OFFICE POLICY. I, have read and understand the Financial Policy of Brandon Family Medical Care and agree to meet all financial obligations.
|
|
- Bethanie Walters
- 8 years ago
- Views:
Transcription
1 OFFICE POLIC The doctors and staff at Brandon Family Medical Care would like to welcome you to our Practice. Our goal is to provide excellent medical care and make your visits as convenient as possible. By signing below you confirm that you have read this policy and understand that: It is the patient s responsibility to inform the office of any address or telephone changes. The patient s account must be kept current. All self-pay or insurance co-payments, co-insurances and deductibles will be collected at the time of service. Payable by cash, check (with driver s license) or credit card. If the patient does not have their payment(s), the appointment will be rescheduled. Due to time allowed for each appointment patients may be asked to schedule another appointment for issues other than the reason of the original appointment. A returned check will result in a minimum service charge of $25.00 and checks will not be accepted for future payment(s). Unpaid returned checks will be turned over to the state attorney s office. There is a $50.00 minimum for all FMLA and Short Term Disability, and any medical report form. All other forms have a minimum charge of $ Payment due at time of service. Medical records copy fee $1.00 per page for copies up to 25 pages and $0.25 per page for copies of 26 pages and greater. Copy Service will handle all medical records request. A request for review of your medical record(s) requires an appointment with a minimum of seven-business days notice. Twenty-four hour notice must be given to reschedule or cancel appointment to avoid cancel/no show charge. If the proper notice is not given there is a charge of $20.00 for a (15) minute appointment, a $40.00 charge for a (30) minute appointment, and $30.00 for an urgent appointment. Saturday appointments are all urgent and any no show or cancellation will have a $30.00 charge. There is no phone service on Saturdays, answering service only. Prescription refills require a seven (7)-business day notice. No narcotics called in after hours by any on call physician. If you re insurance requires a referral it is your responsibility to get all information to the primary care doctor for processing within seven (7) business days. If the correct time is not allowed the patient may need to reschedule. Appointment is required to request a referral with a specialist. HEALTH INSURANCE COVERAGE Claims will be submitted, however we must emphasize that as medical providers, the relationship is with patients, NOT insurance companies. Although we attempts to verify benefits with insurance policies, please be advised this is only an estimate of the coverage based on the information given at the time of inquiry. It is the patient s responsibility to inform us of any changes in their insurance. Not all services are covered benefits with all insurance plans. It is the patient s responsibility to be aware of the service(s) provided, and their covered benefit(s) under the insurance policy. The patient is responsible for any non-covered charges not payable by the insurance policy. Although filing insurance claim(s) is a courtesy extended to the patient, all charges are always the patient s responsibility from the date services are rendered. Any unpaid balances older than 30 days may be subject to a 1.5% interest per month. If a patient s account is turned over to a collection agency, the patient will be responsible for any costs incurred in collection of the balance, which will include collection agency fees, court cost, and attorney fees. In the event that a patient does not meet their financial obligation, the patient will be discharged from the practice. I, have read and understand the Financial Policy of Brandon Family Medical Care and agree to meet all financial obligations. Print Name of Patient Patient/responsible party Date Signature Responsible Party Print Name Brandon Family Medical 1218 Millennium Parkway Brandon, FL (813) Brandon Family Medical Care Brandon 1218 Family Millennium Medical Parkway Care, P.A. 414 West Brandon, Robertson FL Street Brandon, (813) Florida (813)
2 PATIENT HISTOR FORM LAST NAME _ FIRST NAME: DOB: DATE Review of Systems (2 pages) Circle es or No. General Symptoms NOW PAST (Comments) Genitourinary NOW PAST (Comments) Weight change N N Change in stream N N Chills N N Nocturia (getting up at night) N N Sleep Disorder N N Urinary frequency > 8 times/day N N Eyes Double vision Glaucoma Cataracts N N N N N N Musculoskeletal Bone pain Muscle pain Joint pain N N N N N N Ear/Nose/Throat/Mouth Hearing changes Sore throat Sinus problem N N N N N N Skin Rash Lumps or bumps Moles, skin tags N N N N N N Cardiovascular Chest pain Irregular heartbeat Swelling in ankles N N N N N N Neurological Tremors Dizzy spells Numbness/tingling N N N N N N Psychologic Are you generally happy? N N Do you feel depressed? N N Do you feel anxious? N N Do you feel safe in your home? N N Endocrine Excessive thirst N N Too hot/cold N N Tired/sluggish N N Respiratory Wheezing Frequent cough Shortness of breath Gastrointestinal Abdominal pain Nausea/vomiting Indigestion/heartburn N N N N N N N N N N N N Hematologic/Lymphatic Swollen glands Blood clotting problem Bruising N N N N N N Sexual History Change in sex drive? Sexual performance satisfactory? (i.e. sexual trauma) N N Allergic/Immune Last Exams or Lab tests: Please enter date (mo/yr) Hay Fever N N Dental: Eye : Drug allergies N N Pelvic: _ PAP smear: Food N N Mammogram: Cholesterol: Colonoscopy:_ Stool Tested: Prostate _ PSA test: _ Living Will? es No Advanced Directive? es No Doctor s signature: ( Please Complete Side )
