Auto Accident Injury Package New Patient Forms
|
|
- Neil Doyle
- 8 years ago
- Views:
Transcription
1 Auto Accident Injury Package New Patient Forms The Following Individual Documents have been combined into ONE Auto Accident Injury Package of Downloadable PDF New Patient Forms. New Patient Forms Auto Accident Injury IF you are have sustained injuries due to being involved in an Auto Related Accident CLICK the Button Below to Print ALL Forms you will need to Complete for your First Office Visit. Print ALL Required Forms New Patient Health History Pain Description and Location HIPPA Notice of Privacy Assignment of Benefits Auto Accident Injury Report NY State Motor Vehicle No Fault Form Dow Chiropractic believes Your Time is Valuable; therefore, we encourage our New Patients to print and complete the attached PDF forms PRIOR to visiting our office for the first time. This will save both you and us time. Any areas within the forms that you don t understand can be left unanswered to be completed with our office staff s assistance. IF You Have Any Questions Call Us Thomas Dow, D.C., P.C [Auto Accident Injury Package Cover]
2 New Patient Health History Today s Date Patient Data / / File Number Last Name First Name MI Address* * Your address will NOT be shared with any 3 rd parties. It is only used for occasional office announcements and reminders. Name You Prefer to be Called Male Female Date of Birth Age SSN Employer Occupation Marital Status Spouse s Name Spouse Phone Number of Children Contact Data Address City ST ZIP Home Phone Work Phone Cell Phone Referred By Emergency Contact Phone Reason For Visit Reason Work Auto Sports Sudden Chronic Date of Injury Date Symptoms Appeared Describe What Happened NOTE: Complete Separate Form for Pain Description, Location and Pain Level Is this Condition Getting Worse? Yes No Constant Comes and Goes Does Condition Interfere with Work Sleep Daily Routine Please Explain Have you Experienced the Same or Similar Condition in the Past? Yes No If Yes, When? Please Explain List Other Practitioners Seen for this Condition Previously Treated By a Chiropractor? Yes No If Yes, Whom? Phone Describe Insurance Information (Please Inform Front Desk of 2 nd Insurance Source) Insurance Company Ins. Company Ph # ID #: Company Address Insured s Employer: Insured s Name Relation to you: Group #: Date of Birth Insured s SSN ID #: Doctor s Notes [New Patient Health History Page 1]
3 Have You Ever Suffered From (Check All That Apply) Habits Review Please place a in the Box that Most Closely Describes Your Level Please list ALL Drugs / Over-the-Counter Meds / Vitamins / Supplements you are Taking with Dosage: Comments: Daily Activities Please Indicate Whether or Not the Following Apply to You: Do you experience pain every day? Yes No Do you exercise? No Yes Are your symptoms worse during certain times of the day? Yes No IF Yes - How Often? Daily 2-3 Times/Week Varies Do your symptoms interfere with daily life? Yes No Has Your Weight Fluctuated in the Past Year? Yes No Do changes in the weather affect your symptoms? Yes No If Yes Up or Down How Much? What activities aggravate your symptoms? What improves your symptoms? Signatures Insured s Name Patient s Signature Spouse or Guardian Signature Date Date I understand and agree that health/accident insurance policies are an arrangement between the insurance carrier and me. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable. Doctor s Notes [New Patient Health History Page 2]
4 Patient Pain Description - Location - Level Right Left Left Right Front Left Please mark the areas of your medical complaint on the diagram above. Use BOTH of the following Alphabetical and Numerical symbols on the body diagram to accurately identify the SPECIFIC DESCRIPTION, LOCATION and LEVEL of your Pain: Right Back Degree of Pain from: 1 (Discomfort) to 10 (Extreme Pain) Other Comments: D A 7 S A 8 Example N T 5 Back NAME (Print) SIGNATURE DATE [Pain Description Location Level]
5 HIPPA Notice of Privacy Practices 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. This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carryout treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. Protected health information is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health condition and related health care services. USES AND DISCLOSURES OF PROTECTED HEALH INFORMATION Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician s practice, and any other use required by law. Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission. Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician s practice. These activities include, but are not limited to, quality assessment, employee review, training of medical students, licensing, fundraising, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment, and inform you about treatment alternatives or other health-related benefits and services that may be of interest to you. We may use or disclose your protected health information in the following situations without your authorization. These situations include: as required by law, public health issues as required by law, communicable diseases, health oversight, abuse or neglect, food and drug administration requirements, legal proceedings, law enforcement, coroners, funeral directors, organ donation, research, criminal activity, military activity and national security, workers compensation, inmates, and other required uses and disclosures. Under the law, we must make disclosures to you upon your request. Under the law, we must also disclose your protected health information when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements under Section Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization or opportunity to object unless required by law. You may revoke the authorization, at any time, in writing, except to the extent that your physician or the physician s practice has taken an action in reliance on the use or disclosure indicated in the authorization. [HIPPA Notice of Privacy Page 1]
