Last Name First Name Middle Initial. Address City State Zip Code. Date of Birth Social Security. Home Number Cell Phone. Employer Work Number.
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1 Last Name First Name Middle Initial Address City State Zip Code Date of Birth Social Security Home Number Cell Phone Employer Work Number Insurance Company Policy Holder's Name: If you are not the policy holder, what is your relationship to them? Policy Holder DOB SSN# Emergency Contact Name Relationship Contact Number Primary Doctor Referring Doctor Parents Name if Minor DOB SS# May we leave a voice mail on your answering machine? Yes No May we contact you by: Cell phone Yes No or Yes No We may impose a return check fee of $25.00 if any check or electronic payment authorization you provide as payment on your account is not honored upon first presentation. By signing below, I authorize the release of any medical information necessary to process my claim. I also authorize payment of medical benefits to the physician or supplier of service as indicated on the claim. In the event it is necessary to refer my account to a collection agency or an attorney, I agree to pay all collection costs, including attorney fees and court costs. ATTENTION SELFPAY PATIENTS and Insurance patients Labs, pap smears and biopsy fees are not included in the office charge and you will be billed separately by the laboratory. (Only exception is with our self pay rate for an annual exam, it includes the Pap lab bill only.) Its your responsibility to know your coverage and if you are unsure of any aspect of your coverage, please call the member service number on the back of your insurance card. The member services representative will be able to assist you with any questions you may have. Our office utilizes an automated collections system. If you have not set up a payment plan or paid your balance within 120 days (approx. 4 statements) your account will be sent to collections, and we will not be able to see you. It is your responsibility to contact us if you have any questions about a statement you receive. Once your account is sent to collections, no changes can be made to the balance. Print Name Patient Signature Date
2 Dear Patient, Under the Florida law, physicians are generally required to carry medical malpractice insurance or otherwise demonstrate financial responsibility to cover potential claims for Medical Malpractice. Your obstetrics and gynecology physician has decided not to carry medical malpractice insurance. This is permitted under the Florida Law subject to certain conditions. Florida law imposes strict penalties against non-insured OB/GYN physicians who fail to satisfy adverse judgment arising from claims of medical malpractice. This notice is provided to you pursuant to Florida Law. If you have any hesitations, please speak with any of our staff members. Sincerely, The Women's Center I have read and understand that this office does not carry malpractice insurance. Signature Print Name Date Witness Signature Date
3 HIPPA Notice of Privacy I, _ have read the HIPPA Notice of Privacy Practices. Please list any persons that you authorize our practice to speak with regarding your medical health information. We will not give out information to anyone whose name does not appear below. You have the right to change this authorization at any time, however, additions to this list must be made in person at one of our seven locations. Patient Signature Date
4 I acknowledge that I have read and received a copy of The Women's Center practice guidelines as it appears below and agree to follow those guidelines. Patient Signature Date Practice Guidelines Welcome! We are pleased that you have chosen our practice for your care. We are a patient oriented office, committed to providing the highest standards of care possible. Our friendly, well trained staff is here to serve your needs. Providers for The Women's Center are Douglas E. Gearity, M.D., Yasmine N. Kareem, M.D., Wilfredo Vega-Montalvo, M.D., Shene Dozier-Allen, M.D., Alejandro Pena, M.D., Lee Smyk, M.D., Sherra Forde-Kelly, M.D., Jeffrey Feld, M.D., Tamika Lewis, M.D., Linda Peterson, P.A.-C, Aileen Trauger, P.A.-C, Kriselle Rondon, N.P.-C, Jennifer Ivy, A.R.N.P., C.N.M., and Caprice Wright, A.R.N.P., C.N.M. We currently have seven office locations to accommodate our patients: Hunter s Creek, downtown Orlando, Clermont, Oviedo, St. Cloud, Ocoee, and Lake Mary. We see patients by appointment from 7:30am-5:00pm Monday through Thursday, Fridays 8:00am-12:00pm, and Saturdays at several office locations from 8:00am-12:00pm. For after hours emergencies please call and follow the automated system instructions. Once your appointment is scheduled, you will receive a confirmation call 48 hours before. If you have a privacy detector on your phone you will not receive the confirmation call through our automated service. In the event that you must cancel or reschedule, or if you are running late to your appointment, please call our office so we can make the necessary adjustments in our patient schedule. If you are more than fifteen minutes late you may have additional wait time or may have to reschedule for another day. Should you request your medical records, there is a charge of $1.00 per page up to $ The release of records directly to another physician is free of charge. It may take up to 72 hours to prepare and release records. If you are in need of Family Medical Leave Act forms, disability verifications or other papers, there is a $10.00 charge for processing the forms. At your first visit a review of your medical history will be completed by one of our providers. We will offer advice based on our findings and answer any questions you may have. If you require additional testing it will be ordered at that time. It is our office policy that you make a follow-up appointment to review any medical findings including lab results and to answer any questions you may have. The provider will also discuss an appropriate plan of treatment with you during this appointment and insurance will be charged for that visit. Your insurance policy may require an office visit co-payment; that amount is due in full at the time of your visit. Per your insurance company: Benefits are quoted as an estimate only and are not a guarantee of payment. Final determination will be made by your insurance carrier once the claim is received. Self Pay patient office fees are also due in full at the time of service. Labs incurred during your visit will be billed separately from the lab and are not included in our fees. Our success can only be measured by your satisfaction with the health care you receive. We welcome your comments as to how we may, in any way, satisfy your medical needs. Please give us your thoughts at comments@wcorlando.com. Thank you for choosing The Women s Center for your healthcare needs.
