ADVANCED GASTROENTEROLOGICAL ASSOCIATES M. Badar Anwer, M.D. Welcome To Our Practice!
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1 ADVANCED GASTROENTEROLOGICAL ASSOCIATES M. Badar Anwer, M.D. 210 E. Monument Ave, Suite A Kissimmee, FL Phone: Fax: W 410 Celebration Place, Suite 400 Celebration, FL Phone: Fax: Welcome To Our Practice! We are so glad that you chose our Practice for your medical needs. It is important to us that you have an experience while being a patient of ours that exceeds your expectations. We want you to be actively involved in your plan of care that you and Dr. Anwer will jointly discuss and develop. It is essential for you and our staff to be able to communicate with each other in an easy and effective manner. We want you to know that any question s you may have are very important to us and our goal is to be able to communicate with you regarding your questions on a timely basis. We, therefore, want to share with you the most effective way for you to communicate with Dr. Anwer and any member of the staff. We offer different ways for you to communicate with us so we can respond to your inquiries at our very earliest convenience. For scheduling your initial office visit with our Practice calling us directly at our Celebration or Kissimmee office was the best method. Now that your appointment has been scheduled with us if you have any further questions we recommend that you use one of our addresses. For questions related to your scheduled office visit only such as verifying or changing your appointment time, insurance coverage, etc. use address: Reception@anweraga.com. If you have been scheduled for surgery/procedure and have any questions related to your upcoming surgery/procedure use address: Backoffice@anweraga.com. Of course if you don t have access to , please do not hesitate to call us at either one of our offices: Celebration or Kissimmee If you only need directions to one of our offices you may call either office or press 5 for directions to the Kissimmee office and press 6 for directions to the Celebration office. Should you have any questions after your care with us has been completed you can use our address: Reception@anweraga.com or one of our telephone numbers. We look forward to meeting you when you come to our office for your scheduled office visit. We assure you that we will do everything to make your visit and experience as comfortable for you as we possibly can. Sincerely, Dr. Anwer and Staff
2 Advanced Gastroenterological Associates Gastroenterology, Hepatology, Therapeutic & Bilary Endoscopy Diagnostic & Interventional Endoscopic Ultrasound 210 E. Monument Ave., Suite A 410 Celebration Place, Suite #400 Kissimmee, FL Celebration, FL Phone Fax Phone Fax reception@anweraga.com Website: dranwer.com Name: DOB: Sex: Race: SSN: Marital Status: Age: Address: City: State: Zip Code: Home Phone: Work Phone: Cell Phone: Employer: Occupation: Name of Referring Physician: Emergency Contact Information Name: Relationship: Home Phone: Work Phone: Cell Phone: Insurance Information Insurance Carrier: Phone: Address: Policy ID Number: Group Number: Insured Name: DOB: SSN: Relationship to Insured: Signature: Date:
3 210 E. Monument Ave, Suite A Kissimmee, FL Phone: Fax: ADVANCED GASTROENTEROLOGICAL ASSOCIATES M. Badar Anwer, M.D. Medical Consent I,, hereby authorize Advanced Gastroenterological Associates to use and/or disclose my health information which specifically identifies me or which can reasonably be used to identify me to carry out treatment, payment and health care operations. I understand that while this consent is voluntary, if I refuse to sign this consent Advanced Gastroenterological Associates can refuse to treat me. I have received a copy of the Notice of Privacy Standards ( Notice ) which more fully describes the Uses and Disclosures that can be made of individually identifiable health information for treatment, payment and health care operations. I fully understand my rights to the Privacy Practice. I understand that if I wish a copy of this Notice, I have the right to request one. I understand that I may revoke this consent at any time by notifying Advanced Gastroenterological Associates in writing, but if I revoke my consent, such revocation will not affect any actions that Advanced Gastroenterological Associates took before receiving my revocation. I understand that Advanced Gastroenterological Associates has reserved the right to change his/her Privacy Practices and that I can obtain such changed notice upon request. I understand that I have the right to request that Advanced Gastroenterological Associates restricts how my individually identifiable health information is used and/or disclosed to carry out treatment, payment or health care operations. I