6 YOUR RIGHTS The following are statements of your rights with respect to your protected health information. You have the right to inspect and copy your protected health information (fees may apply) Under federal law, however, you may not inspect or copy the following records: Psychotherapy notes, information compiled in reasonable anticipation of, or used in, a civil, criminal, or administrative action or proceeding, protected health information restricted by law, information that is related to medical research in which you have agreed to participate, information whose disclosure may result in harm or injury to you or to another person, or information that was obtained under a promise of confidentiality. You have the right to request a restriction of your protected health information This means you may ask us not to use or disclose any part of your protected health information and by law we must comply when the protected health information pertains solely to a health care item or service for which the health care provider involved has been paid out of pocket in full. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. By law, you may not request that we restrict the disclosure of your PHI for treatment purposes. You have the right to request to receive confidential communications You have the right to request confidential communication from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically. You have the right to request an amendment to your protected health information If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. You have the right to receive an accounting of certain disclosures You have the right to receive an accounting of all disclosures except for disclosures: pursuant to an authorization, for purposes of treatment, payment, healthcare operations; required by law, that occurred prior to April 14, 2003, or six years prior to the date of this request. You have the right to obtain a paper copy of this notice may from us even if you have agreed to receive the notice electronically. We reserve the right to change the terms of this notice and we will notify you of such changes on the following appointment. We will also make available copies of our new notice if you wish to obtain one. COMPLAINTS You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Compliance Officer of your complaint. We will not retaliate against you for filing a complaint. We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. We are also required to abide by the terms of the notice currently in effect. If you have any questions in reference to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number. Please sign the Acknowledgment of Receipt shown below. You are only acknowledging that you have received or been given the opportunity to receive a copy of our Notice of Privacy Practices. Print Name: Signature: Date: [HIPPA Notice of Privacy Page 2]
7 Assignment of Benefits PATIENT NAME: LAST FIRST MI MAIDEN OR OTHER NAME In consideration of services rendered or to be rendered, I hereby assign Thomas E. Dow D.C., P.C., my first party insurance benefits and rights, attendant thereto, as shall equal the full amount of the bill for said services and Thomas E. Dow D.C., P.C., may secure same in my name. I further understand if said sum is not collected, I will remain personally liable therefore. OR SIGNATURE OF PATIENT DATE PARENT / LEGAL GUARDIAN DATE WITNESS DATE [Assignment of Benefits]
8 Auto Accident or Injury Report Today s Date / / File Number Last Name First Name MI Auto Related Accident Date of Accident Time of Accident AM PM Were you the: Driver Front Passenger Rear Passenger Pedestrian If a traffic violation was issued, to whom was it issued? Me Other Person Number of people in accident vehicle you occupied? Did the police come to the accident site? Yes No Was a police report filed? Yes No Were there any witnesses? Yes No Were you wearing your seat belt? Yes No Was this vehicle equipped with airbags? Yes No If YES, did it/they inflate? Yes No In relation to the base of your skull, where was the headrest? Above Below At Base of Skull What did your vehicle impact? Another Vehicle Other If Other Please Describe: Did any part of your body strike anything in the vehicle? Yes No If Yes Please Describe: Who owned the vehicle you were in / struck by? Make and Model of vehicle you were occupying: Name of the Location / Street on which you were traveling? In which Direction were you headed? North South East West What was the approximate speed of your vehicle? Did the impact to your vehicle come from the: Front Rear Right Side Left Side Other During impact, were you facing: Right Left Forward Were you aware or surprised by the impact? Aware Surprised Did accident vehicle made impact with another vehicle? Another Object? If so, What? Direction other vehicle was headed? North South East West Approximate Speed of other vehicle? In your words, please describe the accident: After Injury Information Did the accident render you unconscious? Yes No If yes for how long? Please describe how you felt immediately after the accident: Have you gone to a hospital or seen any other doctor since the accident? Yes No When did you go? Just After Accident The Next Day 2 Days Plus Name of Hospital and/or Attending Doctor? Describe any treatment or tests you received: How did you get there: Ambulance Private Transportation Is He/She a: D.C. M.D. D.O. D.D.S. [Auto Accident Injury Report - Page 1]
9 Were X-Rays taken? Yes No Was Medication Prescribed? Yes No If Yes Describe: Have you been able to work since this injury? Yes No Give Dates you were unable to work: Are your work activities restricted as a result of this injury? Yes No Have you returned to work? Yes No Indicate the symptoms that are a result of this accident: Is your condition getting worse? Yes No Constant Comes & Goes Indicate your degree of comfort while performing the following activities: Laying on Back Laying on Side Lying on Stomach Sitting Standing Stretching Lovemaking Walking Running Sports Working Lifting Bending Kneeling Pulling Reaching Have you retained an attorney? Yes No If yes, whom: Phone Number: Recovery information To evaluate the effect that continuing work will have on your recovery please complete the following: How many hours are in your normal work day? Please indicate your daily job duties and any activities which you are occasionally asked to perform at work: What positions can you work in with minimum physical effort and for how long? Prior to the injury were you capable of working on an equal basis with others your age? Yes No N/A Do you work with others who can help you with any heavy lifting? Yes No N/A While in recovery is there any light duty work you could request? Yes No N/A N/A Signatures Insured s Name Patient s Signature Spouse or Guardian Signature Date Date If any of your medical or account information has changes, please inform our front desk personnel. Remember You are ultimately responsible for your account. Doctor s Notes [Auto Accident Injury Report - Page 2]
10 NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS Motor Vehicle Accident Indemnification Corporation 110 WILLIAM STREET NEW YORK, N.Y NAME AND ADDRESS OF APPLICANT
11 APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS [Page 2]
12 APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS [Page 3]
13 Thomas E. Dow, D.C., P.C. 535 Broadhollow Road, Suite A-10 Melville, New York ATTORNEY LIEN To Attorney: I do hereby authorize Thomas E. Dow, D.C., P.C. (TEDDCPC), to furnish you, my attorney/insurance carrier with a full report of my case history, examination, diagnosis, treatment and prognosis in regard to my accident which occurred on (Date). I hereby authorize and direct you, my attorney, to pay directly to TEDDCPC such sums as may be due owing TEDDCPC for professional services rendered to me both by reason of this accident, and by reason of any other bills that are do his office. Such sums owed TEDDCPC are to be withheld from my settlement/judgment, or verdict as may be necessary to protect said doctor. I hereby further authorize the funds be paid to TEDDCPC immediately upon receipt by you my attorney, and that such funds owed TEDDCPC are not to be held in escrow for any reason to delay payment to TEDDCPC. You as my attorney will also not engage in any negotiation with TEDDCPC to lower the fees owed, when my settlement is obtained by you. I understand that TEDDCPC must be paid first prior to any fees being released to me or you my attorney. I further understand that I am directly and fully responsible to TEDDCPC for all professional bills submitted by TEDDCPC for services rendered to me and that this agreement is made solely for TEDDCPC s additional protection and in consideration of his awaiting payment. I further understand that such payment is not contingent on any settlement, judgment or verdict by which I may eventually recover said fee. Patient s Name: Patient s Signature: Date: The undersigned, being the attorney of record for the above patient, does hereby agree to observe all the terms of the above and agrees to withhold such sums from any settlement, judgment, or verdict as may be necessary to adequately protect TEDDCPC named above. Attorney s Name: Attorney s Signature: Date: Attorney: PLEASE DATE, SIGN AND RETURN ONE COPY TO TEDDCPC S OFFICE AT ONCE SO THAT WE MAY CONTINUE TREATING YOUR CLIENT.
4765 Carmel Mountain Rd. Ste 202, San Diego, CA 92130 Phone (848) 847-0055 Fax (858) 847-9944
4765 Carmel Mountain Rd. Ste 202, San Diego, CA 92130 Phone (848) 847-0055 Fax (858) 847-9944 Dear Patient, Your insurance may pay your total bill for services rendered by Pilates People Torrey Hills.
More informationHIPAA-ACKNOWLEDGEMENT OF RECEIPT Notice of Privacy Practices
PEDIATRIC ENDOCRINE ASSOCIATES, P.C. 8200 E. Belleview Avenue, Suite 510E Greenwood Village, CO 80111 303-783-3883 HIPAA-ACKNOWLEDGEMENT OF RECEIPT Notice of Privacy Practices Printed Patient Name: Patient
More informationWellness Consultation Policies. HIPAA Notice of Privacy Practices
Wellness Consultation Policies Cancellation Policy: There is a $50 charge for cancellations of less than 24 hours or failure to show up for a scheduled appointment. Email Policy: Email may be used for
More informationVirginia South Psychiatric & Family Services
All forms must be completed before seeing the Physician Information for Medical Records Patient s Name: Social Security #: Date of Birth: Sex: Male Female Marital Status: Single Married Divorced Widow
More informationGeneral Medical Questionnaire
JONATHAN S LYONS MD, THOMAS H YAU MD, LLC ROBERT P FRIEDLAENDER MD ARUSHA GUPTA MD EYE PHYSICIANS AND SURGEONS 8630 Fenton Street, Suite 514 Silver Spring MD 20910 PATIENT INFORMATION FORM (PLEASE CIRCLE)
