Referral for Residency from the Applicant s Treatment Team
|
|
- Raymond Walker
- 7 years ago
- Views:
Transcription
1 Please send completed form to: CooperRiis, 101 Healing Farm Lane Mill Spring, NC FAX Referral for Residency from the Applicant s Treatment Team Applicant s Name Address City State Zip Male Female Marital Status Date of Birth / / Applicant s Parent(s), Guardian(s), or Spouse: (Please circle one) Address: Home Phone City State Zip Cell Phone If the applicant has a preference between CooperRiis two campuses, please indicate that below. Rural Mill Spring Urban - Asheville Is the applicant open to either campus? Yes No I. Strategic questions. Your considered and focused opinion about these issues is very important to us; please ATTACH your brief answers: (Any member of the Team may address these.) 1) What/Who prompts you to refer this applicant? 2) What do you perceive to be the key goals, hopes and dreams of the applicant? 3) What are the applicant s fundamental strengths that we can build on? 4) What are the crucial issues impeding the applicant s progress? 5) What are the main resources that CooperRiis can provide to assist with the applicant s recovery? II. Psychiatric Profile. Please attach all relevant records, psycho-social summaries and discharge summaries. Please also have the applicant sign and send authorization forms to relevant agencies/hospitals, asking that they send care summaries to us. (The applicant s physician must fill out this section.) A. Applicant s Diagnosis: B. Please submit a detailed, current psychiatric evaluation and prognosis, along with an overview of the applicant s psychiatric, social, educational and work history. C. What is your assessment about whether or not the applicant is currently at risk of suicide or inclined in any way to be destructive or abusive toward him or herself or others? Be specific as well about the history of such behavior. D. Is the applicant able to be responsible for his/her own behavior and safety in an open rural and/or urban environment, able to care for his/her personal hygiene, able and motivated to participate in the CooperRiis program, able to refrain completely from the use of alcohol and illegal drugs, able to confine cigarette smoking to designated areas, able to function relatively independently without close supervision? Yes No If the answer is no, please fully explain why in an attachment. Page 1 of 2
2 III. Current Medications: The applicant must arrive with at least a two week supply of all current medications. The medications will be dispensed based on this form. If there are ANY changes before the exploratory visit, please update us with a current medications list at the time of the visit. Medication Dose Time Taken Reason Prescribed Any PRN medications and for what target symptoms: Medication Dose Time Taken Reason Prescribed Previously unsuccessful medications? Is the applicant treatment adherent? If no, explain IV. Complementary Care for the Resident. CooperRiis program is comprehensive. In addition to providing psychiatric services, psycho-education, community work and service, and a therapeutic milieu, we incorporate nutritional and dietary planning, access to massage therapy and other modalities, smoking cessation and physical exercise programming into the resident s personal recovery plan. Which of these complementary approaches would be most beneficial for the applicant? (Please attach your answer.) V. Your suggested length of stay for the applicant? VI. Clinician Signature: (Attests to Section II and III) Printed Name Date Address: City/State/ZIP Phone Treatment Team Contact Person: Phone PLEASE SEND AT LEAST A TWO WEEK S SUPPLY OF ALL CURRENT MEDICATIONS 05/16 Page 2 of 2
3 Please send completed form to: CooperRiis, 101 Healing Farm Lane Mill Spring, NC Family Form for Application to CooperRiis Applicant s Name Applicant s Social Security Number Date of Birth / / CooperRiis Pledge: We will do our best to provide your family member with a beneficial, comprehensive program of the highest quality, which should assist him or her in recovering from mental illness or emotional distress. Please help us to know of relevant background information: Your vision: Your family member will, of course, have his/her own vision or dream statement. We are also interested in your current hopes for him/her and for his/her future. Please write a brief statement that captures your desire and hope for your family member s recovery. What is your vision? What are some of the key things you hope CooperRiis will help your family member to achieve or accomplish? (You are welcome to use extra sheets.) Disclosure: The CooperRiis environment is open. There are no locked gates and we do not provide one-on-one supervision or staffing. Therefore, risky behavior can be difficult to monitor. Given this, we ask that you answer the following questions carefully, using a separate sheet of paper if necessary. 1) What is your assessment about whether or not the applicant is currently at risk of suicide or inclined in any way to be destructive or abusive toward himself/herself or others? Be specific as well about the history of such behavior. 2) What is your assessment of the applicant s ability.. a) to be responsible for his/her own behavior and safety in an open rural or urban environment? b) to care for his/her personal hygiene? c) to be able and motivated to participate in the CooperRiis program? d) to refrain from the use of alcohol and illegal drugs and to confine cigarette smoking to designated areas? e) to function relatively independently and safely without close supervision? By signing below I am indicating that I have provided the most accurate and truthful information regarding these crucial issues related to the safety and welfare of my loved one. Signature: Relationship to Applicant: Page 1 of 4
