OFFICE POLICIES AND PROCEDURES

Size: px
Start display at page:

Download "OFFICE POLICIES AND PROCEDURES"

Transcription

1

2

3

4

5 David Fivenson, MD, Dermatology, PLLC 3001 Miller Road, Ann Arbor, MI Phone: Fax: OFFICE POLICIES AND PROCEDURES Thank you for choosing our office for your medical dermatology needs. If we can improve our service, please let us know. Office hours -Our office will be open M-F from 8:00am to 5:00pm, with appointments scheduled from 8am to 4:15pm. -When our office is closed during a regular workday, the answering service will give instructions on leaving a message or who to call with questions. -We will try to be available to help you with any questions that might arise related to your skin conditions, and will try to have a live person answer every phone call. is a very efficient way to communicate with us and we encourage this way to get your questions answered (if a personal call is not needed). Appointments NO-SHOW/CANCELLATION POLICY -It is our policy to encourage patients to arrive and receive care at their scheduled arrival time, or to give appropriate notice of cancellation to allow other patients to receive timely care. -If you are unable to make your scheduled arrival time, we request that you notify us as soon as possible, but no later than 24 hours prior to your scheduled arrival time. Additionally, we request that you arrive at your scheduled arrival time. -By either not providing 24 hour notice or arriving late, you may be assessed a $50.00 fee for a missed office visit. If three (3) or more appointments are missed, our office reserves the right to terminate our relationship with you. It is not our intent to assess an additional financial burden, but it is costly if you miss your appointment and do not give us time to schedule another patient in your time slot. -Minor children (age 17 and younger) must be accompanied by their parent or legal guardian. Prescription Refills We require 48 hours notice for all prescription renewals For mail-in prescriptions, be sure to allow time for insurance verification/authorizations -We will fill prescriptions for topical medications (at our discretion) up to one (1) year after the last office visit and internal medications (at our discretion) up to six (6) months after the last office visit. -To refill a prescription, we will need the following information for each prescription you are requesting: Your full (legal) name, Date of birth Name of the drug, medication vehicle (i.e. cream, lotion, solution, gel or ointment and the size or number of tablets previously prescribed. Strength How often it is taken Pharmacy name, location and phone number be specific Daytime phone number and an alternative number where you can be reached, your daytime phone number, the pharmacy name and phone number, your type of insurance, the medication name, dose previously prescribed, the medication vehicle (i.e. cream, lotion, solution, gel or ointment and the size or number of tablets previously prescribed. -Please feel free to leave this information on our answering machine or it to us. Please allow up to three days for prescription refills to be processed. Continued on back

6 David Fivenson, MD, Dermatology, PLLC 3001 Miller Road, Ann Arbor, MI Phone: Fax: Laboratory Studies -We send most biopsy specimens and blood work to St. Joseph Mercy Hospital in Ann Arbor. -It is your responsibility to inform us if your insurance requires use of a different laboratory for lab/ pathology services. Please be aware that these services are billed separately from our office fees. -We are happy to notify patients by mail or telephone of any or all laboratory results. If you have not heard from us in 2 weeks please call and leave us a message. If you would like your results left as a phone message or sent by , please authorize this below. Billing -Payment is due at the time of service, unless Dr. Fivenson participates with your insurance. All co-pays are due at the time of service. We accept cash, check, MasterCard or Visa. Please ask prior to your appointment if you have any other concerns regarding our fees. -Patient statements will be mailed monthly by our billing service and prompt payment of remaining balances is appreciated. -There will be a $50 service charge for any check returned to us from the bank. -Balances of greater than 60 days past due will be subject to a 2 % monthly fee. Remember many of these insurance companies are HMO s and require a referral to see a specialist. Verify this with your individual plan to see if a referral is required and be sure to bring it with you to your appointment. If a referral is necessary and you have not requested one from your primary care physician, you will be responsible for paying for your visit in full. Privacy Statement We respect that your personal information is private and will only exchange such information with those parties whom we have your permission to and only as part of your health care in Dr. Fivenson s practice. Confidential health care information is only released with your permission to other health care providers. Your health care information may also be shared with your insurance company to allow us to collect for Dr. Fivenson s services. Details of our HIPAA Policy are available for your review. PLEASE SIGN BELOW I give my consent for treatment: Signed Date Print Name: I understand the above policies and have been advised of and offered to review the practices HIPAA Privacy policies. (Initial) I have read the above and consent to phone messages or notification of laboratory results. (Initial) I hereby give my consent to Dr. Fivenson to access and download my medication history electronically into my chart. (Initial) I hereby give my consent to Dr. Fivenson to have results of any procedures or blood work from St. Joseph Hospital clinical laboratory be sent electronically through Lifepointe (an HL7 partner interface) into my chart. (Initial)