More informationWELCOME TO TRI-COUNTY EYE CLINIC
WELCOME TO TRI-COUNTY EYE CLINIC Thank you for choosing Tri-County Eye Clinic as the provider for your eye care. You have an appointment at one of the following two locations: 15122 Dedeaux Road, Gulfport,
More informationPersonal Injury Questionnaire
Personal Injury Questionnaire Name Date of Birth Phone Do you want to be contacted via text: Name of cellphone carrier (ie: T-Mobile): Address City State Zip SSN: Weight & Height: Dominant hand: Employer
More informationTell Us About Your Child. Dental History. Medical History
Tell Us About Your Child Today s Date Social Security# Child s Name: Child s Birthdate: Last First MI Child s Age: Nickname Male Female School Grade Child s Home Address: Who may we thank for referring
More informationCell Phone / Best Number To Reach You: Your e-mail address: Race: C AA Asian Other. Copay: Copay:
DUS Family Medical Practice, LLC 7525 Greenway Center Drive, Suite # 105 Greenbelt, MD 20770 Phone: (301)313-0425 Fax: (301)313-0435 Patient s Last Name: First Name: MI: Address: City: State: Zip Code:
More informationPersonal Injury Intake Form
Personal Injury Intake Form Patient Information: Name Home Phone Address Work Phone Cell Phone Date of Birth Social Security # Sex Male Female Height Weight lbs Occupation Marital Status Employer No of
More informationPENNSYLVANIA PLASTIC SURGERY ASSOCIATES, P.C. Howard S. Caplan, M.D. Francine A. Cedrone, M.D. Account #
PENNSYLVANIA PLASTIC SURGERY ASSOCIATES, P.C. Howard S. Caplan, M.D. Francine A. Cedrone, M.D. Account # PATIENT INFORMATION QUESTIONNAIRE Patient Name Resp. Party/Spouse Address Address City, State, Zip
More informationNOVA Pain & Rehab Center Accident Forms. Patient Information
NOVA Pain & Rehab Center Accident Forms Patient Information Please provide all information requested. If you have any questions or need help, please call the office (703-535-8887) or see one of the staff
More informationHIPAA Notice of Privacy Practices
HIPAA Notice of Privacy Practices Hilton-Diminick Orthodontic Associates, P.C. This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
More informationNOTICE OF PRIVACY PRACTICES
NOTICE OF PRIVACY PRACTICES The Pain Treatment Center, Inc. d/b/a Stone Road Surgery Center THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS
More informationRiver Valley Therapy & Sports Medicine, Inc. Notice of Privacy Practices
River Valley Therapy & Sports Medicine, Inc. Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
More informationNorthwest Cardiology Associates 400 W. Northwest Hwy Barrington, IL 60010 847.382.4600 Fax 847.382.1771. HIPAA Notice of Privacy Practices ( Notice )
Northwest Cardiology Associates 400 W. Northwest Hwy Barrington, IL 60010 847.382.4600 Fax 847.382.1771 HIPAA Notice of Privacy Practices ( Notice ) THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY
More informationThe College of William and Mary Division of Sports Medicine. Notice of Privacy Practices
Notice of Privacy Practices 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. If you have any
More informationPersonal Injury Questionnaire
Welcome to Chiro Spa, we are looking forward to serving you to a lifetime of wellness. Personal Injury Questionnaire Name Nick Name: Email: Address City State Zip Best two (2) phone numbers to reach you
More informationInsurance (Let us make a copy of your insurance card and you can skip this section)
Today s Date: Name: What do you prefer to be called: Male / Female (please circle) Birth Date: Mailing Address: City: State: Zip: Home Phone: Cell Phone: Email: Referred By: Employer: How long employed:
More informationMohammad Djafari Pediatric. 15-17 Kennedy Parkway. Cortland, New York 13045. Notice of Privacy Practices
Mohammad Djafari Pediatric 15-17 Kennedy Parkway Cortland, New York 13045 Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOUR CHILD/CHILDREN MAY BE USED AND DISCLOSED AND
More informationPlease remember to bring these important things with you on your appointment date:
WELCOME! Diagnostic Professionals would like to take this opportunity to welcome you as a new or returning patient to our facility. Diagnostic procedures are not something that people look forward to doing.
More informationName: Sex: Male Female. Address: Apt#: Home #: ( ) Cell #: ( ) Other: ( ) DOB: Age: S.S. No. E-mail: Employer: Business # ( ) Occupation:
You deserve to be healthy. Life is a miracle and so are you. When you were created, you were given all the blue-prints, intelligence, tools, and systems to live an active healthy life. Unfortunately, your
More informationGONZABA MEDICAL GROUP PATIENT REGISTRATION FORM
GONZABA MEDICAL GROUP PATIENT REGISTRATION FORM DATE: CHART#: GUARANTOR INFORMATION LAST NAME: FIRST NAME: MI: ADDRESS: HOME PHONE: ADDRESS: CITY/STATE: ZIP CODE: **************************************************************************************
More informationADVANCED INTEGRATIVE REHABILITATION AND PAIN CENTER David P. Sniezek, DC, MD, MBA, FAAIM NOTICE OF PRIVACY PRACTICES
ADVANCED INTEGRATIVE REHABILITATION AND PAIN CENTER David P. Sniezek, DC, MD, MBA, FAAIM NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND
More informationHIPAA Omnibus Notice of Privacy Practices Effective Date: March 03, 2012 Revised on: July 1, 2015
HIPAA Omnibus Notice of Privacy Practices Effective Date: March 03, 2012 Revised on: July 1, 2015 Mobile Physician Group PC 231 High Street Suite 1, Mount Holly, NJ 08060 1-855-MPG-DOCS THIS NOTICE DESCRIBES
More informationLAS VEGAS PAIN INSTITUTE & MEDICAL CENTER, L.L.C.