4 Please send completed form to: CooperRiis, 101 Healing Farm Lane Mill Spring, NC Family Form for Application to CooperRiis..Continued We will offer our private, not-for-profit, professionally staffed program for a reasonable fee. CooperRiis has been built entirely from private philanthropy and continues to attract donations so that need-based rate reductions may also be offered after the first three months of residency to families who are unable to pay our standard fee. We ask that you read, answer and agree to statements a) through e). Please initial all that apply As parent(s), guardian, or spouse, of,, I (we) Applicant s Name a) Agree to pre- pay CooperRiis monthly program fee of $19,500 for the first month, plus a refundable security and incidental expense deposit of $1,000, upon admission, noting that the maximum monthly standard fee reduces to $15,500 as of the fourth month of residency. I (we) understand that fees are to be pre-paid on a monthly basis, from the day of arrival and that no refund allowances will be made for early discharges. Charges are also not reduced when a resident is away from the campus for trips home, for hospitalization, or vacations. In order to qualify for a rate reduction, the full rate of $19,500 must be paid for the first three months. Financial Assistance Explanation: After three months of residency, the standard rate reduces to $15,500 for all families. Parents, spouse or guardians, who are unable to sustain payments of the $15,500 standard monthly fee after the first three months of full rate, may seek a rate reduction. We will strive to meet the family s financial circumstances, especially for those residents who are demonstrating a strong commitment to their recovery. CooperRiis seeks to offer rate reductions based on the financial situation of the resident, of his or her parents (even if divorced), and/or of the resident s spouse or life partner (if there is one). If a reduced rate is set, pre-payments on a monthly basis will still be expected. Rate reductions will be limited to six month increments at each level of the program. As parent(s), guardian, spouse and/or life partner, of the applicant, I (we) [Please initial one]: b) Wish to notify CooperRiis that I (we) will seek a rate reduction at the appropriate time, or c) Do not expect that I (we) will seek a rate reduction, although I (we) do not waive my (our) right to re-consider this option later.
5 Page 2 of 4 Please send completed form to: CooperRiis, 101 Healing Farm Lane Mill Spring, NC Family Form for Application to CooperRiis..Continued Additional mutual obligations: We are committed to communicating with you as much as the law allows about the applicant, during his or her residency. We will encourage the applicant to sign release of information forms that will authorize us to keep you fully informed about his or her condition. We hope that we will only be bringing you positive news. Nonetheless, despite our best efforts, this may not always be so. We may even approach you at an inopportune time and ask that you pick up the applicant immediately because of medical, psychiatric, legal, or behavioral reasons. Since we are a voluntary program, this need may also arise if the applicant decides to leave CooperRiis. You may also be asked to come, if the applicant has required local hospitalization and is not returning to CooperRiis. d) As the individual or individuals willing to take responsibility for the applicant, I (we) agree to come for him or her at once, if the Chief Program Officer or Managing Director asks us to do so. e) I(we) agree to participate in CooperRiis Family Education programs, which include at least one on-site, three day experience and participation in an online education program. This will be further explained and scheduled through your family member s recovery coordinator. f) I(we) also understand that the CooperRiis monthly fee does not include external physicians fees, medication, dental care, personal entertainment or transportation costs, phone calls, etc. Families often ask, What are the costs for any additional services that are not covered by the standard CooperRiis fee? The primary extra costs are: Psychiatrist: I (we) understand that fees for Psychiatric treatment will be billed to me (us) in addition to the monthly CooperRiis program fee, and I (we) will agree to pay these fees upon receipt of the billing. I am aware that I (we) are responsible to seek any insurance reimbursement for services rendered. (CooperRiis will provide a bill with coding that may help you obtain re-imbursement from your medical insurance company.) Cane Creek Pharmacy: I (we) understand that it is likely that my (our) family member will receive psychiatric medications and CooperRiis orders these medications on behalf of my (our) family member from Cane Creek. Also understand that the Pharmacy has the ability to bill the bulk of the costs for the medications to public and private insurance, if my family member has access to this coverage. Understand that I (we) are obligated to pay for any medication costs that are not covered by any existing insurance coverage. Dietary Supplements: I (we) understand that sometimes residents are advised to take supplements in addition to their regular medications by our Psychiatrists and our nutritionist. If so, I agree to these extra costs. Personal Transportation: I (we) understand that residents sometime require personalized transportation to airports, doctor s appointments, internships, etc. and that I will be obliged to pay for these extra services Drug Screens: I (we) understand that residents with drug use/abuse histories are required to submit to regular random drug screens as deemed appropriate by their CooperRiis Treatment team. If my family member is required, I(we) agree to these extra costs. g) I(we) also understand that CooperRiis does not file claims with private insurance companies or Medicare or Medicaid. The invoices that we provide may be used by the family to seek reimbursement from their private insurance company. We are not a Medicare/Medicaid provider. (If the applicant is a Medicare recipient, I acknowledge that a private provider contract is required for all psychiatric services provided) Page 3 of 4