7

Brain & Spine Center of Texas, L.L.P. Dallas Minimally Invasive Spine

Brain & Spine Center of Texas, L.L.P. Dallas Minimally Invasive Spine Please print clearly so that we can process your information quickly and efficiently. Thank you! Name (First, M.I., Last) Date of Birth Social Security # Male / Female Race Ethnicity (Latino / Non Latino)

More information

AUBURN MEMORIAL MEDICAL SERVICES, P.C.

AUBURN MEMORIAL MEDICAL SERVICES, P.C. AUBURN MEMORIAL MEDICAL SERVICES, P.C. Office Policies We would like to thank you for choosing as your medical provider. We have written this policy to keep you informed of our current office policies.

More information

Patient Financial Policies

Patient Financial Policies Patient Financial Policies Diabetes & Internal Medicine Associates, PLLC 2302 E. Terry St., Pocatello, ID 82301 208-235-5910 Fax 208-235-5920 Thank you for choosing Diabetes & Internal Medicine Associates,

More information

Putnam North Family Medical Center An Affiliate of Advance Pain Management of Oklahoma

Putnam North Family Medical Center An Affiliate of Advance Pain Management of Oklahoma PATIENT INFORMATION AND PRACTICE POLICIES The Putnam North Family Medical Center's commitment to maintaining a broad knowledge and skill base enables your family to benefit from comprehensive and convenient

More information

Athens Neuro & Balance Rehabilitation

Athens Neuro & Balance Rehabilitation Acknowledgement of Receipt Of Notice of Privacy Practices Patient Name & Address: I have a received a copy of the Notice of Privacy Practices for the above named practice. Signature For Office Use Only

More information

Office Policies Dear Patient: We would like to take the opportunity to explain the policies of our office. Please take notice of the following:

Office Policies Dear Patient: We would like to take the opportunity to explain the policies of our office. Please take notice of the following: Office Policies Dear Patient: We would like to take the opportunity to explain the policies of our office. Please take notice of the following: Please contact our answering service after hours for EMERGENCY

More information

PATIENT REGISTRATION Date:

PATIENT REGISTRATION Date: 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

More information

PATIENT REGISTRATION (Please Print) Social Security # Address City State Zip. Address

PATIENT REGISTRATION (Please Print) Social Security # Address City State Zip.  Address PATIENT REGISTRATION (Please Print) Date Name (Last) (First) (MI) Clinician Social Security # Address City State Zip Email Address Home Phone ( ) Mobile/Alt. Phone ( ) Work Phone ( ) PLEASE IDENTIFY WHICH

More information

All routine calls will be be returned within 24 24 hours, in in the order in in which they were received.

All routine calls will be be returned within 24 24 hours, in in the order in in which they were received. Office Policies We would like to to take the opportunity to to explain the policies of of our office. Please take notice of of include fever, changes with r surgical incision or or increased pain, NO medication

More information

PATIENT REGISTRATION FORM

PATIENT REGISTRATION FORM Phone: 831-708-2919 Fax: 831-708-2937 PATIENT REGISTRATION FORM Who may we thank for referring you to us? Name (First, Mid Int. Last) Address City State Zip Code Home Phone w/ area code Email Cell Phone

More information

Nova Medical & Urgent Care Center, Inc Financial Policy

Nova Medical & Urgent Care Center, Inc Financial Policy Welcome and thank you for choosing Nova Medical & Urgent Care Center, Inc (hereafter referred to as Nova ) for your medical care. We are committed to providing you with the highest quality medical care

More information

OFFICE POLICIES. Please note that NO controlled substance requests can be filled via phone as per DEA regulations. (initial)

OFFICE POLICIES. Please note that NO controlled substance requests can be filled via phone as per DEA regulations. (initial) OFFICE POLICIES Thank you for choosing Spencer Dermatology and Skin Surgery Center for your health care needs. We recognize that you have a choice in health care providers and we appreciate the trust that

More information

Dr. 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

Dr. 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 information

Pediatric Ophthalmology Date: PLEASE PRINT: PATIENT NAME: Male: Female: AGE: First Middle Last BIRTH DATE: / / HOME PHONE: (

Pediatric Ophthalmology Date: PLEASE PRINT: PATIENT NAME: Male: Female: AGE: First Middle Last BIRTH DATE: / / HOME PHONE: ( Eye Consultants of Atlanta, P.C. Scottish Rite Office 5445 Meridian Mark Road, Suite 220, Atlanta, GA 30342 Phone: (404-255-2419) - Fax (404-255-3101) Zane Pollard, M.D. Marc F. Greenberg, M.D. Mark A.