LAST NAME: FIRST NAME: DOB: / / AGE: MARITAL STATUS: SEX: M F SSN: - - HOME#: CELL#: WORK#: STREET ADDRESS: CITY: STATE: ZIP: EMPLOYER NAME & ADDRESS: SPOUSE S NAME: DOB: / / SSN: - - WORK#: EMPLOYER NAME
More informationASSIGNMENT OF BENEFITS FOR DIRECT PAYMENT TO DOCTOR Private, Group, Accident and Health Insurance
ASSIGNMENT OF BENEFITS FOR DIRECT PAYMENT TO DOCTOR Private, Group, Accident and Health Insurance Accordance to legislation Bill HB1165-Bill 10-16-106.7, assignment of health insurance benefits Concerning
More informationUnderstanding Your Health Record Information
Associated Retina Consultant s, Ltd. Notice of Information Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
More informationAuto Accident Form. Occupation: #Hours per week currently working
Telephone: (360) 694-0300 Fax : (360) 694-0301 1610 C St. Ste. 103 Vancouver, WA 98663 www.vancouverspinalcare.com Auto Accident Form Name: DOB: Date: Address: City: State: Zip Code: Home Phone: Cell Phone:
More informationHIPAA Notice of Privacy Practices
HIPAA Notice of Privacy Practices 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. This Notice
More informationNotice of Privacy Practices
DERMATOLOGY CENTER of SOUTHERN INDIANA, P.c. David A. Byrne, M.D.. M. Kathleen McTigue, M.D.. Matthew C. Reeck, M.D. 1200 S. Rogers Street, Bloomington, IN 47403 Telephone 812-339-6434/1-800-834-5840/
More informationCAROLINA DENTAL Notice of Privacy Practices
CAROLINA DENTAL Notice of Privacy Practices 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.
More informationFLORIDA MEDICAL CLINIC, P.A. NOTICE OF PRIVACY PRACTICES
FLORIDA MEDICAL CLINIC, P.A. NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW
More informationPersonal Injury Office Policies Dixon Center for Integrative Health Care 211 Old Hickory Blvd. Nashville, TN 37221 (615) 646-1003
Personal Injury Office Policies Dixon Center for Integrative Health Care 211 Old Hickory Blvd. Nashville, TN 37221 (615) 646-1003 The following information outlines Dixon Center s policies on personal
More informationJerry M. Ruhl Ph.D. Clinical Psychologist (Texas #34359) 5200 Montrose Blvd. Houston, TX 77006
Jerry M. Ruhl Ph.D. Clinical Psychologist (Texas #34359) 5200 Montrose Blvd. Houston, TX 77006 CELL (937) 684-7746 PLEASE USE THIS NUMBER TO SCHEDULE OR CHANGE APPOINTMENTS INFORMED CONSENT FOR TREATMENT
More informationWorker s Compensation Intake Form
Worker s Compensation Intake Form Patient Information: Name Home Phone Address Work Phone Social Security No. Date of Birth Sex Male Female Height Weight lbs Occupation Marital Status Employer No of Children
More informationHISTORY OF PRESENT ILLNESS
d/b/a Guggino Eye Center 3115 W. Swann Ave., Tampa, FL 33609 (813) 879-7711 13904 N. Dale Mabry Hwy., Suite 200, Tampa, FL 33618 (813) 908-2020 3205 Physicians Way, Sebring, FL 33870 (863) 385-1544 HISTORY
More informationDr. Brett Haderlie, D.C. Patient Information (Please Print)
CONNECT CH I ROPRAC TIC Dr. Brett Haderlie, D.C. Patient Information (Please Print) Thank you for choosing our practice for your chiropractic needs. Name SS/HIC/Patient ID# Address City State Zip Birthdate
More informationPHENIX CITY SPINE & JOINT CENTER
PHENIX CITY SPINE & JOINT CENTER Name: Street Address: Please list ALL medications City: State: Zip: Home Phone: Cell #: Name Of Medication Dosage/ Strength Frequency Date Started Cell Phone Carrier: Race:
More informationPRIVACY NOTICE. In certain situations, we may also disclose patient information to another provider or health plan for their health care operations.