6 Please send completed form to: CooperRiis, 101 Healing Farm Lane Mill Spring, NC Family Form for Application to CooperRiis..Continued Disclosure: Movement between the CooperRiis programs will not occur until outstanding bills have been paid. I (we) pledge to comply with the requirements listed in a) g): First Signature: Date: Printed name: Relationship: Address: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Additional Signature: Date: Printed name: Relationship: Address: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Please give us a contact to reach in an emergency, if you can not be reached: Name: Home Phone: Business Phone: Cell Phone: Address: Medical Insurance Information: (Please attach copies of all insurance cards for Pharmacy.) *Note: CooperRiis does not file with Medicare/Medicaid or private insurance. Medicare: Medicaid: Other: 1/16 Page 4 of 4
7 Physical Form from Applicant s MEDICAL Treatment Team Applicant s Name Date of Birth / / Address City State Zip I. Medical Profile A. Applicant s Diagnosis (DSM-IV-R) Axis III: II. General Medical History: A. Please indicate whether the applicant currently has or has had any of the following medical problems. We require that all medical records/lab results relating to conditions for which the applicant is currently being treated and those that require ongoing treatment. B. Does the applicant use any medical aids/devices such as glasses, CPAP, hearing aids? C. Is this applicant capable of participating in a life skills program which includes physical work outside? If not, explain D. Any physical limitations/restrictions? E. Does applicant need further medical follow up? III. Current Medications Please send completed form to: CooperRiis, 101 Healing Farm Lane Mill Spring, NC Allergies and/or Adverse reactions to medications: Dizziness, fainting, seizures N Y Blood Pressure N Y Diabetes N Y Migraines N Y High Cholesterol N Y Cancer N Y Head Injury N Y Thyroid N Y Anemia/Other Blood disorder N Y Stroke N Y Neck/Back Injury N Y Kidney disease N Y Asthma/Lung Disease N Y Arthritis N Y Major surgeries N Y Heart Disease/Murmur N Y Fractures N Y Other N Y High Risk for TB N Y please provide proof of two-step TB test If yes, please explain: Medication Dose Time Taken Reason Prescribed IV. Physician Signature (Attests to Medical Profile): Printed Name Date Address: Phone City/State/ZIP 07/10
8
9
Midha Medical Clinic REGISTRATION FORM
Midha Medical Clinic REGISTRATION FORM Today s / / (PLEASE PRINT NEATLY) PATIENT INFORMATION Last Name: First Name: Middle Initial: IS THIS YOUR LEGAL NAME? YES NO IF NOT, WHAT IS YOUR LEGAL NAME DATE
More informationPATIENT INFORMATION SHEET PHYSICIAN YOU ARE SEEING TODAY DATE OF OFFICE VISIT REFERRING PHYSICIAN LAST NAME FIRST NAME MI
275 Collier Road NW, Suite 470 Atlanta, GA 30309 Tel: 404-351-1002 Fax: 404-350-8290 PATIENT INFORMATION SHEET PHYSICIAN YOU ARE SEEING TODAY DATE OF OFFICE VISIT REFERRING PHYSICIAN LAST NAME FIRST NAME
More informationWelcome 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:
More informationX 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
More informationHorizon Eye Care, P.A. Patient Information Sheet. For your convenience, please print and complete the pre-registration forms before your visit.
Patient Information Sheet For your convenience, please print and complete the pre-registration forms before your visit. Section 1: Patient's Legal Name: (First, MI, Last) Parent / Guardian: (If applicable)
More informationPATIENT REGISTRATION FORM PATIENT INFORMATION
Siepser Laser Eye Care PATIENT REGISTRATION FORM : PATIENT INFORMATION First Name Middle Initial: Last Name: Birth : Gender: Male Female Marital Status: SSN: Driver s License #: Address: City: State: Zip:
More informationGREETINGS FROM THE VERDE VALLEY SCHOOL HEALTH CENTER
GREETINGS FROM THE VERDE VALLEY SCHOOL HEALTH CENTER Dear Parent, Verde Valley School is committed to providing your child with the best possible care. It is with this goal in mind that the school requires
More informationPATIENT REGISTRATION Must complete entirely. Reason for today's visit: New Patient: Y N Existing Patient: Y N. Date of Birth: Age:
Anthony N. Dardano, D.O., P.A., F.A.C.S. AESTHETIC AND RECONSTRUCTIVE PLASTIC SURGERY Diplomate of the American Board of Plastic Surgery Diplomate of the American Board of Surgery 951 N.W. 13 th Street,
More informationSingle 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
More informationPlease bring the following with you to your appointment: Completed New Patient forms A list of all prescribed medications with dosages and quantity
Mark E. Hollingshead, M.D. Cataract & Refractive Surgeon Welcome: We look forward to being of assistance to you on your first visit with Hollingshead Eye Center. In order to provide the best possible service,
More informationTHE AYURVEDIC CENTER OF VERMONT, LLC Health Information and History
THE AYURVEDIC CENTER OF VERMONT, LLC Health Information and History Name DOB Date Age Occupation Email Address Home address City State Zip Home phone Cell Phone Referred By Physician Physician Phone Please
More informationReferring 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:
More informationPatient 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:
More informationAGREEMENT AND INFORMATION
AGREEMENT AND INFORMATION We would like to welcome you to our office. Please review this Agreement and Information sheet to assist you in understanding our office policies. Our therapists are private practitioners.