More information

Date of Birth: Phone # Home Cell Work (please circle) Alternate Phone # Home Cell Work (please circle) Home Address. Insurance Billing Address:

Date of Birth: Phone # Home Cell Work (please circle) Alternate Phone # Home Cell Work (please circle) Home Address. Insurance Billing Address: Patient Demographics Name: _ of Birth: SS# Phone # Home Cell Work (please circle) Alternate Phone # Home Cell Work (please circle) Email: _ Home Address Insurance Information Insurance Provider: Group

More information

Updated as of 05/15/13-1 -

Updated as of 05/15/13-1 - Updated as of 05/15/13-1 - GENERAL OFFICE POLICIES Thank you for choosing the Quiroz Adult Medicine Clinic, PA (QAMC) as your health care provider. The following general office policies are provided to

More information

Welcome to Crozer-Keystone Health Network Primary Care

Welcome to Crozer-Keystone Health Network Primary Care Welcome to Crozer-Keystone Health Network Primary Care A Guide to Your CKHN Patient-Centered Medical Home: What you can expect from us... What we will need from you......so you can gain the full benefits

More information

HIPAA Security Manual Administrative Security/Omnibus Rule

HIPAA Security Manual Administrative Security/Omnibus Rule Notice of Privacy Policies Form ***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!*** The tells

More information

You are scheduled to see Dr. Kennard: at. On the day of your visit, he will be located at: (Directions are enclosed)

You 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 information

THE WORLD OF PEDIATRICS. Medical Records/Health Information Release (Please fill out and fax or send to your current practice or pediatrician)

THE WORLD OF PEDIATRICS. Medical Records/Health Information Release (Please fill out and fax or send to your current practice or pediatrician) Medical Records/Health Information Release (Please fill out and fax or send to your current practice or pediatrician) Date: To: Fax: Please, release a copy of medical records for the following patient(s):

More information

Patient Registration Form

Patient Registration Form 900 Carillon Parkway Suite 404 St. Petersburg, FL 33716 727-572-1333 727-572-1331 fax www.spencerdermatology.com Patient Registration Form Today s : Name: Suffix First Middle Last of Birth: / / Age: Sex:

More information

Stonebridge Adult Medicine, P.A. Registration Form (Please Print)

Stonebridge 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 information

Who to call for an emergency: Name: Relationship: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) -

Who 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 information

Office Policy & Procedures

Office Policy & Procedures Office Policy & Procedures Office hours are: Monday Thursday from 8am to 8pm, Friday from 8am to 6pm and Saturday/Sunday/Holidays open for sick visits only. Appointments are not scheduled ahead of time

More information

Street Address Apt. or Post Office Box. City State Zip. Telephone Primary: ( ) Home Work Cell. Date of Birth / / Social Security # - -

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

More information

New York Ophthalmology, P.C.

New York Ophthalmology, P.C. New York Ophthalmology, P.C. Dear Patient, Ophthalmology * PLEASE PRINT ON SINGLE SIDED, WHITE PAPER * Opthalmic Surgery Optometry * PLEASE USE BLACK INK ON ALL FORMS * Cornea External Disease Laser Vision

More information

Patient Intake Form (Adult)

Patient Intake Form (Adult) Patient Intake Form (Adult) Facility: Clinician: Resilience Counseling & Psychiatric Services Nashville, TN Brandon Teeftaller, APN & Debra Cohen, APN Name: Date of birth: Date of Visit: Referral source:

More information

OFFICE POLICIES, EFFECTIVE October 19, 2009

OFFICE POLICIES, EFFECTIVE October 19, 2009 Thank you for choosing our office for your medical care. We have written these policies to keep you informed of our current office policies. Please refer to our website for policy updates. OFFICE POLICIES,

More information

New/Updated Patient Information

New/Updated Patient Information New/Updated Patient Information Please Fill Out Completely: Date: Patient Name: Nickname: First M.I. Last Date of Birth: // Age: SSN: _/_/_ Gender: M F Email: Mailing Address: Marital Status: Single Married

More information

5044 Tennyson Parkway Suite B Plano, TX 75024 Phone 972-985-9003 Fax 972-985-1176. Welcome to The Center for Dermatology and Cosmetic Laser Surgery!