understand that Advanced Gastroenterological Associate does not have to agree to such restrictions, but that once such restrictions are agreed to, Advanced Gastroenterological Associates must adhere to such restrictions. I hereby authorize Advanced Gastroenterological Associates to release any medical, financial or incidental information that may be necessary for either medical care or in processing applications for financial benefits. I hereby grant permission to Advanced Gastroenterological Associates or its representatives to leave messages about my health care status to myself by phone calls, voic s, answering machines, or address provided. I also hereby grant permission to Advanced Gastroenterological Associates to leave messages about my healthcare status to referring providers and authorized person via phone calls, voic , answering machines, and address. I hereby authorize Advanced Gastroenterological Associates to use the clinical information about me for research and academic purposes. A photocopy of this document shall be valid as the original. At any point during the patient-doctor relation, the patient has the right to seek a second medical opinion. Medical science is a rapidly growing and changing field: recommendations may vary from time to time. 410 Celebration Place, Suite 400 Celebration, FL Phone: Fax: reception@anweraga.com Signature of Patient Or Patient s Representative: Date: Printed Name Of Patient Or Patient s Representative: Relationship to Patient:
4 210 E. Monument Ave. Ste. A Kissimmee, Fl Ph Fax reception@anweraga.com Website: ADVANCED GASTROENTEROLOGICAL ASSOCIATES M. Badar Anwer, M.D. Financial Policy & Consent 410 Celebration Place, Suite 400 Celebration, FL Phone: Fax: We are dedicated to providing the best possible care for you, and we want you to completely understand our financial policies. 1. Payment is due at the time of service unless arrangements have been made in advance with the Practice. We accept the following types of payment: cash, check, debit/credit card (Visa, MasterCard and Discovery). 2. We have made prior arrangements with most insurance companies and health plans to accept an assignment of benefits. Therefore you are authorizing direct payment of medical/surgical benefits to Advanced Gastroenterological Associates for all services rendered by the physician or under his supervision. We will bill your insurance carrier but you are required to pay applicable, deductibles copayments, or coinsurances prior to services being rendered. You will also be responsible for any balance not covered by your insurance. 3. In most cases a written referral or prior authorization is required from the physician making your referral to our Practice. This is required by your insurance carrier in order for us to properly process your claim. It is your responsibility to provide us with this written information. If we haven t received this information in our Office prior to your scheduled appointment we may need to reschedule your appointment and a cancellation fee may be assessed. 4. If you are having a procedure our normal policy will be for you to pay a deposit toward your out of pocket expenses required by your Health Plan and prior to services being rendered. 5. If you choose to pay your bill out of pocket meaning, you are a self-pay patient, you will need to provide payment in full prior to services being rendered. 6. If you are insured by a health plan that we are not contracted with you have two options: 1) We will prepare and send the claim for you on an unassigned basis, or 2) We will provide you with a claim so you can bill your Health Plan. With either option payment for your care is due in full prior to services being rendered. 7. Your insurance policy basically is a contract between you and your insurance company and as a service to you, we will file your insurance claim if you assign the benefits to the doctor meaning you are authorizing your insurance company to pay the doctor directly. If your insurance company does not pay the Practice within a reasonable period, we will have to look to you for payment. If we later receive payment from your insurance company, we will refund any overpayment to you. 8. Not all insurance carriers or health plans cover all services. In the event of your Health Plan determines a service to be no covered, you will be responsible for the complete charge. Payment in full is due upon receipt of a statement from our Office. 9. If you miss a scheduled appointment the Practice and other patients needing an appointment are affected. Therefore, please, provide us with a minimum of 24 hour advance notice if you are unable to keep your appointment. If you fail to provide us with this notice you will be charged a $25 no show fee.