More informationCARSON PHYSICAL THERAPY, INC.
PATIENTS WITH WORKER'S COMPENSATION INSURANCE We are interested in providing you with the best and most effective care possible. In order to begin your Physical Therapy as soon as possible, we offer you
More informationMedical 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 informationREHAB RESOURCES, INC. CONSENT FOR TREATMENT ASSIGNMENT OF BENEFITS BILLING AUTHORZATION ADULT (18 years and over)
CONSENT FOR TREATMENT ASSIGNMENT OF BENEFITS BILLING AUTHORZATION ADULT (18 years and over) Rehab Resources, Inc. is a certified agency that provides outpatient therapy services. Occupational, Physical,
More informationWelcome to Tri-State Rehab Services
Welcome to Tri-State Rehab Services Ashland Ironton Jackson Louisa New Boston Westmoreland Thank you for choosing our facility. To help us meet all your physical therapy needs, please fill out forms completely
More informationPERSONAL RECOVERY PROGRAM INTAKE APPLICATION
Attention: Intake Coordinator 1801 S. 35 th Ave Phoenix, AZ 85009 Phone: (602) 346-3360; Fax: (602) 233-1329 phoenixrescuemission.org PERSONAL RECOVERY PROGRAM INTAKE APPLICATION Thank you for taking this
More informationWelcome Letter - School Based Health Center
Regional Alliance for Welcome Letter - School Based Health Center NOT A MEDICAL RECORD DOCUMENT Dear Student/Parent or Guardian: Regional Alliance for is unique school-based health centers providing services
More informationPATIENT INFORMATION - Please complete and/or verify all information and make changes as necessary.
PATIENT INFORMATION - Please complete and/or verify all information and make changes as necessary. Today s : Are you here for an injury that is work-related? YES NO N/A Patient Name (First-Middle-Last)
More informationAssisted Living Center - Salisbury
Assisted Living Center - Salisbury The Affordable Alternative Full Application for Residency Date Application Mailed Date Application Received Application for Residence/Admission to the Assisted Living
More informationAdvantage Physical Therapy Patient Registration
Appointment Date/Time: Therapist: Advantage Physical Therapy Patient Registration ****Please note ALL patients are required to have a prescription for Physical Therapy from a referring Physician prior
More information11120 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
More informationST. LAWRENCE REHABILITATION CENTER OUTPATIENT POLICIES AND REGISTRATION INFORMATION
Outpatient Services 2381 Lawrenceville Road 609-896-9500 voice Patient Name: Account #: ST. LAWRENCE REHABILITATION CENTER OUTPATIENT POLICIES AND REGISTRATION INFORMATION Your first day of outpatient
More information1 Central 601 West Second Street, Bloomington, IN 47402 t 812.353.9484 800.934.6074
Locations 1 Central 601 West Second Street, Bloomington, IN 47402 t 812.353.9484 800.934.6074 2 East 328 S. Woodcrest Drive, Bloomington, IN 47401 t 812.353.3278 866.353.3278 3 West 2499 W. Cota Drive,
More informationWELCOME TO AMOSKEAG CHIROPRACTIC, INC. SPINAL CORRECTIVE CARE FOR THE ENTIRE FAMILY ADULT. Full Name: What would you prefer to be called?
Today s Date: / / WELCOME TO AMOSKEAG CHIROPRACTIC, INC. SPINAL CORRECTIVE CARE FOR THE ENTIRE FAMILY ADULT Full Name: What would you prefer to be called? Street Address (If P. O. Box, provide street address
More informationPatient Information. Last First MI (Preferred Name) Male Female Married Single Child. City State Zip Code Emergency Contact/Relation Phone
LEWIS C. COLE DMD Family and Cosmetic Dentistry 525 ENERGY CENTER BLVD SUITE 1603 NORTHPORT, AL 35473 PHONE 205.344.6900 FAX 205.344.6910 www.lewiscoledentistry.com Patient Name: Patient Information Date:
More informationFlorida Eye Center Patient Registration Form (Please Print Clearly)
Florida Eye Center Patient Registration Form (Please Print Clearly) Personal Information Legal Name: Last First MI Suffix Nickname: Social Security: - - Drivers License # Date of Birth: / / Mailing Address:
More informationMedicare Supplement Application Aetna Life Insurance Company Aetna Administrator, P.O. Box 10374, Des Moines, IA 50306
Medicare Supplement Application Aetna Administrator, P.O. Box 10374, Des Moines, IA 50306 INSTRUCTIONS: To be considered complete, all sections on this form must be filled out, unless marked optional.