3 Medical Medical History None (High Blood Pressure, Diabetes, Cancer, Heart Disease, etc.) Surgical Pregnancy History ear Sex Complications None (Tonsillectomy, Appendectomy, Hysterectomy, Hernia, etc - Please enter year surgery was done if known) Allergies to medications? None (If es, please explain type of reaction, i.e. hives, wheezing, upset stomach, swelling, etc.) Last Immunizations: FLU / / PNEU // Tetanus / / // Current prescription medicines: None Name of drug mg dose # tablets # times per day Additional current prescription medicines: Name of drug mg dose # tablets # times per day Current Non-Prescription Medicine (Aspirin, Tylenol, Ibuprofen, Aleve, vitamins, anti-acids, herbals.) Family History Father: Living - Age: Deceased, Age at Death (Cause) Mother: Living - Age: Deceased, Age at Death (Cause) Siblings: Number Living Number deceased (Cause) List other illnesses in your family (Example - Diabetes, heart disease, colon, breast, or prostate cancer, arthritis, depression etc) ( Family Member) (Illness ) ( Family Member) (Illness) (Family Member) ( Illness) = = _= _ Social History Caffeine es No If yes, how much? Smoke? es No If yes, how much? # of packs/day _ # of years When did you stop smoking? Alcohol? es No If yes, how much? OCCUPATION. Retired Significant prior industrial or agricultural exposures? es No MARITAL STATUS MARRIED SINGLE DIVORCED WIDOWED NUMBER OF CHILDREN None Exercise regularly? es No If yes, what and how frequently?
4 BRANDON FAMIL MEDICAL CARE PATIENT INFORMATION PATIENT NAME MI LAST NAME ADDRESS (REQUIRED) CITSTATE ZIP HOME PHONE CELL PHONE WORK PHONE_ DATE OF BIRTH SEX SS# RACE (REQUIRED) DRIVERS LICENSE_ MARITAL STATUS_ (PHOTO ID REQUIRED) address Can we leave a message at home es No Can we leave a message at work es No (circle one) (circle one) GUARANTOR/SPOUSE/PARENT INFORMATION REQUIRED GUARANTOR/SPOUSE/PARENT NAME_ ADDRESS TELEPHONE NUMBERCELL PHONE POLIC HOLDER S INFORMATION REQUIRED POLIC HOLDERS NAME ADDRESS TELEPHONE NUMBER CELL PHONE SOCIAL SECURIT NUMBER DATE OF BIRTH_ EMPLOER NAME EMPLOER PHONE NUMBER EMPLOER ADDRESS PATIENT S RELATIONSHIP TO POLIC HOLDER (CIRCLE): SELF SPOUSE CHILD OTHER: INSURANCE COMPAN (INSURANCE CARD REQUIRED, PRESENT TO FRONT DESK) DO OU CURRENTL HAVE AN ADVANCE DIRECTIVE ES NO HOW DID OU HEAR OF US _ I AUTHORIZE BRANDON FAMIL MEDICAL CARE TO RELEASE AN MEDICAL INFORMATION NECESSAR TO PROCESS CLAIMS, COORDINATE CARE, REFERRALS, AND FOR QUALIT MANAGEMENT AND/OR UTILIZATION ACTIVITIES. I AUTHORIZE PAMENT OF MEDICAL BENEFITS TO BRANDON FAMIL MEDICAL CARE FOR SERVICE S RENDERED. SIGNATURE: DATE
5 Office Policy for FMLA and Short Term Disability Forms Completion of forms requires an office visit. A minimum charge of $50.00 per form is due at time of service. It is the patient s responsibility to bring in the correct forms at the time of visit. Appointment may be rescheduled if the correct paperwork in not available. Patient is required to provide a copy of his/her job description at time of service. All forms require a two week period before the dead line date. No exceptions. FMLA/Disability paperwork is not considered an emergency or urgent appointment. I, have read and understand the FMLA /Short Term form Policy of Brandon Family Medical Care. I understand that this policy cannot be altered and if I do not agree with the policy, I understand that I may find another physician to follow my care. Print name of patient Patient Signature Date Brandon Family Medical Care 1218 Millennium Parkway Brandon, FL (813) Amended 5/10/13
6 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION I hereby authorize_phone# Fax# and its entities, its officers or agents to permit inspection, copying and/or release of health information compiled in the ordinary course of business in connection with the following: Patient Name: Address: Date of Birth: _ Telephone: _ Social Security #: _ I further understand and acknowledge that in complying with my request for release, such disclosure will require Brandon Family Medical Care to disclose, as provided under applicable federal law, Protected Health Information, as defined in 42 C.F.R. 160 et seq. Information to be disclosed: Complete Health Record Discharge Summary History & Physical Exam Consultation Reports Progress notes Laboratory Tests (Please Specify) Radiology Reports Abstract/Pertinent Information Emergency Department Record I UNDERSTAND THIS MA INCLUDE INFORMATION RELATING TO THE FOLLOWING UNLESS EXPRESSL EXCLUDED B CHECKING THE BOX(ES) BELOW: Acquired Immunodeficiency Syndrome (AIDS) or infection with Human Immunodeficiency Virus (HIV) Psychiatric Care (behavioral Health) 1 Genetic Testing Treatment for Alcohol and/ or Drug Abuse 2 Sexually Transmitted Diseases (STDs) This information is to be disclosed to: I understand there may be a charge for copying my records as provided under federal and state law. I understand this authorization may be revoked in writing at any time, except to the extent that action has been taken in reliance on this authorization. Unless otherwise revoked in writing, this authorization will expire 60 dates from the date of execution. A photocopy or FAX of this document is valid as the original. The facility, its employees, officers and physicians are hereby released from any legal responsibility or liability for