5044 Tennyson Parkway Suite B Plano, TX 75024 Phone 972-985-9003 Fax 972-985-1176. Welcome to The Center for Dermatology and Cosmetic Laser Surgery! Center for Dermatology & Cosmetic Laser Surgery Bryan A. Selkin MD Michael Wells MD Gilbert Selkin MD, DMD Angel Puryear MD Mara Dacso MD, MS Ami Bhattacharya PA-C Hope Thibodeaux PA-C Lauren Hughes PA-C

More information

PATIENT DEMOGRAPHIC INFORMATION FORM

PATIENT DEMOGRAPHIC INFORMATION FORM If you did not complete these forms in advance and bring them with your initial appointment today, then please complete them, and sign them now. Our office does not receive email from patients. We do use

More information

Atlanta Diabetes Associates Patient Registration Form. Patient Name: First Middle Last. Address: City: State: Zip Code:

Atlanta Diabetes Associates Patient Registration Form. Patient Name: First Middle Last. Address: City: State: Zip Code: Atlanta Diabetes Associates Patient Registration Form : Chart #: Which Doctor are you seeing today: _ Patient Name: First Middle Last Address: City: State: Zip Code: _ Home Phone: Work Phone: of Birth:

More information

PATIENT REGISTRATION FORM

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

More information

Patient s Last Name First MI. Social Security # Date of Birth. Age Sex M F Family Referring Doctor Doctor. Home Address Apt # City State Zip

Patient s Last Name First MI. Social Security # Date of Birth. Age Sex M F Family Referring Doctor Doctor. Home Address Apt # City State Zip Klein & Associates, M.D., P.A. Registration Form Patient s Last Name First MI Social Security # Date of Birth Age Sex M F Family Referring Doctor Doctor Home Address Apt # City State Zip Home Phone ( )

More information

PATIENT REGISTRATION Date:

PATIENT REGISTRATION Date: 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

More information

Dear New Patient, Sincerely, Staff and Providers at Brown Clinic

Dear New Patient, Sincerely, Staff and Providers at Brown Clinic Dear New Patient, Thank you for selecting Brown Clinic and its providers for your healthcare needs. It is our desire to provide you with comprehensive care in a family atmosphere. We are here to answer

More information

FAMILY PRACTICE PATIENT REGISTRATION FORM

FAMILY PRACTICE PATIENT REGISTRATION FORM FAMILY PRACTICE PATIENT REGISTRATION FORM **Today s Date: Clinic Name: Healthy Texan Pediatrics and Family Medicine PATIENT INFORMATION: (Please use full legal name, no nicknames) *Last Name: _ *First

More information

CPAP (Continuous Positive Airway Pressure) Titration Study

CPAP (Continuous Positive Airway Pressure) Titration Study Helene A. Emsellem, MD Medical Director John R. Ruddy, MD Linda Croom, ANPC Karen Murtagh, CRNP Richard Currey, PA-C CPAP (Continuous Positive Airway Pressure) Titration Study About the CPAP Titration

More information

Medication Therapy Management Program. A service for better understanding and managing the drugs you take at no additional cost to you.

Medication Therapy Management Program. A service for better understanding and managing the drugs you take at no additional cost to you. Medication Therapy Management Program A service for better understanding and managing the drugs you take at no additional cost to you. Better information for better outcomes at no additional cost to you

More information

Clifford A. Selsky, PhD, M.D. Fouad Hajjar, M.D. Ada de la Osa, ARNP-BC Shari Feinberg, CPON, CPOP Kourtnie Ramirez, MSN, CPNP

Clifford A. Selsky, PhD, M.D. Fouad Hajjar, M.D. Ada de la Osa, ARNP-BC Shari Feinberg, CPON, CPOP Kourtnie Ramirez, MSN, CPNP Clifford A. Selsky, PhD, M.D. Fouad Hajjar, M.D. Ada de la Osa, ARNP-BC Shari Feinberg, CPON, CPOP Kourtnie Ramirez, MSN, CPNP 2501 N. Orange Ave. Suite 589 Orlando, Florida 32804-3520 Phone: 407-303-2080

More information

Dermatology and Minor Surgery Services

Dermatology and Minor Surgery Services South Tyneside NHS Foundation Trust Dermatology and Minor Surgery Services Providing a range of NHS services in Gateshead, South Tyneside and Sunderland. Dermatology and Minor Surgery Services The dermatology

More information

Psychiatric Associates of Atlanta, LLC Twelve Piedmont Center, Suite 410 3495 Piedmont Road, NE Atlanta, GA 30305 404-495-5900 404-495-5901 (fax)

Psychiatric Associates of Atlanta, LLC Twelve Piedmont Center, Suite 410 3495 Piedmont Road, NE Atlanta, GA 30305 404-495-5900 404-495-5901 (fax) PATIENT INFORMATION: Psychiatric Associates of Atlanta, LLC Twelve Piedmont Center, Suite 410 3495 Piedmont Road, NE Atlanta, GA 30305 404-495-5900 404-495-5901 (fax) Last Name: First: MI: Address: City:

More information

Patient Agreement. Welcome to Community Psychiatry. Treatment - What to Expect. Children and Appointments

Patient Agreement. Welcome to Community Psychiatry. Treatment - What to Expect. Children and Appointments Welcome to Community Psychiatry Our dedicated medical providers and staff are committed to providing the highest quality medical care for each and every patient. Set forth below is our Patient Agreement,

More information

PATIENT FINANCIAL POLICIES Effective Date: June 1, 2015

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

More information

* Do you wish to receive our monthly newsletter? Yes No Marital Status: Single Married Legally Separated Divorced Other Employer Name: (If applicable)

* Do you wish to receive our monthly newsletter? Yes No Marital Status: Single Married Legally Separated Divorced Other Employer Name: (If applicable) Doctor: Patient Name: Address: State: Date of Birth: Home Phone: Work Phone: Zip: Patient Demographics Maiden Name: City: Social Security Number: Cell Phone: Email Address: * Do you wish to receive our

More information

California Pain Consultants - PATIENT REGISTRATION FORM

California Pain Consultants - PATIENT REGISTRATION FORM Patient Information California Pain Consultants - PATIENT REGISTRATION FORM First name: Last name: Middle Initial: Address: City, State, Zip Home phone :( ) -Work phone: ( ) -_Cell: ( ) - Birth Date: Age:

More information

Saratoga Cardiology Associates, PC 6 Care Lane Saratoga Springs, NY 12866 Phone: (518) 587-7625 Fax: (518) 587-0273

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

More information

Activate Health & Wellness Center Frequently Asked Questions

Activate Health & Wellness Center Frequently Asked Questions Activate Health & Wellness Center Frequently Asked Questions Q. Who is Activate Healthcare? A. Activate Healthcare s mission is to transform health care by activating associates and their families to take

More information

Patient Registration Please Print Patient Name Last First Middle

Patient 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 information

WELCOME TO PCCMA. We look forward to being of service to you and helping you to be healthier in the future.

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

More information

Signature: Date: Witness:

Signature: 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 information

Willow Bend OB/GYN Obstetrics, Gynecology & Infertility

Willow Bend OB/GYN Obstetrics, Gynecology & Infertility Dear Patient, Welcome to our medical office. We look forward to meeting you soon. In order to provide you with the best possible care, please complete our registration forms prior to your first visit and

More information

Preferred Pharmacy: Phone: Fax:

Preferred Pharmacy: Phone: Fax: PATIENT INFORMATION: TODAY S DATE Last Name: Date of Birth: Sex: Male Female First Name: SS#: Middle Initial: Marital Status: Street Address: City: State: Home Phone: Work Phone: Mobile Phone: Email: Contact

More information

David A. Wang, MD Primary Care Sports Medicine Physician PRINT NAME: ADDRESS: DOB: AGE: SEX: SS# HOME: MOBILE PHONE: WORK: FAX:

David A. Wang, MD Primary Care Sports Medicine Physician PRINT NAME: ADDRESS: DOB: AGE: SEX: SS# HOME: MOBILE PHONE: WORK: FAX: David A. Wang, MD Primary Care Sports Medicine Physician PRINT NAME: ADDRESS: DOB: AGE: SEX: SS# HOME: MOBILE PHONE: WORK: FAX: INSURANCE INFORMATION Did you injure yourself at work or is this injury a

More information

When you arrive for your first appointment, please bring the following with you:

When you arrive for your first appointment, please bring the following with you: 115 N. Sumter Street, Suite 400, Sumter, SC 29150 Phone (803) 774-7425 (SICK) / Fax (803) 774-9426 www.cfmsumter.com WELCOME We are honored that you have chosen Carolina Family Medicine of Sumter for your

More information

Quiroz Adult Medicine Clinic, P.A. General Office Policies

Quiroz Adult Medicine Clinic, P.A. General Office Policies General Office Policies Thank you for choosing Quiroz Adult Medicine Clinic P.A. (QAMC) as your health care provider. The following general office policies are provided to understand our office protocols

More information

Thank you for choosing this office and welcome.

