secondary insurance (if any) Are you the primary subscriber? Y N If no, then please complete the following for the primary subscriber: Same as for primary insurance Name of subscriber: Sex: M F Street address: City: State: Zip: Social Security Number: of birth: Phone #: address: Employer: Relationship to patient: PI Page 2 of 5

3 Consent and Assignment Consent for Treatment: I hereby give consent to the physician and/or her is designee(s) for treatment and the administration of medication. I authorize you to give reasonable and proper medical care by today s standard. I understand that no guarantee or assurance has been made as to the result that may be obtained. Assignment of Benefits and Authorization to Release Information: I authorize and assignment payment of medical benefits by my insurance company directly to for the services rendered, and authorize the release of medical information necessary to process the claim. I agree that a photocopy of this, the original authorization, shall be considered equally authentic. I further understand that I am responsible for any health insurance deductibles, co-insurance (copay), and non-covered charges. Financial Agreement: It is our policy that all fees are to be due upon completion of the office visit unless submitted to an insurance company in which participates. Any outstanding balance or portion of fee unpaid by the patient/responsible party after 30 days will be subject to a $10.00 rebilling fee each month that account has a delinquent balance, unless a payment arrangement has been made in advance. Any returned check will be subject to a $10.00 charge. I understand that I will be subject to a $25 no show fee if I do not call to cancel or reschedule an appointment with at least 24 hrs notice. Legal Assignment: I, the undersigned, understand that I am financially responsible of these charges not paid by my insurance company. I also understand that if, upon default, this matter is referred to an attorney for collection, I agree to pay for an attorney s fee of fifteen percent (15%) of outstanding balance at the time of referral, which percent and the amount resulting there from are considered reasonable by the undersigned, and any and all court costs incurred therewith. The undersigned certifies that he/she has read the foregoing paragraphs and is the Patient, or Parent, or Legal Guardian of the Patient, or is duly authorized to execute and accept its terms. Printed name of patient or legal representative: If signed by legal representative, relationship to patient: PI Page 3 of 5

4 Acknowledgement of Receipt of Notice of Privacy Practices and HIPAA Compliance Patient of Birth: I hereby acknowledge that I have received a copy of the Privacy Practices for Dr. Wilbur Kuo & Associates Internal Medicine in accordance with HIPAA regulations. In an emergency, please contact: In compliance with HIPAA, I hereby authorize this office to release/share my medical information to the above person as well as the following persons: If signed by legal representative, relationship to patient: PI Page 4 of 5

5 Acknowledgement of Receipt of Notice of Privacy Practices and HIPAA Compliance My Contact Preferences I prefer to receive notification that my prescriptions are called in by: text message the online patient portal phone call I prefer to receive billing information by: the online patient portal mail If my test results are normal, I prefer to receive notification by: text message the online patient portal phone call If voice mail, an answering machine, or someone other than you or the persons you authorized in compliance with HIPAA answers the telephone, please: leave the name of the office and reason for the call along with a detailed message, including test results and/or answers to my questions leave the name and number of the office and request that I call the office back leave the number of the office only and request that I call the office back do not leave any messages * Please be aware that depending on your carrier or service provider, text messaging, electronic mail, and voice mail/ answering machine privacy cannot be guaranteed. * Our office phone number to receive text messages is If signed by legal representative, relationship to patient: PI Page 5 of 5