disclosures of the above information to the extent indicated and authorized herein: Signature of Patient or Legal Representative Date Witness: Date The patient information requested above may not be further disclosed to any party under any circumstances except with the patient's express written consent or as otherwise permitted by law. The information may not be used except for the need specified above. (form updated 2/11/10) 1 Except psychotherapy notes as provided under federal and state laws. 2 PROHIBITION ON REDISCLOSURE: This information has been disclosed from records whose confidentiality is protected by federal and state law. Federal Regulation (42 CFR Part2) prohibit the receiver of these records from making any further disclosure of this information except with the specific written consent of the person who it pertains. A general authorization for the release of medical or other information if held by another party is not sufficient for this purpose. Brandon Family Medical Care P.O. Box 2637 Brandon, FL Phone: (813) Fax: (813)
7 What can be charged for medical records pursuant to Florida Administrative Code? 64B Costs of Reproducing Medical Records (1) Any person licensed pursuant to Chapter 458, F.S., required to release copies of patient medical records may condition such release upon payment by the requesting party of the reasonable costs of reproducing the records. (2) For patients and government entities, the reasonable costs of reproducing copies of written or typed documents of reports shall not be more than the following: (a) For the first 25 pages, the cost shall be $1.00 per page. (b) For each page in excess of 25 pages, the cost shall be 25 cents. (3) For other entities, the reasonable costs of reproducing copies of written or typed documents or reports shall not be more than $1.00 per page. (4) Reasonable costs of reproducing x-rays, and such other special kinds of records shall be the actual costs. The phrase actual costs means the cost of the material and supplies used to duplicate the record, as well as the labor costs and overhead costs associated with such duplication.
8 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVAC PRACTICES & PERMISSION TO SHARE HEALTH INFORMATION I have read Brandon Family Medical Care Notice of Privacy Practices Act. I understand that I may have a copy upon request. Patient Name: Signature: DOB: _ Date: _ NOTIFICATION OF FAMIL AND FRIENDS I hereby authorize Brandon Family Medical Care to disclose my health information to the following person(s): 1) 2) 3) 4) Signature: RESTRICTIONS ON THE USE & DISCLOSURE OF OUR HEALTH INFORMATION As further described in the Brandon Family Medical Care Notice of Privacy Practice, I understand that I may request certain restrictions on the use and disclosure of my health information. I request the following restrictions. Brandon Family Medical Care is not required to agree to my requests. 1) 2) 3) Signature DATE: EXP DATE: OFFICE STAFF WITNESS:
9 Referral Process Agreement It is the responsibility of the patient to verify with his or her insurance company if the doctor or radiology center is In-Network with their insurance plan before scheduling an appointment. Once this information is confirmed by your insurance company, we will need the following information to move forward with obtaining your Authorization. Specialist Doctors Office's: Doctor Name Phone # Date & Time of Appointment Diagnosis & Procedure Codes (if this is a follow up appointment only) Radiology Centers: Facility Name & Location Phone # Date and time of Appointment Diagnosis (if ordered by another doctor's office only) Brandon Family Medical Care requires (7) Business Days to process your referral requests. If the above Required information and the allotted time of (7) days are not allowed, you may be required to reschedule your appointment with the specialist/radiology center. I have read and understand my responsibility to provide the required information needed to process my referral request. Any appointments scheduled will comply with the 7 day time frame needed to process the referral request. _ Patient Signature Printed Name DOB Date
Financial/Office Policy Brandon Family Medical Care, P.A. 414 West Robertson Street Brandon, Florida 33511 (813) 684-5255
Brandon B Family MEDICAL CARE Financial/Office Policy The doctors and staff at Brandon Family Medical Care would like to welcome you to our Practice. Our goal is to provide excellent medical care and make
More informationPatient Registration Form
PATIENT INFORMATION Patient Registration Form (Please Print) Dr. Miss Mr. Mrs. Ms. Sir Jr. Sr. Patient s Name (Last) (First) (MI) Previous Name Mailing Address City, State, ZIP (+4) Physical Address City,
More informationSouthwest General Surgical Associates General & Vascular Surgery 8230 Walnut Hill Lane Suite 408 Dallas, TX 75231 Phone-214)369-5432 Fax-214)369-5591
Southwest General Surgical Associates General & Vascular Surgery 8230 Walnut Hill Lane Suite 408 Dallas, TX 75231 Phone-214)369-5432 Fax-214)369-5591 Andres U. Katz, M.D. Richard S. Anderson, M.D. G. Thomas
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 informationPOINCIANA INTERNAL MEDICINE PA. Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address:
Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address: (Street) (City/State/Zip) Home Phone: ( ) E Mail Address: Would you be interested in
More informationSouthwestern Foot & Ankle Associates, P.C. 3880 Parkwood Blvd, Suite 602 Frisco, TX 75034 Phone: 972-335-9071 Fax: 972-335-8920 Dr. Thomas H.
Phone: 972-335-9071 Fax: 972-335-8920 Date: Home Phone ( ) Patient Information (Please Print) Email: Name: SS/Patient ID # Last Name First Name Middle Initial Address Cell Phone ( ) City State Zip Sex
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 informationPatient Demographics Sheet
Patient Demographics Sheet PLEASE PROVIDE YOUR PHARMACY INFORMATION BELOW: PREFERRED PHARMACY: PHARMACY LOCATION: PHARMACY PHONE NUMBER: FOR OFFICE USE ONLY Dr. Goldblatt Dr. Brown Last Name: First Name:
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 informationAssociates in Pediatric & Adult Urology, PA A division of Garden State Urology 282 Route 46 PO Box 1160 Denville, NJ 07834
Associates in Pediatric & Adult Urology, PA A division of Garden State Urology 282 Route 46 PO Box 1160 Denville, NJ 07834 Dear New Patient: Welcome to Associates in Pediatric and Adult Urology, PA, a
More informationCopayment Is Due At Time Of Visit. Self-pay (payment due at time of service)
REGISTRATION FORM Please present your insurance card and photo ID at time of check-in. Settlement of patient financial responsibility is expected at time of service. Copayment Is Due At Time Of Visit.
More informationPlease review, complete, and return all paperwork included in this packet. If you have any questions or concerns please feel free to contact us at
Your child has been referred to the Health4Life Program at Children's Healthcare of Atlanta. We are located at the Scottish Rite Campus in the Medical Office Building. In order to serve you and your child
More informationRoswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico 88201 (575)-622-2911 Fax: (575)-622-2598
Roswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico 88201 (575)-622-2911 Fax: (575)-622-2598 Patient Registration Form: (Please Print all Pertinent Information) Last
More informationHow To Get A Medical Checkup
NAFISA TEJPAR, M.D., F.A.C.S. 2501 N. Orange Ave, Ste 513 Orlando, FL 32804 (407) 894-1280 APPOINTMENT TIME: (Please be at the office 30 minutes before) Welcome to NAFISA TEJPAR, M.D. PA. We appreciate
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 informationWelcome to Eye Physicians & Surgeons, PC, Atlanta LASIK Center and Atlanta Eyewear
Welcome to Eye Physicians & Surgeons, PC, Atlanta LASIK Center and Atlanta Eyewear If you are a new patient to our practice and would like to complete new patient forms before you arrive, please print
More informationPATIENT INFORMATION FORM. Name: Address: City: State: Zip: Social Security Number: Telephone Numbers Home: Age: Sex: M / F Work: Email: Cell:
PATIENT INFORMATION FORM Name: Address: City: State: Zip: Social Security Number: Telephone Numbers DOB: Home: Age: Sex: M / F Work: Email: Cell: Marital Status: Single Married Spouse s Name: Widowed Divorced
More informationAssociated Ear, Nose & Throat Specialists, LLC. OCCUPATION: Employer: Work Phone: PHYSICIAN REQUESTING CONSULTATION: TOWN: PHONE:
Associated Ear, Nose & Throat Specialists, LLC Todd A. Zachs, M.D. Kevin C. Krebsbach, M.D Thomas Hinchey, Au.D., CCC-A Amanda Hessenauer, Au.D. Name: Birth date: SOCIAL SECURITY SEX: M F (IF MINOR) PARENT'S
More informationLAWRENCE J. FINKEL, M.D., P.C. 360 CHURCH STREET WARRENTON, VA 20186 (540) 347-2020 PHONE (540) 341-7980 FAX www.finkelderm.net
360 CHURCH STREET WARRENTON, VA 20186 (540) 347-2020 PHONE (540) 341-7980 FAX www.finkelderm.net Dear Patient: Welcome to our Practice. We have you scheduled for your first appointment at our office on
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 informationIMS Allergy & Immunology New Patient Registration Sheet. Personal Information
Personal Information Today s : Patient First Name: Initial: Last Name: DOB: Age: Social Security #: E-mail: Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: Gender: M F Language: ENGLISH
More informationWelcome to our office: New Patient Paperwork: Co-Pays and Deductibles: Insurance information: Prescription Refills: Medical Records Request:
9330 Poppy Dr. Suite 400 Dallas, TX. 75218 Phone: (469) 619-2897 Fax: (972) 412-7383 Welcome to our office: Thank you for choosing our practice and allowing us to take part in your medical care. It is
More informationPEDIATRIC MEDICAL HISTORY FORM
Patient s First and Last Name / / PEDIATRIC MEDICAL HISTORY FORM PRESENT HEALTH CONCERN (Reason for today s visit.) ALLERGIES List all allergies to medications, foods and/or other agents. Medication/Food/Other
More informationPATIENT REGISTRATION FORM
GENERAL INFORMATION PATIENT REGISTRATION FORM All forms must be completed and signed prior to treatment. Account #: Patient Name: Address: Home Phone No: Cell Phone No: First Middle Last Work Phone No:
More informationPatient Information. Name: Soc Security #: Date of Birth: Age: Male / Female. LOCAL Address: Street City State Zip. Phone: Home: Cell / Work:
Patient Information PERSONAL INFORMATION (Please Print Clearly) Name: Soc Security #: Date of Birth: Age: Male / Female LOCAL Address: Street City State Zip Phone: Home: Cell / Work: Email Address: Out
More informationPATIENT REGISTRATION
Evan Wolf, MD PhD Jacob Frank, OD PATIENT REGISTRATION Welcome to our office. In order to serve you properly, we will need the following information. (Please Print) Patient First Name Middle Initial Last
More informationLITTLE ELM MEDICAL CLINIC S PATIENT DEMOGRAPHIC INFORMATION
A-02 form.patient.demographic.information Rev. (01/14) DATE: SIGNATURE: PHYSICIAN (PLEASE PRINT) LITTLE ELM MEDICAL CLINIC S PATIENT DEMOGRAPHIC INFORMATION PATIENT'S FULL NAME ADDRESS APT. # CITY STATE
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 informationWestoaks Orthopaedic Associates
Westoaks Orthopaedic Associates Name: Address: Patient ID #: Sex: M [ ] F [ ] Date of Birth: Social Security #: City, State, Zip: Email: [ ] Home [ ] Work [ ] Mobile [ ] Married [ ] Single Referring Physician:
More informationPulmonary Associates of Richmond
Pulmonary Associates of Richmond Name: Address One: City: Home Phone#: Work Phone#: Cell Phone#: State: Zip: Sex: Social Security Number: Referring Doctor: of Birth: Employer: Primary Care Doctor: Employment
More informationTALLAHASSEE EYE CENTER
TALLAHASSEE EYE CENTER PATIENT INFORMATION Date: Name: Gender: M / F First MI Last Date of Birth: / / Address: City: State: ZIP: Phone Numbers: Home: Cellular: Work: E-Mail: SS#: - - What is the best way
More informationMEDICAL-SURGICAL EYE CARE, P.A.
MEDICAL-SURGICAL EYE CARE, P.A. DATE PATIENT'S NAME: ADDRESS: CITY/STATE/ZIP: DATE OF BIRTH: MARTIAL STATUS: M S D W HOME PHONE: ( ) SEX: M F AGE: CELLPHONE: ( ) IF CHILD; PARENT OR GUARDIAN NAME: EMERGENCY
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 informationDr. H. Lokesh M.D Dr. R. Desai M.D Tarah Savino MMS, P.A. C 4804 Rowan Road New Port Richey, FL 34653 (727) 375 5242 (727) 375 5198 Fax
Practice Policies for Patients It is important to read all the enclosed information carefully. Confirmation and Cancellation of Appointments: Our patients are very important to us. Missed appointments
More informationCLINIC APPLICATION. Client Information
ICNA Relief USA Shifa Free Medical Clinic 1092 Johnnie Dodds Boulevard, Suite 108 Mount Pleasant, SC 29464 Tel: (843) 352-4580 Fax: (843) 375-9063 Last Name Street Address City, State, Zip Code Home Phone
More informationAcknowledgement of Receipt of Notice of Privacy Practices
Acknowledgement of Receipt of Notice of Privacy Practices **You May Refuse to Sign This Acknowledgement** I,, have received a copy of this office s Notice of Privacy Practices. Signature For Office Use
More informationSignature: Date: Witness:
: Patient Relationship to Guarantor: of Birth: Sex: M F Social Security Number: Home Address: City: State: Zip Code: Home Telephone:( ) Referred By: Pharmacy of Choice: Pharmacy Address: Pharmacy Phone
More informationPATIENT INFORMATION INSURANCE INFORMATION
(mm/dd/yyyy): Have you been to Physicians Urgent Care before? Yes No Arrival Time: If yes, when? Is this a follow-up to a previous visit: Yes No PATIENT INFORMATION Patient s First Name: Middle Name: Last
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 informationRALEIGH NEUROSURGICAL CLINIC, INC.
Revised 09/26/14 PATIENT INFORMATION RALEIGH NEUROSURGICAL CLINIC, INC. Age: Sex: M F Date Last Name First Name Middle Initial Mailing Address City State Zip Social Security # Home Phone ( ) Cell Phone
More informationPersonal Injury Questionnaire
Personal Injury Questionnaire Patient Information Date Date of Birth Health Insurance Do you have a Flex Spending (FSA) or Health Savings (HSA) Account? Y N Patient Name First M Last What do you prefer
More informationLast Name First Name MI. Sex (circle): Male Female Date of Birth SS# Marital Status (circle): Married Single Divorced Widowed Separated
Patient Information Last Name First Name MI Sex (circle): Male Female Date of Birth SS# Marital Status (circle): Married Single Divorced Widowed Separated Race (circle): Black White Asian Other Ethnicity
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 informationWelcome to Denver Arthritis Clinic!
Welcome to Denver Arthritis Clinic! We would like to introduce your to our DAC ehealth Portal with the convenience of 24-hour-a-day access. DAC ehealth Portal is a unique personalized service that allows
More informationInsured Party Information (please complete if the insurance is not in your name)
Price M. Kloess, M.D. / Andrew J. Velazquez, M.D. / J. Randall Pitts, M.D. Holly Young, O.D./ Audrey Richards, O.D./ Brittany M. Mitchell, O.D. Patient Registration and Financial Agreement Patient s Dr
More informationHow to Remove a Social History Smoke?
AUSTIN RETINA ASSOCIATES PATIENT INFORMATION NAME: MAILING ADDRESS or NURSING HOME NAME & ADDRESS: Last First Middle Initial CITY: STATE: ZIP CODE: - TELEPHONE: HOME:( ) CELL: ( ) WORK:( ) DATE OF BIRTH:
More informationOrthopaedic Institute of Ohio Demographic Information Date:
Orthopaedic Institute of Ohio Demographic Information Date: Patient Name Home Phone Cell Phone Employer Phone Mailing Address (include PO Box and Apt. #) Family Doctor Name and Phone Number City, State,
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 informationWomen s Continence and Pelvic Health Center
Women s Continence and Pelvic Health Center Committed to Caring 580-590 Court Street Keene, New Hampshire 03431 (603) 354-5454 Ext. 6643 URINARY INCONTINENCE QUESTIONNAIRE The purpose of this questionnaire
More informationName Today's Date Sex. Street Address City State Zip Code. Home # Work # Cell # Would you like to receive text confirmations:
Patient Information 219 Old Hook Road Westwood, NJ 07675 Office: (201) 664-0847 Fax: (201) 664 8890 E-Mail: Mail@2020nj.com Thank you for choosing Valley Eye Associates for you eyecare needs. Please complete
More informationShelby Foot & Ankle 1. PATIENT INFORMATION 2. INSURANCE. 50505 Schoenherr Road, Suite 230 Shelby Township, MI 48315 (586) 580-3728 www.shelbyfoot.
: 1. PATIENT INFORMATION 2. INSURANCE SS/H/C/Patient ID#: Patient Last Name: Who is responsible for this account? Relationship to Patient: Insurance Co.: Patient First Name: Middle Int: Group #: Address:
More informationPersonal Contact and Insurance Information
Kenneth A. Holt, M.D. 3320 Executive Drive Tele: 919-877-1100 Building E, Suite 222 Fax: 919-877-8118 Raleigh, NC 27609 Personal Contact and Insurance Information Please fill out this form as completely
More informationWho to call for an emergency: Name: Relationship: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) -
4425 Ponce de Leon Blvd., Suite 115 Email:info@ Dr. Mercedes Gonzalez, Pediatric Dermatologist Patient Information: Patient Name: Social Security Number: / / Date of Birth: / / Sex: M / F (Circle one)
More informationNEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)
PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only) 1. What is the main problem that you are having? (If additional space is required, please use the back of this
More informationHealthy 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
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 informationPATIENT INFORMATION FILL OUT ALL ITEMS
PATIENT INFORMATION FILL OUT ALL ITEMS FAILURE TO COMPLETELY FILL OUT THIS FORM MAY RESULT IN YOU BEING BILLED IN FULL Patient Last Name: First: MI:. Address:. Date of Birth: Gender: M or F Marital Status:
More informationCommunity Internal Medicine of Athens 1500 Oglethorpe Avenue Suite 200D Athens, GA 30606 Phone: (706) 389-3875 Fax: (706) 389-3876
Please Fill Out Completely: Community Internal Medicine of Athens Phone: (706) 389-3875 Fax: (706) 389-3876 Patient s Last Name First Name MI Social Security Number Date of Birth Age Gender Race Marital
More informationPrinceton and Rutgers Neurology, P.A. A Center Of Excellence
DEMOGRAPHICS Patient s Last Name: First Name: Address: City: State: Zip Code: Tel # (Cell): Tel # (Home): Tel # (Work) #: Preferred Method Of Contact: [] Cell Phone [] Home Phone [] Work Phone SS #: /
More informationHow To Write A Medical History Questionnaire For An Aransas Plastic Surgery
Arkansas Plastic Surgery O David H. Bauer, M.D. O Gary E. Talbert, M.D. Appointment Date Patient Information INFORMATION FOR CASE HISTORY FILE Patient s Name: SS# First Middle Last Date of Birth: Patient
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 informationFAMILY CONTACT INFORMATION
FAMILY CONTACT INFORMATION -------------------- PLEASE COMPLETE THIS FORM IN BLACK INK ONLY -------------------- Date Account # Children Names DOB Gender School Goes By Cell Phone # Email Address Please
More informationYou are scheduled to see Dr. Kennard: at. On the day of your visit, he will be located at: (Directions are enclosed)
Your dermatologist has referred you for treatment of your skin condition. We would like to take this opportunity to welcome you and give you information that will make your appointment with us go smoothly.
More informationPATIENT INFORMATION. Office Location:
Date: PATIENT NAME (Last, First M.I.): PATIENT INFORMATION (Please complete all sections) Office Location: DATE OF BIRTH: / / NAME OF PARENT(S) OR GUARDIAN(S): SSN#: SEX: (_) Male (_) Female MARITAL STATUS:
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 informationAgnes Ju Chang, M.D., F.A.A.D.
Agnes Ju Chang, M.D., F.A.A.D. Dear Valued Patient: Thank you for choosing Integrated Dermatology of K Street, the office of board certified dermatologists, Dr. Agnes Ju Chang, Dr. David A. Lee, Allison
More informationIntegrated Medical Services (IMS) New Patient Registration Sheet
Personal Information Today s Date: Patient First Name: Initial: Last Name: DOB: Age: Social Security #: Email: Address: Street Apt # City/State/Zip Home Phone: Work Phone: Cell phone: Gender : M F Language:
More informationSt. Luke s MS Center New Patient Questionnaire. Name: Date: Birth date: Right or Left handed? Who is your Primary Doctor?
St. Luke s MS Center New Patient Questionnaire Name: Date: Birth date: Right or Left handed? Who is your Primary Doctor? Who referred you to the MS Center? List any other doctors you see: Reason you have
More informationOMNI DERMATOLOGY, INC. NEW PATIENT INFORMATION RECORD
OMNI DERMATOLOGY, INC. NEW PATIENT INFORMATION RECORD Name Last: First: MI: Social Security Number: Date of birth: / / Sex: M F Address: Street City State: Zip Code: Contact Numbers: Home Phone: ( ) -
More informationMedical History Form
MAIN SATELLITE 49 Veronica Avenue Suite 202 901 West Main Street Suite 203 Somerset, NJ 08873 Freehold, NJ 07728 P: 732 640 5316 P: 732 640 5327 F: 800 689 2361 F: 800 689 2361 128 Rehill Avenue Suite
More informationDallas Neurosurgical and Spine Associates, P.A Patient Health History
Dallas Neurosurgical and Spine Associates, P.A Patient Health History DOB: Date: Reason for your visit (Chief complaint): Past Medical History Please check corresponding box if you have ever had any of
More informationApplication For Admission To The Non-Surgical Spinal Decompression Program At The Spinal Decompression Center of Long Beach
Application For Admission To The Non-Surgical Spinal Decompression Program At The Spinal Decompression Center of Long Beach If you are reading this form, you have qualified for a consultation with Dr.
More informationNew Patient Registration Form
New Patient Registration Form PLEASE PRINT How did you learn about our practice? DATE Physician Relative Friend Website Phone book Newspaper Other Patient s Full Name Age Home Address City State Zip Home
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 informationTHE EYE INSTITUTE. Dear Patient:
THE EYE INSTITUTE Eye Associates of Wayne P.A. 968 Hamburg Turnpike Wayne, NJ 07470 p. 973-696-0300 f. 973-696-0464 Eye Institute North, LLC 5677 Berkshire Valley Rd. Oak Ridge, NJ 07438 p. 973-208-0600
More informationCARY ORTHOPAEDIC SPORTS/SPINE SPECIALISTS/PERFORMANCE PHYSICAL THERAPY NEW PATIENT INFORMATION RECORD
CARY ORTHOPAEDIC SPORTS/SPINE SPECIALISTS/PERFORMANCE PHYSICAL THERAPY NEW PATIENT INFORMATION RECORD DATE PATIENT INFORMATION OUR DOCTOR CHART NO. LAST NAME FIRST NAME MIDDLE INITIAL MAIDEN NAME Are you
More informationMountain View Natural Medicine PATIENT REGISTRATION FORM PATIENT INFORMATION
Mountain View Natural Medicine Lorilee Schoenbeck ND, PC Jessica Stadtmauer ND Dana Dabransky ND Sara Norris ND 185 Tilley Dr. Suite 51 S. Burlington, VT 05403 Phone: (802) 860-3366 Fax: (866) 440-8220
More informationPLEASE COMPLETE PRIOR TO VISIT***Place your name at the bottom of each sheet
PLEASE COMPLETE PRIOR TO VISIT***Place your name at the bottom of each sheet GASTROINTESTINAL ASSOCIATES, INC. PATIENT REGISTRATION Welcome to our practice. Please complete all sections of this registration
More informationBOWLING GREEN INTERNAL MEDICINE AND PEDIATRICS ASSOCIATES TREATMENT AUTHORIZATIONS AND FINANCIAL POLICIES
BOWLING GREEN INTERNAL MEDICINE AND PEDIATRICS ASSOCIATES TREATMENT AUTHORIZATIONS AND FINANCIAL POLICIES Patient Name: Date: FINANCIAL POLICY FOR PATIENTS Effective July 10, 2000 our office has established
More informationNorth Country Holistic Care Center PATIENT REGISTRATION FORM. Patient Information. Name: Address: City: State: Zip: Email
PATIENT REGISTRATION FORM Patient Information Name: Address: City: State: Zip: Telephone #: Home: Cell: Email Date of Birth: Age: Sex: M F Social Security #: - - Referred by: Employment Information Employer:
More informationCreekside Physical Therapy and Rehabilitation
Creekside Physical Therapy and Rehabilitation PATIENT INFORMATION Patient s Name: Social Security #: Age: Sex: M/ F Date of Birth: Email: Home Address: City: State: Zip: Telephone (Hm): Work: Mobile: Employer:
More informationWelcome! Thank you for choosing our practice for your eye care needs! Please fill out our new patient registration paperwork.
Welcome! Thank you for choosing our practice for your eye care needs! Please fill out our new patient registration paperwork. So we may eliminate any potential waiting time, please fax the completed forms
More informationThank you for making an appointment with our office. We look forward to serving your visual needs.
Dear New Patient, Thank you for making an appointment with our office. We look forward to serving your visual needs. Enclosed you will find our New Patient Questionnaires. Please complete these and fax
More informationDate 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
More informationPlease fill out forms, sign where needed and bring with you to your first visit. If you have any questions please call the office at 212-751-8300.
Welcome to Manhattan Sports Medicine and the office of Dr. Kyle Worell. Before we get started please see all forms below: Personal History (Intake) Informed Consent Payments HIPPA Please fill out forms,
More informationJAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557
FIGHTING PAIN. TOUCHING LIVES. JAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557 Personal Information Emergency Contact Today s Date: Name: Patient: Realtionship: Birth Date: Age: Sex:
More informationPATIENT REGISTRATION
PATIENT REGISTRATION Patient s Last Name: Patient s First Name: MI: Address: City, State Zip code: Patient s Date of Birth: Patient s Social Security: Best Number to contact: Secondary Number: Marital
More informationWorkman s Compensation
Workman s Compensation Name: Sex: Phone Number: Age: Address (Street/City/State/Zip) Name of Employer: Phone: Address of Employer (Street/City/State/Zip) Date and time of accident?: Where were you taken
More informationPatient Registration Form
PATIENT INFORMATION Patient Registration Form Date Patient Name (Last) (First) (Middle) Address City State Zip 911 Address (if different from above) Sex: M/F Birth date Age Social Security # Marital status:
More informationPatient Registration Please Print Patient Name Last First Middle
Patient Registration Please Print Patient Name Last First Middle Address City Zip Home Phone Work Ext Cell Birthdate - - Social Security # - - Gender Marital Status Employer Referred by_emergency Contact
More information1MFBTF GJMM PVU GPSNT BOE GBY 'PSNT XJMM CF TJHOFE BU ZPVS BQQPJOUNFOU
CELL PHONE: PATIENT HISTORY FORM - CONFIDENTIAL DATE: PATIENT: (LAST NAME) (FIRST NAME) (Ml) (NICKNAME) DOB: Primary Physician/ Family Doctor: Phone: Past Medical History (Click all that apply) High blood
More informationPATIENT/PARENT/GUARDIAN SIGNATURE
PATIENT REGISTRATION PATIENT S NAME: SEX MALE FEMALE DOB: SOCIAL SECURITY #: CITY/STATE/ZIP: PHONE # GUARANTOR INFORMATION (if responsible party is not the patient) MOTHER S NAME: DOB: SS#: CITY/STATE/ZIP:
More informationOrthopedic Specialists Of SW FL New Patient Information Form
Orthopedic Specialists Of SW FL New Patient Information Form Patient Name: DOB Age M or F SS# Home Ph# Cell Ph# Work# Local Address City/State Zip Code Northern/Other Address City/State Zip Code Reason
More informationNew Patient Registration Information
New Patient Registration Information Form 8026 5/09 3038 PR&C Dear WellSpan Orthopedics Patient: Welcome to WellSpan Orthopedics. Thank you for allowing us the opportunity to assist with your health care
More informationPATIENT DEMOGRAPHICS
PATIENT DEMOGRAPHICS Prefix: Patient's First Name: Preferred Name: M.I.: Last Name: Mailing Address: Apt: City: State: Zip Code: Social Security No. (necessary for billing): Guardian's Last Name (if patient
More informationWestern Center Eye Care 2720 Western Center Blvd Ste 316 Fort Worth, TX 76131
Today s Date Western Center Eye Care WELCOME TO OUR OFFICE Patient s Name (First, Middle, Last): Address: City: State: Zip Code: Email: Main Contact #: Alternate#: Date of Birth: / / Sex: Male Female Primary
More informationRegistration Forms (Please leave NO blanks, if something does not apply write N/A and if unknown write unknown)
Registration Forms (Please leave NO blanks, if something does not apply write N/A and if unknown write unknown) Patient Name: Date of Birth Mailing Address: City: State Zip: Apt/Ste/Unit/Bldg Primary Number:
More informationMedical Insurance and Vision Plans
Notice of Privacy Practices Methods of Payments No Insurance? No problem! Claremore Eye Associates offers a discount for all non- insurance patients for their vision exam. We also accept all major credit
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 informationRALPH R. GARRAMONE, MD, FACS (239) 482-1900
Information as of (enter today s date) (Please Print Legibly & Fill In or Correct All Fields) s Name Address First Middle Last Street & Apt # City State Zip Home Phone Cell Phone Other Phone Any restrictions
More information