More informationBody Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,,
Medical History Existing or Relevant Previous Conditions Allergies Yes No Dizzy Spells Yes No MRSA Yes No Anemia Yes No Emphysema/Bronchitis Yes No Multiple Sclerosis Yes No Anxiety Yes No Fibromyalgia
More informationWilliam A. Barber, MD, FACS Amanda. Morehouse, MD, FACS Erin Bowman, MD Anna Deriso, RNC, WHNP, MSN Kristy Donaldson, PA-C
275 Collier Road NW Suite 470 Atlanta, GA 30309 William A. Barber, MD, FACS Amanda. Morehouse, MD, FACS Erin Bowman, MD Anna Deriso, RNC, WHNP, MSN Kristy Donaldson, PA-C www.atlantabreastcare.com Phone:
More informationPATIENT INFORMATION: PATIENT CONTACT PHONE NUMBERS: PHYSICIAN INFORMATION: HEALTH INSURANCE INFORMATION:
PATIENT INFORMATION: TODAY S DATE: HOW DID YOU HEAR ABOUT US?: LAST NAME: FIRST NAME: STREET CITY: STATE: ZIP: EMAIL MARTIAL STATUS: SINGLE MARRIED DIVORCED WIDOWED SEPARATED BIRTHDATE: AGE: SEX: MALE
More informationTHANK YOU FOR CHOOSING QPT FOR YOUR PHYSICAL THERAPY NEEDS!
THANK YOU FOR CHOOSING QPT FOR YOUR PHYSICAL THERAPY NEEDS! Please complete and sign all of the enclosed forms. Bring these forms, your physician s referral if required and any other documents required
More informationPREMIER PLASTIC SURGERY CENTER OF NEW JERSEY 310 MADISON AVENUE, SUITE 100, MORRISTOWN, NJ 07960 PHONE: 973-889-9300 FAX: 973-889-9400
PREMIER PLASTIC SURGERY CENTER OF NEW JERSEY 310 MADISON AVENUE, SUITE 100, MORRISTOWN, NJ 07960 PHONE: 973-889-9300 FAX: 973-889-9400 Patient Information as of (todays date). Please print legibly and
More informationPatient 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 informationPatient Case Information (Please Fill Out Forms Completely) (IF PATIENT IS UNDER 18 YEARS OF AGE LEGAL GUARDIAN MUST SIGN ALL PAPERWORK)
Patient Name: Patient Case Information (Please Fill Out Forms Completely) (IF PATIENT IS UNDER 18 YEARS OF AGE LEGAL GUARDIAN MUST SIGN ALL PAPERWORK) (Last), (First) (Middle Initial) Address: City: State:
More information1455 West Fair, Marquette, MI 49855 Phone - 906.226.0574 // Fax - 1.888.347.1135 // info@mqtrehab.com
To our valued patients, In order to speed up the registration process and begin your treatment as soon as possible, please complete the forms listed below and bring the proper documentation to your first
More informationBeach Cities Medical Weight Loss
Beach Cities Medical Weight Loss PATIENT HEALTH HISTORY Name: Address: City/State: Zip: Phone: (home) Cell: Date of Birth: Occupation: Driver s License # Expiration: Emergency Contact Name: Relationship:
More informationPATIENT REGISTRATION FORM PATIENT INFORMATION
Siepser Laser Eye Care PATIENT REGISTRATION FORM : PATIENT INFORMATION First Name Middle Initial: Last Name: Birth : Gender: Male Female Marital Status: SSN: Driver s License #: Address: City: State: Zip:
More informationFrequently Asked Questions About Our Preventative Care Offering
Frequently Asked Questions About Our Preventative Care Offering Q: What is different in the Preventative Care service that I would not get in the Traditional service? Time, access, and focus on healthy
More informationCENTENNIAL 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 informationStonebridge 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 informationPLEASE 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 informationLake 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 informationNew Patient Registration Information
New Patient Registration Information ADAMS COUNTY LOCATIONS YORK COUNTY LOCATIONS Adams Health Center........ (717) 339-2620 Apple Hill................ (717) 741-8240 Aspers Health Center........ (717)
More informationMEDICAL CLEARANCE FORM CHECKLIST
Office of Study Abroad 720 Northern Blvd Brookville, NY 11548 (516) 299-2508 patricia.seaman@liu.edu MEDICAL CLEARANCE FORM CHECKLIST Read all requirements and instructions carefully. MEDICAL HEALTH HISTORY
More informationNew River Health will bill private insurance, Medicaid, and CHIP for eligible students. No child will be denied services due to inability to pay.