1 PRIVACY NOTICE 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. This Privacy Notice is being
More informationFamily First Chiropractic & Wellness Center 9430 Clairemont Mesa Blvd., Suite E San Diego, CA 92123
PATIENT NAME: DATE: ADDRESS: CITY: STATE/ZIP CODE: HOME PHONE NUMBER: CELL PHONE NUMBER: SOCIAL SECURITY NUMBER: DATE OF BIRTH: AGE: GENDER: EMERGENCY CONTACT NAME: EMERGENCY CONTACT PHONE NUMBER: EMPLOYER
More informationNOTICE OF PRIVACY PRACTICES Walter Chiropractic Clinic, 5219 Peters Creek Rd Ste 5, Roanoke VA 24019
Effective Date: 5/18/15 NOTICE OF PRIVACY PRACTICES Walter Chiropractic Clinic, 5219 Peters Creek Rd Ste 5, Roanoke VA 24019 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
More informationNotice of Privacy Practices
Notice of Privacy Practices 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. Carnegie Mellon
More informationBILLING 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,
More informationPsychological Services & Holistic Health, Inc.
Psychological Services & Holistic Health, Inc. 626 Wilshire Boulevard, Suite 910 3990 Westerly Place, Suite 160 Los Angeles, CA 90017 Newport Beach, CA 92660 Phone: (213) 622-0633 Fax: (213) 622-5633 NOTICE
More informationCoastal Radiology Associates
Coastal Radiology Associates Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review
More informationSpracklin Chiropractic Andrew Spracklin D.C.
Spracklin Chiropractic Andrew Spracklin D.C. PRIVACY NOTICE VERSION 1.2 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THAT INFORMATION.
More informationAPPLETREE PEDIATRICS, PA NOTICE OF PRIVACY PRACTICES
APPLETREE PEDIATRICS, PA NOTICE OF PRIVACY PRACTICES 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.
More informationPulmonary Associates of Richmond, Inc. Notice of Privacy Practices Page 1 of 6
Page 1 of 6 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. If you have any questions about
More informationPatient Name: Patient Signature:
HIPAA PRIVACY POLICY 3518 Riverside Dr. Suite 104, Upper Arlington, OH 43221 Name: Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed and how
More informationEXCEL PHYSICAL THERAPY, INC.
EXCEL PHYSICAL THERAPY, INC. Medical History Form Name: Date of Birth: Date: Are you employed? YES NO Right Handed Left Handed If NO, last day worked? Do you smoke? YES NO #of packs/day Occupation: Height:
More informationWELCOME 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
More informationIf physical therapy is being sought due to an accident, please indicate the and of the accident
2919 S. 120 th St. Omaha, NE 68144 Office Phone: (402) 504-3535 Cell Phone: (402) 630-9756 Fax: (402) 934-3866 OUTPATIENT THERAPY TREATMENT AGREEMENT If physical therapy is being sought due to an accident,
More informationJOINT NOTICE OF OUR HEALTH INFORMATION PRACTICES
JOINT NOTICE OF OUR HEALTH INFORMATION PRACTICES THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Jennings
More informationNorth Florida Medical Centers, Inc. Notice of Information Practices
North Florida Medical Centers, Inc. Notice of Information Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
More informationGary E. Lee, D.C. Chiropractic Physician 6216 South Redwood Road, Salt Lake City UT 84123 (801) 974-5555
Gary E. Lee, D.C. Chiropractic Physician 6216 South Redwood Road, Salt Lake City UT 84123 (801) 974-5555 General information: Name Today s date of Accident Time of Accident Marital status: r Married r
More informationDetailed Notice of Privacy Practices Effective Date: September 20, 2013
Detailed Notice of Privacy Practices Effective Date: September 20, 2013 Purpose of This Notice: This Notice describes your legal rights, advises you of our privacy practices, and lets you know how Butler
More informationNOTICE OF PRIVACY PRACTICES Allergy Treatment Center of New Jersey, P.C. Effective Date: April 14, 2003
Allergy Treatment Center of New Jersey, P.C. 388 Pompton Avenue 415 Avenel Street Cedar Grove, NJ 07009 Avenel, NJ 07001 (973) 857 9890 (732) 636-7030 NOTICE OF PRIVACY PRACTICES Allergy Treatment Center
More informationBallantyne Medical Associates, PLLC. REGISTRATION FORM (Please Print) PATIENT INFORMATION
Today s date: Ballantyne Medical Associates, PLLC. REGISTRATION FORM (Please Print) PCP: PATIENT INFORMATION Patient s last name: First: Middle:! Mr.! Miss Marital status (circle one)! Mrs.! Ms. Single
More informationHIPAA Notice of Privacy Practices HAND & MICROSURGERY ASSOCIATES, INC.