Thank you for choosing this office and welcome. Thank you for choosing this office and welcome. My office has scheduled an initial consultation for you for a psychiatric evaluation. This initial evaluation will last approximately one and a half hours.

More information

Patient Information Booklet. Appointments

Patient Information Booklet. Appointments Patient Information Booklet The providers and staff of Orchard Medical Center S.C. would like to welcome you to our practice. Patient satisfaction is the commitment we make to every patient seen in our

More information

TEXAS ASSOCIATION OF PEDIATRIC NEUROLOGY, P.A. Jerry J. Tomasovic, M.D.

TEXAS ASSOCIATION OF PEDIATRIC NEUROLOGY, P.A. Jerry J. Tomasovic, M.D. Jerry J. Tomasovic, M.D. PATIENT NAME D.O.B. Who referred you today? What are the concerns that brought you here today? What specific questions do you have today? Please list present medication and dosage:

More information

PLEASE BRING THE FOLLOWING WITH YOU TO YOUR APPOINTMENT:

PLEASE BRING THE FOLLOWING WITH YOU TO YOUR APPOINTMENT: To Our New Patient: Our primary concern is providing you with excellent eye care. Your understanding of our policies and your cooperation with our procedures enables us to provide this care. Complete eye

More information

NAFISA TEJPAR, M.D., F.A.C.S. 2501 N. Orange Ave, Ste 513 Orlando, FL 32804 (407) 894-1280

NAFISA TEJPAR, M.D., F.A.C.S. 2501 N. Orange Ave, Ste 513 Orlando, FL 32804 (407) 894-1280 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 information

HSE Medical Associates Family Practice

HSE Medical Associates Family Practice HSE Medical Associates Family Practice PLEASE CHECK WHICH PROVIDER YOU ARE HERE TO SEE M.D. P.A. David W. Hoefer, M.D. Paul E. Shepard, M.D. Alfredo T. Ermac, M.D. Sergio G. Perossa, Darcy Bevil, P.A.

More information

Nursing Home Facility Implementation Overview

Nursing Home Facility Implementation Overview DrConnect Improved Communication; Improved Care Nursing Home Facility Implementation Overview clevelandclinic.org/drconnect Cleveland Clinic 1995-2013. All Rights Reserved. Table of Contents Table of Contents...2

More information

Patient Registration Form (ecw) (First) (MI) Previous Name. Address

Patient Registration Form (ecw) (First) (MI) Previous Name. Address Patient Registration Form (ecw) PATIENT INFORMATION (Please Print) Dr. Miss Mr. Mrs. Ms. Patient's Name (Last) (First) (MI) Previous Name Address City, State ZIP Check the best contact number q Home Phone

More information

REGISTRATION FORM (Please print)

REGISTRATION FORM (Please print) REGISTRATION FORM (Please print) PATIENT INFORMATION Patient s last name: First: Middle: Mr. Mrs. Miss Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid Is this your legal name? If not so,

More information

INSURANCE INFORMATION Secondary Insurance

INSURANCE INFORMATION Secondary Insurance 17756 KATY FREEWAY STE G-1 PATIENT REGISTRATION Welcome and thank you for visiting our office today! My staff and I are committed to providing you with quality care. Please make yourself comfortable and

More information

Your appointment is scheduled for at with Dr. Your arrival time is.

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

More information

Welcome Information. Registration: All patients must complete a patient information form before seeing their provider.

Welcome Information. Registration: All patients must complete a patient information form before seeing their provider. Welcome Information Thank you for choosing our practice to take care of your health care needs! We know that you have a choice in selecting your medical care and we strive to provide you with the best

More information

Dear Parents: Welcome and thank you for choosing Coastal Pediatrics! We appreciate the opportunity to provide your child with the highest quality

Dear Parents: Welcome and thank you for choosing Coastal Pediatrics! We appreciate the opportunity to provide your child with the highest quality Dear Parents: Welcome and thank you for choosing Coastal Pediatrics! We appreciate the opportunity to provide your child with the highest quality pediatric care. Additionally, we promise to offer superior

More information

Is 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: 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 information

MEDICAL MUTUAL Self-Assessment Form

MEDICAL MUTUAL Self-Assessment Form MEDICAL MUTUAL Self-Assessment Form PURPOSE: The purpose of the self-assessment form is to highlight those areas within the non-clinical aspect of office practice including documentation of medical records,