The Richwood School-Based Health Center is pleased to offer medical, mental health counseling, health education, and on site dental services to all Richwood Middle School and Richwood High School students.
More informationTechnical Assistance Document 5
Technical Assistance Document 5 Information Sharing with Family Members of Adult Behavioral Health Recipients Developed by the Arizona Department of Health Services Division of Behavioral Health Services
More informationSTUDY ABROAD HEALTH CLEARANCE INSTRUCTIONS. For Students
STUDY ABROAD HEALTH CLEARANCE INSTRUCTIONS For Students 1. Fill out the student sections on pages 1, 2 and 5. Take all the pages with you to your physical exam appointment. 2. During your physical exam,
More informationDepartment of State Academic Exchanges Participant Medical History and Examination Form
Department of State Academic Exchanges Participant Medical History and Examination Form Having been selected to participate in a U.S. Department of State educational exchange program, you are required
More informationMangione 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:
More informationFaculty 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 informationPELED PLASTIC SURGERY HEADACHE HISTORY FORM
HEADACHE HISTORY FORM IF THIS IS YOUR FIRST VISIT, PLEASE TAKE THE TIME TO FILL THIS FORM OUT COMPLETELY. Patient Name: Age: Date of Birth: Weight: Height: Address: City: State: Zip: Home Phone: Cell Phone:
More information3 Emergency Contact. Eaton Chiropractic & Rehab Center. 1 Patient Information. 2 Insurance / Guarantor. 4 Accident Information. Emergency Contact:
Eaton Chiropractic & Rehab Center 1 Patient Information Name: First Initial Last Address: Home: Work: Cell: DOB: Male Sex: Female SSN: Email: Single Divorced Marital Status: Married Separated Widowed Full
More information(928) 854-4307 MEDICAL HISTORY. Weight: _ Shoe size: _
2302 N. Stockton Hill Rd Ste. G 1731 Mesquite Ave Ste 4 1200 Mohave Rd MEDICAL HISTORY Weight: Shoe size: ~~~~~~~~~~~~~~~~~~~~~~~~~~PLEASECIRCLE: RIGHT or LE~ Is your problem due to an accident? YES or
More informationPolicy and Procedure Manual
Policy and Procedure Manual Resident Assessment (RA) Table of Contents RA-01 RA-02 RA-03 RA-04 RA-05 RA-06 RA-07 RA-08 RA-09 RA-10 RA-11 RA-12 RA-13 Admission. History, Physicals and Routine Health Care
More informationNew England Pain Management Consultants At New England Baptist Hospital
New England Pain Management Consultants At New England Baptist Hospital Pain Management Center Health Assessment Dear New Pain Management Patient, Welcome to the New England Pain Management Consultants
More informationElectronic Health Records Intake Form
Dr. Sam Yoder, D.C. 101 Winston Way Ste B Campbellsville, KY 42718 Electronic Health Records Intake Form In compliance with requirements for the government EHR incentive program First Name: Address: Last
More informationMILLRISE MEDICAL PRACTICE NEW PATIENT REGISTRATION/HEALTH QUESTIONNAIRE
MILLRISE MEDICAL PRACTICE NEW PATIENT REGISTRATION/HEALTH QUESTIONNAIRE PLEASE COMPLETE THIS FORM IN BLOCK CAPITALS. To register with the Practice please complete this questionnaire as fully as possible.
More informationIntake for Services. Birth date: Age: Gender: Name of Spouse: Years Married: Spouse's Age:
Intake for Services Today's Date Last name: First name: Birth date: Age: Gender: Address: City/State/Zip Email: Home Phone: Cell phone: Marital Status: No. of Children & ages: If presently married: Name
More informationPediatric 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 informationPATIENT INFORMATION FORM
737 Pearl Street, Suite 108 Phone: 858.456.2114 Fax: 858.456.2103 www.abilityrehabsd.com PATIENT INFORMATION FORM Please print and complete ALL items. If an item doesn t apply, put N/A Patient Name: Age:
More informationWelcome! We look forward to serving YOU. If we can do anything to make your time with us more enjoyable, please let us know.
Welcome! We want to thank you for allowing us the opportunity to provide you with the highest level of quality rehabilitation services possible. We are committed to providing you with a comfortable, friendly
More informationApplication Form. Global Green MBA
Faculty of Management The International School Application Form Global Green MBA Instructions All of the following materials must be submitted before your application will be processed: Application Form
More informationAON Physical Therapy & Wellness
AON Physical Therapy & Wellness PATIENT REGISTRATION Patients First and Last Name Intake Taken By- Appointment Date / Therapist Date- Date of Birth: Is the patient Under 18? If so, who is the guarantor?