HIPAA Notice of Privacy Practices HAND & MICROSURGERY ASSOCIATES, INC. THIS NOTICE OF PRIVACY PRACTICES (THE NOTICE ) DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN
More informationSOUTHLAKE DERMATOLOGY 1170 N. Carroll Ave. Southlake, TX 76092 www.southlakedermatology.com Main 817-251-6500 Fax 817-442-0550
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. EFFECTIVE September 15, 2014 This Notice of
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 informationDr. Adam Apfelblat 5140 Highland Road Waterford 48327 Phone: (248)618-3467 Fax: (248)618-3515
Dr. Adam Apfelblat 5140 Highland Road Waterford 48327 HIPAA NOTICE OF PRIVACY PRACTICES PLEASE REVIEW THIS NOTICE CAREFULLY. IT DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW
More informationHIPAA NOTICE TO PATIENTS
HIPAA NOTICE TO PATIENTS 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. Federal regulations
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 informationPatient Signature: Printed Name: Date:
UTC Health and Rehab (UTCH) was established in 2006 for the purpose of treating patients under the Federal Worker s compensation guidelines through the Department of Labor, and Texas Worker s Compensation
More informationSarasota Personal Medicine 1250 S. Tamiami Trail, Suite 202 Sarasota, FL 34239 Phone 941.954.9990 Fax 941.954.9995
Sarasota Personal Medicine 1250 S. Tamiami Trail, Suite 202 Sarasota, FL 34239 Phone 941.954.9990 Fax 941.954.9995 NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY
More informationJoint Effort Rehab, LLC New Patient Forms
Patient Information DEMOGRAPHICS Joint Effort Rehab, LLC First Name: MI: Last Name: Sex: M F Home Phone: Work Phone: Cell Phone: SSN: of Birth: Email: Referring Physician: Employer Name: Primary Insurance
More informationOAHU SPINE & REHAB Patient Information Form
Date: OAHU SPINE & REHAB Patient Information Form Pt. Number: First Name Last Name Date of Birth / / Address City State Zip Home Ph ( ) Work Ph ( ) Age Email Social Security # - - Sex: M / F Driver s License
More informationNOTICE OF PRIVACY PRACTICES
THE PHYSICIAN PRACTICE, P.A. NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW
More informationReason(s) For Referral: Current medications:
1540 Sunday Drive Suite 200Raleigh, NC 27607 Office: 919-859-9040FAX: 919-859-9030 Name: Date Examined: Responsible Person: _ Birth Date: Address: Age: Sex: M F Marital Status: S M D W SSN: Home Phone:
More informationTo help us provide you the best possible care, please fill out the following information.
WELCOME TO OUR TREATMENT CENTER! To help us provide you the best possible care, please fill out the following information. Demographic Information: Name: DOB: Gender: M or F SSN: How long have you lived
More informationATLANTIS CHIROPRACTIC, INC.
ATLANTIS CHIROPRACTIC, INC. NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THAT INFORMATION PLEASE REVIEW THIS
More informationRichmond Gastroenterology Associates, Inc.
Richmond Gastroenterology Associates, Inc. Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFOMRATION.
More informationACE PHYSICAL THERAPY & SPORTS MEDICINE INSTITUTE PATIENT REGISTRATION
ACE PHYSICAL THERAPY & SPORTS MEDICINE INSTITUTE PATIENT REGISTRATION ALEXANDRIA FAIRFAX FALLS CHURCH LEESBURG HERNDON TYSONS CORNER PATIENT INFORMATION (Please Print Clearly) Name Last First Middle of
More informationUNITED CEREBRAL PALSY OF NORTHWEST MISSOURI NOTICE OF PRIVACY PRACTICES EFFECTIVE DATE: OCTOBER 22, 2014
UNITED CEREBRAL PALSY OF NORTHWEST MISSOURI NOTICE OF PRIVACY PRACTICES EFFECTIVE DATE: OCTOBER 22, 2014 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN
More informationVALPARAISO UNIVERSITY NOTICE OF PRIVACY PRACTICES. Health, Dental and Vision Benefits Health Care Reimbursement Account
VALPARAISO UNIVERSITY NOTICE OF PRIVACY PRACTICES 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.
More informationNotice of Privacy Practices. Human Resources Division Employees Benefits Section
Notice of Privacy Practices Human Resources Division Employees Benefits Section THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
More informationWe ask that you allow our office 24-48 hours to respond to telephone messages and callbacks.
NOTICE OF PRIVACY PRACTICE Associated Physicians Group This notice describes how your medical information may be disclosed and how you can get access to this information. Please review these policies carefully.