More information

LAWRENCE J. FINKEL, M.D., P.C. 360 CHURCH STREET WARRENTON, VA 20186 (540) 347-2020 PHONE (540) 341-7980 FAX www.finkelderm.net

LAWRENCE 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 information

UNDERSTANDING YOUR MEDICAL BILL. Thank you for choosing Your Personal Physicians at:

UNDERSTANDING YOUR MEDICAL BILL. Thank you for choosing Your Personal Physicians at: UNDERSTANDING YOUR MEDICAL BILL Thank you for choosing Your Personal Physicians at: Mercy Medical Center Lutherville Overlea Worthington/Reisterstown Glen Burnie Canton as your healthcare provider. We

More information

LAST NAME FIRST NAME MI BIRTHDATE ADDRESS CITY STATE ZIP HOME PHONE# CELL# S.S. # EMAIL ADDRESS

LAST NAME FIRST NAME MI BIRTHDATE ADDRESS CITY STATE ZIP HOME PHONE# CELL# S.S. # EMAIL ADDRESS The more information we know about you and your family, the better medical care we can provide you. None of this information will be released to any person except with your written consent. LAST NAME FIRST

More information

PATIENT/PARENT/GUARDIAN SIGNATURE

PATIENT/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 information

Stonebriar Psychiatric Services, P.A. Policies

Stonebriar Psychiatric Services, P.A. Policies OFFICE HOURS: Stonebriar Psychiatric Services, P.A. Policies Monday through Thursday, 8:00 a.m. to 4:00 p.m. The office is closed major holidays and the week between Christmas Eve and New Year s. APPOINTMENTS:

More information

Understanding Your Medical Bill

Understanding Your Medical Bill Understanding Your Medical Bill THANK YOU for choosing University of Maryland Medical Center (UMMC) as your healthcare provider. We are committed to providing excellence in the delivery of healthcare.

More information

Keweenaw Holistic Family Medicine Patient Registration Form

Keweenaw Holistic Family Medicine Patient Registration Form Keweenaw Holistic Family Medicine Patient Registration Form How did you first learn of our Clinic? Circle one: Attended Lecture Internet KHFM website Newspaper Sign in window Yellow Pages Physician Friend

More information

Thank you for your cooperation.

Thank you for your cooperation. DR. RICHARD P. TOWNSEND M.D. VERONICA DEAN FNP-C Family Nurse Practitioner LAURA GRUNDY FNP-BC Family Nurse Practitioner Dr. Richard Townsend is a third generation physician. He was educated in Canada

More information

P.S. Please remember to bring your completed forms to your office visit!

P.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 information

Cell Phone / Best Number To Reach You: Your e-mail address: Race: C AA Asian Other. Copay: Copay:

Cell 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 information

The Center for ADHD, Inc.

The Center for ADHD, Inc. Consent to Evaluate and Treat Date: Patient: Age: Date of Birth Female Male Black Hispanic White Other Address: City, State, Zip Code: Home Phone: Work/Cell: Person(s) Responsible for Payment: Address

More information

21031 Michigan Avenue Dearborn, MI 48124

21031 Michigan Avenue Dearborn, MI 48124 21031 Michigan Avenue Dearborn, MI 48124 19725 Allen Rd #102 Brownstown, MI 48134 44633 Joy Rd #200 Canton, MI 48187 Phone: 313-277-6700 FAX: 313-277-2483 Date: Dear Patient: An appointment has been scheduled

More information

Nephrology Consultants of Georgia, P.C.

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

More information

Faculty Group Practice Patient Demographic Form

Faculty Group Practice Patient Demographic Form Name (Last, First, MI) Faculty Group Practice Patient Demographic Form Today s Date Patient Information Street Address City State Zip Home Phone Work Phone Cell Phone ( ) Preferred ( ) Preferred ( ) Preferred

More information

I authorize the Center for ADHD, Inc./R. Timothy Brown, M.D. to evaluate and treat.

I authorize the Center for ADHD, Inc./R. Timothy Brown, M.D. to evaluate and treat. CENTER FOR ADHD, INC. AND R. TIMOTHY BROWN, M.D., LLC Consent to Evaluate and Treat Patient: Age: Date of Birth: Female Male Black Hispanic White Other Address: City, State, Zip Code: Home Phone: Business/Cell

More information

PLEASE REMEMBER THAT REGARDLESS OF INSURANCE COVERAGE, YOU ARE RESPONSIBLE FOR YOUR BILL.