More informationNew 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 informationPatient Registration Form Please print clearly and complete all items. Patient First Name. Street Address. City State Zip
Oakland Orthopedic Partners, P.C., offices of Bruce T. Henderson Paul C. Lewis 44555 Woodward Ave., Ste 406 & 407 Pontiac, MI 48341 Office 248.334.0524 Fax 248.858.3887 www.oaklandorthopedic.com Patient
More informationHSE Medical Associates Family Practice
HSE Medical Associates Family Practice PLEASE CHECK WHICH PROVIDER YOU ARE HERE TO SEE M.D. P.A. David W. Hoefer, M.D. Paul E. Shepard, M.D. Alfredo T. Ermac, M.D. Sergio G. Perossa, Darcy Bevil, P.A.
More informationIntake / Admissions Processes
Intake / Admissions Processes Now that the elements of providing quality customer service have been reviewed, the intake and admission processes will be covered. Some homecare companies make a distinction
More informationName: 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 informationCONSENT FOR MEDICAL TREATMENT
CONSENT FOR MEDICAL TREATMENT Patient Name DOB Date I, the patient or authorized representative, consent to any examination, evaluation and treatment regarding any illness, injury or other health concern
More informationMEDICAL POLICY No. 91608-R1 MENTAL HEALTH RESIDENTIAL TREATMENT: ADULT
MENTAL HEALTH RESIDENTIAL TREATMENT: ADULT Effective Date: June 4, 2015 Review Dates: 5/14, 5/15 Date Of Origin: May 12, 2014 Status: Current Summary of Changes Clarifications: Pg 4, Description, updated
More informationPatient Information: In Case of Emergency: Physician: Insurance:
For office use only: Start of Care: ICD-9 Codes: Patient Information: Name: Address: City: State: IL Zip: Patient of Birth: Policy Holders of Birth: of Injury or Onset of Symptoms: Home Phone: Work Phone:
More informationINTEGRATED PHYSICAL THERAPY a whole- istic approach to physical therapy
Patient s Name: D.O.B.: Age: Address: City: State: _ Zip Code: Home Phone #: Cell #: _ Business #:_ Social Security Number: E- mail Address: Referring Physician? _ How do you hear about us: Dr. Referral
More informationPatient Information. Date: Date of Birth: / / Name: Social Security: _- - Address: Street City State Zip
Personal Insurance Intake Form Patient Information Date of Birth: / / Social Security: _- - Address: Street City State Zip Email Address: Home Phone: Sex: M or F Work Phone:. Cell Phone: Height: Weight:
More informationHealth Information Form for Adults
A. IDENTIFICATION B. EMERGENCY CONTACTS Name (Last) (First) (Middle) Maiden Name Primary Alternate In Case of Emergency, Notify: Primary Contact Name (Last) (First) (Middle) Relationship Home Work Home
More informationMedicare Patient Information. Patient Name: SS#: - - Date of Birth: / / Sex: Female Male. City: State: Zip Code:
Medicare Patient Information Patient Name: SS#: - - Date of Birth: / / Sex: Female Male Address: Street: City: State: Zip Code: Home Phone: ( ) - Work/Mobile Phone: ( ) - Please print your name as it Appears
More information1960 Ogden St. Suite 120, Denver, CO 80218, 303-318-3840
Dear Valued Patient, 1960 Ogden St. Suite 120, Denver, CO 80218, 303-318-3840 Thank you for choosing Denver Medical Associates as your healthcare provider. We strive to provide you with the best possible
More information[Provider or Facility Name]
[Provider or Facility Name] SECTION: [Facility Name] Residential Treatment Facility (RTF) SUBJECT: Psychiatric Security Review Board (PSRB) In compliance with OAR 309-032-0450 Purpose and Statutory Authority
More informationRetinal Consultants of San Antonio Diseases and Surgery of the Retina and Vitreous www.retinasanantonio. com
Retinal Consultants of San Antonio Diseases and Surgery of the Retina and Vitreous www.retinasanantonio. com 1 Calvin E. Mein, MD 9480 Huebner Rd, Suite 310 (210) 615-1311 Moises A. Chica, MD San Antonio,
More informationPATIENT TREATMENT AGREEMENT
PATIENT TREATMENT AGREEMENT Patient Name: : As a participant in buprenorphine treatment for opioid misuse and dependence, I freely and voluntarily agree to accept this treatment agreement as follows: I
More informationCancellation/No Show Policy
Cancellation/No Show Policy If you are unable to keep your scheduled appointment we require a 24 hour advance notice. Failure to provide this notice will result in a $50.00 cancellation/no show fee. You
More informationSan Ramon Valley Primary Care Medical Group Internal Medicine Patient Information Sheet
San Ramon Valley Primary Care Medical Group Internal Medicine Patient Information Sheet By completing this questionnaire you provide us with important, basic information for our records. Please print your
More informationNotice of Privacy Practices Walter L Cohen High School School-based Health Center. Effective as of August 6, 2004
Effective as of August 6, 2004 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. We are required
More informationConsent 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
More information! 1220 Howell Street Ste. 110, Seattle, WA 98101 (206) 464-9002
! 1220 Howell Street Ste. 110, Seattle, WA 98101 (206) 464-9002 PATIENT INFORMATION PATIENT NAME (Last, First, Middle Initial) DATE OF BIRTH AGE ADDRESS SOCIAL SECURITY NUMBER CITY, STATE, ZIP Male GENDER
More informationHere at PhysioDC we are committed to providing you with excellent care.