5 Patient Copy Please retain for your records Practice Guidelines Welcome! We are pleased that you have chosen our practice for your care. We are a patient oriented office, committed to providing the highest standards of care possible. Our friendly, well trained staff is here to serve your needs. Providers for The Women's Center are Douglas E. Gearity, M.D., Yasmine N. Kareem, M.D., Wilfredo Vega-Montalvo, M.D., Shene Dozier-Allen, M.D., Alejandro Pena, M.D., Lee Smyk, M.D., Sherra Forde-Kelly, M.D., Jeffrey Feld, M.D., Tamika Lewis, M.D., Linda Peterson, P.A.-C, Aileen Trauger, P.A.-C, Kriselle Rondon, N.P.-C, Jennifer Ivy, A.R.N.P., C.N.M., and Caprice Wright, A.R.N.P., C.N.M. We currently have seven office locations to accommodate our patients: Hunter s Creek, downtown Orlando, Clermont, Oviedo, St. Cloud, Ocoee, and Lake Mary. We see patients by appointment from 7:30am-5:00pm Monday through Thursday, Fridays 8:00am-12:00pm, and Saturdays at several office locations from 8:00am-12:00pm. For after hours emergencies please call and follow the automated system instructions. Once your appointment is scheduled, you will receive a confirmation call 48 hours before. If you have a privacy detector on your phone you will not receive the confirmation call through our automated service. In the event that you must cancel or reschedule, or if you are running late to your appointment, please call our office so we can make the necessary adjustments in our patient schedule. If you are more than fifteen minutes late you may have additional wait time or may have to reschedule for another day. Should you request your medical records, there is a charge of $1.00 per page up to $ The release of records directly to another physician is free of charge. It may take up to 72 hours to prepare and release records. If you are in need of Family Medical Leave Act forms, disability verifications or other papers, there is a $10.00 charge for processing the forms. At your first visit a review of your medical history will be completed by one of our providers. We will offer advice based on our findings and answer any questions you may have. If you require additional testing it will be ordered at that time. It is our office policy that you make a follow-up appointment to review any medical findings including lab results and to answer any questions you may have. The provider will also discuss an appropriate plan of treatment with you during this appointment and insurance will be charged for that visit. Your insurance policy may require an office visit co-payment; that amount is due in full at the time of your visit. Per your insurance company: Benefits are quoted as an estimate only and are not a guarantee of payment. Final determination will be made by your insurance carrier once the claim is received. Self Pay patient office fees are also due in full at the time of service. Labs incurred during your visit will be billed separately from the lab and are not included in our fees. Our success can only be measured by your satisfaction with the health care you receive. We welcome your comments as to how we may, in any way, satisfy your medical needs. Please give us your thoughts at comments@wcorlando.com. Thank you for choosing The Women s Center for your healthcare needs.
Date of Birth: Phone # Home Cell Work (please circle) Alternate Phone # Home Cell Work (please circle) Home Address. Insurance Billing Address:
Patient Demographics Name: _ of Birth: SS# Phone # Home Cell Work (please circle) Alternate Phone # Home Cell Work (please circle) Email: _ Home Address Insurance Information Insurance Provider: Group
Last Name First Name MI. Sex (circle): Male Female Date of Birth SS# Marital Status (circle): Married Single Divorced Widowed Separated
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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.
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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:
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Advanced Women's HealthCare, SC Registration Form
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HSE Medical Associates Family Practice
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9525 Katy Freeway, Suite 312 Houston, Texas 77024 Phone (713) 463-9449 Fax (713) 463-7181 www.bhchouston.com. Welcome Friend!
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Guardian/Patient Name. Family Dental Care NC. 1701 Country Club Rd---Jacksonville, NC 28546 Telephone: (910) 346-2345 SIGNATURE ON FILE
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OFFICE POLICIES. Please note that NO controlled substance requests can be filled via phone as per DEA regulations. (initial)
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All routine calls will be be returned within 24 24 hours, in in the order in in which they were received.
Office Policies We would like to to take the opportunity to to explain the policies of of our office. Please take notice of of include fever, changes with r surgical incision or or increased pain, NO medication
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