More informationINTEGRITY WELLNESS CENTER NOTICE OF PRIVACY PRACTICES
INTEGRITY WELLNESS CENTER NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YU CAN GET ACCESS TO THIS INFORMATION- PLEASE REVIEW IT CAREFULLY
More informationPatient or Guardian Signature
Co Payment Policy According to the regulations of individual insurance carriers, patients are responsible for paying co payments at the time of each office visit. PAYMENT POLICY FOR SERVICES RENDERED If
More informationNephrology 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
More informationPLEASE COMPLETE AND RETURN
PLEASE COMPLETE AND RETURN Voluntary Care Network Application Name of Client (Last) (First) (Middle Initial) Street Address Telephone (home) City State Zip Telephone (alternate) Date of Birth US Citizen
More informationNOTICE OF PRIVACY PRACTICES
DeLand Chiropractic and Spinal Decompression NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THAT INFORMATION
More informationPATIENT INFORMATION. Patients Last Name First MI. SSN: DOB Age Sex: M F. Address. City State Zip Code. Home Phone # Alt. Phone #
Boguslaw Gluszak, MD Date: PATIENT INFORMATION Patients Last Name First MI SSN: DOB Age Sex: M F Address City State Zip Code Home Phone # Alt. Phone # Parents/Guardians: N/A Name of Primary Insurance:
More informationIRVING & ASSOCIATES IN BEHAVIORAL HEALTH, P.C. 5151 Mochel Drive, Suite 307 Downers Grove, IL 60515
: / / Client Name: _ SSN: / / of Birth: Age: Sex: Male Female Address: City/State/Zip: Home Phone Number Is it okay to leave a message here? Y/N Work Number Is it okay to leave a message here? Y/N Cell
More informationPLLC NOTICE OF PRIVACY PRACTICES
PLLC 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 PRACTICES The following
More informationPrivacy Notice Document (HIPAA)
Privacy Notice Document (HIPAA) 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. This Privacy
More informationP.S. Please remember to bring your completed forms to your office visit!
Dear Patient: Please print the following forms and complete them as accurately as possible and bring them with you to your office visit. If you have any questions about the forms you can call my office
More informationPRIVACY POLICY (IN ACCORDANCE WITH HIPAA)
PRIVACY POLICY (IN ACCORDANCE WITH HIPAA) The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. This
More informationDALLAS ALLERGY & ASTHMA CENTER
DALLAS ALLERGY & ASTHMA CENTER Gary N. Gross, MD Michael E. Ruff, MD 5499 Glen Lakes Dr., Suite 100 Dallas, TX 75231 Dania A. Wierzbicki, MD Phone: (214) 691-1330 Jane Zepeda, PA-C FAX: (214) 691-6405
More informationAccident / Injury Report
Accident / Injury Report Name Date Date of birth Date of accident Time of accident am / pm. auto injury Were you: Driver Passenger Pedestrian Were you struck from: Behind Right Side Left Side Front Parked
More informationCARING HOSPICE SERVICES NOTICE OF PRIVACY PRACTICES
Original effective date: 2003 Effective date of last Revision: July 17, 2013 CARING HOSPICE SERVICES NOTICE OF PRIVACY PRACTICES Caring Hospice Services of Connecticut Caring Hospice Services of New York
More informationMotor Vehicle Accident Intake Form
2100 SE Lake Rd Ste 1 Milwaukie OR 97222 Motor Vehicle Accident Intake Form Today's Date: About You Name: Gender: Male Female Address: City: State: Zip: Home Number: Work Number: Other Number: Email Address:
More informationOUR LADY OF THE LAKE, HOSPITAL INC. AND OUR LADY OF THE LAKE PHYSICIAN GROUP, LLC NOTICE OF PRIVACY PRACTICES
OUR LADY OF THE LAKE, HOSPITAL INC. AND OUR LADY OF THE LAKE PHYSICIAN GROUP, LLC NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU
More informationFamily Chiropractic and Wellness Kristie Pszczola
Family Chiropractic and Wellness Kristie Pszczola, D.C. 104 Mirramont Lake Dr. Woodstock, GA 30189 Thank you for choosing Family Chiropractic and Wellness as your healthcare provider. We are committed
More informationIs 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.
More informationPERSONAL INJURY QUESTIONNAIRE
PERSONAL INJURY QUESTIONNAIRE NAME: PHONE: ( ) ADDRESS: CITY/STATE/ZIP: AGE: BIRTHDATE: SEX: SS # EMPLOYER'S NAME/ADDRESS: YOUR INSURANCE CO: POLICY #: AGENT'S NAME & PHONE: NAME ON POLICY (IF OTHER THAN
More informationRehabilitation, Sports & Spine Center, P.S. Notice of Privacy Practices. l. Use and Disclosures of Protected Health Information
Rehabilitation, Sports & Spine Center, P.S. Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
More informationHIPAA PRIVACY NOTICE PLEASE REVIEW IT CAREFULLY
HIPAA PRIVACY NOTICE THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. INTRODUCTION PLEASE REVIEW IT CAREFULLY Moriarty
More information