Washington PhysioDC 1001 Connecticut Ave. NW Suite 330 Washington, DC 20036 202-223-8500 202-379-9299 (fax) physiodc@gmail.com CANCELLATION POLICY EFFECTIVE 2016 Here at PhysioDC we are committed to providing
More informationCh. 1130 HOSPICE SERVICES 55 CHAPTER 1130. HOSPICE SERVICES GENERAL PROVISIONS RECIPIENT ELIGIBILITY AND DURATION OF COVERAGE
Ch. 1130 HOSPICE SERVICES 55 CHAPTER 1130. HOSPICE SERVICES Sec. 1130.1. Statutory basis. 1130.2. Policy. 1130.3. Definitions. GENERAL PROVISIONS RECIPIENT ELIGIBILITY AND DURATION OF COVERAGE 1130.21.
More informationHM Group Supplemental Hospital Indemnity Insurance Definitions
Key Benefit Administrators, Inc. (KBA) P.O. Box 519 Fort Mill, SC 29716 Tel: 866-225-9030 Fax: 866-225-9411 hmig.com HM Group Supplemental Hospital Indemnity Insurance Definitions Please note that certain
More informationADULT INTAKE QUESTIONNAIRE. Today s Date: Home phone: Ok to leave message? Yes No. Work phone: Ok to leave message? Yes No
ADULT INTAKE QUESTIONNAIRE Name: Today s Date: Age: Date of Birth: Address: Home phone: Ok to leave message? Yes No Work phone: Ok to leave message? Yes No Cell phone: Ok to leave message? Yes No Email:
More informationStudent & Health Information for Bates College Off-Campus Short Term Courses
Student & Health Information for Bates College Off-Campus Short Term Courses 1. Name Program/Course Bates ID # Email Cell phone: Home Address: Date of Birth Nationality If course is going abroad, attach
More informationINTEGRATED PHYSICAL THERAPY A Holistic Approach to Physical Therapy
Patient s Name: D.O.B.: Age: Address: City: State: Zip Code: Home Phone #: Cell #: Business #: Social Security Number: E-mail Address: Height: Weight: Referring Physician? Status: Married/Single/Other/Full
More informationRIDGE PHYSICAL THERAPY & WELLNESS CENTER. Intake Form
Intake Form : Personal Information please print clearly Name: last first middle initial Home Address: Home Telephone: ( ) Cell Phone: E-Mail Address: Social Security #: of Birth: Age: Sex: M F Marital
More informationWhat is the Phoenix Transition Housing Program? What is the acceptance criteria? How do you apply to access the Phoenix Transition Housing Program?
What is the Phoenix Transition Housing Program? The Phoenix Transition Housing Program is a Provincial Homelessness Initiative developed in partnership with BC Housing that provides safe, structured housing
More informationNearest Relative Information (Not in same household)
Patient Information Name Male Female Address City State Zip Birth Date Age Responsible Party Information Name: Self Parent/Guardian Birth Date SSN# Drivers License# Email Employer Employer Phone# Employer
More informationCAMARILLO AQUATICS AND REHABILITATION SERVICES
CAMARILLO AQUATICS AND REHABILITATION SERVICES Last Name First M.I. Address Apt.# City State Zip Code Phone # SS# Date of Birth Sex M F Driver s License # Marital Status: S M D W Spouse s Name How did
More informationSection A Victim/Applicant Information (A separate application must be completed for each victim.)
Application For Crime Victim Compensation Claim No. Arkansas Crime Victims Reparations Board 323 Center Street, Suite 200 Little Rock, Arkansas 72201 Office of the (501) 682-1020 or 1-800-448-3014 This
More informationOUTPATIENT SERVICES CONTRACT
OUTPATIENT SERVICES CONTRACT Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions
More informationMarian R. Zimmerman, Ph.D.
Marian R. Zimmerman, Ph.D. Clinical Health Psychology www.mzpsychology.com 3550 Parkwood Blvd., 306 (214)618-1451 Phone Frisco, TX 75034 (214)618-2102 Fax Pre-Surgical Evaluation Patient Name: Age: Date
More information