5 10. During the course of your treatment you may be rendered services by other providers requested by the doctor and therefore you will receive a bill directly from these providers. Some of those providers may be: Celebration Surgery Center, pathology laboratory, radiologist, anesthesiologist, hospital, other physician consultants/specialists, etc. 11. There will be a $35 fee assessed for insufficient funds if you pay by check. 12. There will be a fee of $15-$25 for completing a medical form, disability, work restriction, etc. and a notice of 5 to 7 business days is required. 13. We will send copies of your medical records directly to your Primary Care physician at no cost. If you want a personal copy, or copies sent to other physicians there will be a fee of $1 per page up to 25 pages, and 25 cents for all additional pages. We will need a notice of 5 to 7 business days. Regulations also require that we obtain a signed written request from the patient or patient sign consent at the Office. 14. It is your responsibility to provide us with accurate demographic and insurance coverage information. If we are unable to make contact with your insurance company it becomes your responsibility to obtain and then provide us with correct information. It is also your responsibility to notify our Office to update this information for the future. 15. Please be advised that Dr. M. Badar Anwer has financial interest in Celebration Surgery Center, LLC. As such, it is necessary that we disclose the following information to you: You have the right to use a healthcare facility other than Celebration Surgery Center, LLC if you choose. You will not be treated differently by your physician if you choose a healthcare facility other than Celebration Surgery Center, LLC. If you have any questions concerning this notice, please feel free to ask for additional information from your physician or any representative of Dr. M. Badar Anwer. If you are uncomfortable with your physician s relationship with Celebration Surgery Center, LLC and prefer to have your surgery perform elsewhere, we will be happy to honor your request. Please do not hesitate to tell us if you wish to have your surgery performed at a healthcare facility other than Celebration Surgery Center, LLC. By signing this Disclosure of Physician Ownership Form, I acknowledge that I have read the foregoing and I hereby select Celebration Surgery Center, LLC to provide those ambulatory surgery and related services prescribed by my physician. I have read and understand the Financial Policy & Consent and I agree to be bound by its terms. I also understand and agree that such terms may be amended by the Practice. Signature of patient (or responsible party) Date Please print the name of the patient
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PLEASE REMEMBER THAT REGARDLESS OF INSURANCE COVERAGE, YOU ARE RESPONSIBLE FOR YOUR BILL.
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REHAB XCEL, LLC. NEW PATIENT INFORMATION DATE: NAME: LAST: FIRST: MID: MAIL ADDRESS: HOME PHONE: CELL PHONE: WORK PHONE: DATE OF BIRTH: SS# SEX: M OR F EMERGENCY CONTACT: PHONE: MARITAL STATUS: M OR S
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PATIENT REGISTRATION Date: PLEASE PRESENT YOUR DRIVER S LICENSE AND INSURANCE CARDS TO RECEPTION DESK. INSURANCE CO-PAYMENTS ARE EXPECTED BEFORE SERVICES ARE RENDERED. PAYMENT IN FULL IS EXPECTED WHEN
Dr. Wilbur Kuo & Associates Internal Medicine Patient Information
Patient Information Today s : Name of Patient: of Birth: Sex: M F Social Security Number: Marital status: single married, spouse s name: Name and ages of children: Street Address:_ City: State: Zip: Preferred
Airport Way Dental Care
Airport Way Dental Care A Family Dental Practice Committed to Wellness Welcome to our dental office! Our goal and commitment is to provide our patients with the highest quality dental care through education,
WELCOME TO PCCMA. We look forward to being of service to you and helping you to be healthier in the future.
Phone: 717-234-2561 Franklyn J. Myers, III, M.D., F.C.C.P. Alexis B. Aaronson, M.S.N, C.R.N.P. Michele M. Knepper, C.R.N.P. WELCOME TO PCCMA Welcome to our practice. We are specialists in the treatment
PATIENT REGISTRATION FORM
201 N. Park Ave Suite 201 Apopka, FL 32703 Office (407)228-3180 Fax: (407)-228-3725 PATIENT REGISTRATION FORM Last Name: First Name: Middle Initial Male Female Date of Birth: Marital Status: Single Married
105 W. Stone Drive, Suite 2B Kingsport, TN 37660 Telephone 423.247.7500 Facsimile 423.247.7556
105 W. Stone Drive, Suite 2B Kingsport, TN 37660 Telephone 423.247.7500 Facsimile 423.247.7556 Scott Fowler, MD, FACOOG Chad Jarjoura, MD, FACOG Renda Knapp, MD, FACOG Christopher Mitchell, MD, FACOG Daphne
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.