PLEASE REMEMBER THAT REGARDLESS OF INSURANCE COVERAGE, YOU ARE RESPONSIBLE FOR YOUR BILL. Welcome to Our Office! We welcome you to our office and appreciate the opportunity to provide you with medical services. We strive to provide the highest quality eye care to our patients with compassion

More information

Frequently Asked Questions

Frequently Asked Questions Frequently Asked Questions What is an electronic health record? Borgess has transitioned from paper-based medical records to electronic health records (EHRs). An EHR is an electronic version of your medical

More information

Cardiology Consultants of Atlanta, P.C. 2801 N. Decatur Rd. Suite 395, Decatur GA, 30033 (404) 298-2220 phone (678) 904-5336 fax

Cardiology Consultants of Atlanta, P.C. 2801 N. Decatur Rd. Suite 395, Decatur GA, 30033 (404) 298-2220 phone (678) 904-5336 fax OFFICE POLICIES AND PROCEDURES Thank you for choosing Cardiology Consultants of Atlanta for your cardiovascular care. We realize that you have a choice in medical providers and are pleased that you have

More information

X Guarantor/Parent/Guardian Signature

X Guarantor/Parent/Guardian Signature Patient Name: Last First Address City State Zip Phone# (C) (H) (W) Date of Birth Social Security# (REQUIRED FOR BILLING) If Patient is a Minor, a Parent s Name & Social Security# are Required Emergency

More information

USES AND DISCLOSURES FOR TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS [45 CFR 164.506]

USES AND DISCLOSURES FOR TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS [45 CFR 164.506] USES AND DISCLOSURES FOR TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS [45 CFR 164.506] Background The HIPAA Privacy Rule establishes a foundation of Federal protection for personal health information,

More information

Inland Valley Medical Center Rancho Springs Medical Center Requesting Copies of Your Medical Record

Inland Valley Medical Center Rancho Springs Medical Center Requesting Copies of Your Medical Record Inland Valley Medical Center Rancho Springs Medical Center Requesting Copies of Your Medical Record Per Federal and State laws and regulations, patient information is kept in strict confidence and only

More information

HIPAA PATIENT S AUTHORIZATION

HIPAA PATIENT S AUTHORIZATION HIPAA PATIENT S AUTHORIZATION THIS FORM IS TO CONFIRM YOUR AUTHORIZATION TO USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATION FOR THE DAILY HEALTHCARE OPERATIONS OF COSMECTIC AND FAMILY DENTAL CENTER (SAMUEL

More information

Welcome to Our Practice Welcome to Patriot Pediatrics!

Welcome to Our Practice Welcome to Patriot Pediatrics! Welcome to Our Practice Welcome to Patriot Pediatrics! Thank you for choosing Patriot Pediatrics to care for your child s health. You are your child s most important caregiver, and we look forward to working

More information

IMS Allergy & Immunology New Patient Registration Sheet. Personal Information

IMS 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 information

ST. LAWRENCE REHABILITATION CENTER OUTPATIENT POLICIES AND REGISTRATION INFORMATION

ST. LAWRENCE REHABILITATION CENTER OUTPATIENT POLICIES AND REGISTRATION INFORMATION Outpatient Services 2381 Lawrenceville Road 609-896-9500 voice Patient Name: Account #: ST. LAWRENCE REHABILITATION CENTER OUTPATIENT POLICIES AND REGISTRATION INFORMATION Your first day of outpatient

More information

Last Name First Name MI. Sex (circle): Male Female Date of Birth SS# Marital Status (circle): Married Single Divorced Widowed Separated

Last 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 information

CENTENNIAL MEDICAL GROUP & CENTENNIAL SURGERY CENTER New Patient Paperwork

CENTENNIAL 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 information

TOTAL WOMEN S HEALTHCARE Robert L. Levy, M.D.

TOTAL WOMEN S HEALTHCARE Robert L. Levy, M.D. TOTAL WOMEN S HEALTHCARE Robert L. Levy, M.D. PATIENT NAME: DOB: FINANCIAL and other OFFICE POLICIES Please be assured that everyone in this practice is dedicated to providing the highest quality medical

More information

UPDATE FORM 2011. Name: (First) (Last) (Middle Initial) Address: Home Phone: Work/Other Phone. Social Security #: Date of Birth:

UPDATE FORM 2011. Name: (First) (Last) (Middle Initial) Address: Home Phone: Work/Other Phone. Social Security #: Date of Birth: COMPREHENSIVE PSYCHIATRIC CARE Psychopharmacology & Psychotherapy Adults, Adolescents, Children & Seniors UPDATE FORM 2011 Please fill out this form completely (front and back) Name: (First) (Last) (Middle

More information