Garland s Christian Counseling Center
Garland s Christian Counseling Center : PERSONAL DATA Name: Email: Home Phone: Address: Cell Phone: Work Phone: (Street, City, Zip Code) DL #, ST & Exp : SS#: DOB: Sex: Please circle where we may leave
PRO SPORTS THERAPY, INC. (P.S.T.)
Dear Patient, Thank you for choosing Pro Sports Therapy. Enclosed is the paperwork that you will need to complete and bring with you for your physical therapy evaluation. Please arrive at least 15 minutes
Patient Demographic Form
Patient Demographic Form Today s Date This document is part of your permanent record. By law, we are required to collect the following information from every patient treated in our facility. Please assist
Healthy Living Clinic, LLC Phone:(321) 549-2273/ FAX:(321) 549-2066
IDENTIFYING INFORMATION Patient Enrollment Form PATIENT NAME: SEX: MALE FEMALE DOB: / / SS# -- -- MO DAY YEAR CONTACT HOME PHONE: EMAIL: WORK PHONE: Preferred method of communication Email Mail Home Phone
Personal 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
Physical Therapy Services Medical History Form
Physical Therapy Services Medical History Form Last Name First Name DOB Age Diagnosis: Physician: Check Yes or No. If yes, please explain in the space provided. Yes No Are you pregnant? Yes No Currently
Nephrology Consultants of Georgia, P.C.
New Patient O (Check One) Established Patient O Name: (Last) _ (First) (MI) Address: City State Zip D.O.B. SSNO Email Address Ethnicity: O Hispanic or Latino O Not Hispanic or Latino O Patient Refused
For all treatment, we will be asking for payment of the portion of fees not covered by insurance at the time of your procedure.
FINANCIAL POLICY For all treatment, we will be asking for payment of the portion of fees not covered by insurance at the time of your procedure. METHODS OF PAYMENT Acceptable methods of payment are cash,
Welcome 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:
Saratoga Cardiology Associates, PC 6 Care Lane Saratoga Springs, NY 12866 Phone: (518) 587-7625 Fax: (518) 587-0273
Patient Name: DOB: Soc Sec#: Thank you for choosing Saratoga Cardiology for your cardiac care. We would like to welcome you to our practice. Please complete the attached form for our records and bring
Street Address Apt. or Post Office Box. City State Zip. Telephone Primary: ( ) Home Work Cell. Date of Birth / / Social Security # - -
Appointment Information Date: Time: Physician: Patient Information Name: First MI Last Street Address Apt. or Post Office Box City State Zip Telephone Primary: ( ) Home Work Cell Work: ( ) Cell: ( ) Date
New/Updated Patient Information
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Your appointment is scheduled for at with Dr. Your arrival time is.
Dear : We appreciate your selection of our office for your complete eye care. Your appointment is scheduled for at with Dr. Your arrival time is. First visits usually take approximately one and a half
THINK PHYSICAL THERAPY PATIENT INFORMATION Please present your insurance card(s) for copying. Patient Name: Sex: Date of Birth: Age:
THINK PHYSICAL THERAPY PATIENT INFORMATION Please present your insurance card(s) for copying. Patient Name: Sex: Date of Birth: Age: Social Security Number: Employment Status: Marital Status: Emp Unemp
Faculty Group Practice Patient Demographic Form
Name (Last, First, MI) Faculty Group Practice Patient Demographic Form Today s Patient Information Street Address City State Zip Home Phone SSN of Birth Gender Male Female Work Phone Cell Phone Marital
PATIENT 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:
PATIENT FINANCIAL POLICIES Effective Date: June 1, 2015
Cardiovascular Specialists of Central Maryland A Community Specialty Practice of Johns Hopkins Medicine 10710 Charter Drive, Suite 400 Columbia MD 21044 PATIENT FINANCIAL POLICIES Effective Date: June
Community Health Programs Patient Registration. Last Name: First Name: Preferred Name: Zip Code: City: State:
Community Health Programs Patient Registration Last Name: First Name: Preferred Name: Middle Initial: Suffix: Former Last Name: Gender: Male Female Date of Birth: / / Social Security Number: Mailing Address: