Sincerely yours, Rev

Size: px
Start display at page:

Download "Sincerely yours, Rev. 06.10"

Transcription

1 Welcome to RehabXperience. Thank you so much for choosing us. We recognize that you have a choice of physical therapy centers and greatly appreciate you for choosing us as your outpatient physical therapy center of choice. The law requires us to request your authorization and consent prior to providing you with care. Enclosed please find the following forms for your review: Authorization for Evaluation and Treatment, Consent to the Use or Disclosure of Protected Health Information (PHI), Patient Financial Responsibility, Assignment of Insurance Benefits, and Cancellation and No Show. Please review these documents. Please fill in the information in the provided spaces and sign and date each of the documents. Please do not hesitate to draw our attention should you have any question. Please hand the complete documents to our office professional. We strive on providing exceptional service and outstanding clinical results and welcome the opportunity to serve you. Sincerely yours,

2 Authorization for Evaluation and Treatment I, the undersigned, hereby authorize RehabXperience, LLC (RehabXperience) - its employees, independent contractors, and business associates - to perform physical therapy evaluations and treatments on me (or on the Patient, if I am the Legal Guardian of the patient) as related to the care planned for me. I understand that RehabXperience will provide therapy that may involve risk of injury. I realize that no guarantees have been made to me in relation to the examination, care, or treatment. I understand that I have the right to request an explanation of risks and benefits from services provided. I understand that RehabXperience is not legally responsible for the acts and omissions of its independent contractors. Signature: Date: (MM/DD/YYYY) Rev. 06/10

3 Consent to the Use or Disclosure of Protected Health Information (PHI) I, the undersigned, consent to the use or disclosure of my PHI by RehabXperience, LLC (RehabXperience) for the purposes of evaluating or providing treatment to me, obtaining payment for my health care bill or to conduct health care operations and in accord with it Notice of Privacy Practices. I understand that evaluation or treatment of me by RehabXperience may be contingent upon my consent. I understand I have the right to request a restriction as to how my PHI is used or disclosed to carry out treatment, payment or healthcare operations. I understand that if I restrict the disclosure of my PHI to insurance companies and other responsible parties, payment for services rendered will be due at the time of service. My PHI means, in part, my demographic information, collected from me and created or received by RehabXperience, other health care providers, health plans and/or my employer. This PHI relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me. RehabXperience is not required to agree to restrictions on the use or disclosure of my PHI that I request. However, if RehabXperience agrees to a restriction that I request, the restriction is binding on RehabXperience. I have the right to revoke this consent, in writing, at any time, except to the extent that RehabXperience has taken action in reliance on this consent. I understand I have the right to review RehabXperience Notice of Privacy Practices prior to signing this document. The RehabXperience Notice of Privacy Practices has been provided to me. The Notice of Privacy Practices describes the types of uses and disclosures of my PHI that will occur in my treatment, payment of my bills or in the performance of health care operations of RehabXperience. It also describes my rights and RehabXperience duties with respect to my PHI. RehabXperience reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised Notice of Privacy Practices by contacting RehabXperience and requesting that a revised copy be sent to me by regular mail or or by asking for one at the time of my next appointment. Signature: Date: (MM/DD/YYYY)

4 Patient Financial Responsibility Dear Patient, We are here to serve you; to facilitate your way to physical recovery and better quality of life. We are here also to assist you with finding out what financial obligations you may be assuming in connection with our treatment. Nonetheless we highly recommend that learn and understand, prior to your visit, what your insurance plan benefits are and what your responsibility for deductibles, co-insurance, or co-payment amounts may be. Not all services are covered under all insurance policies. Furthermore, benefits and coverage rules and policies differ among insurers and even between different plans of the same insurer. Either if you have insurance coverage to pay your medical bills or if your insurance plan does not cover a service or a procedure, you are ultimately responsible for full payment of charges. To find out what your insurance plan covers and what your financial obligation may be, you may call the customer service or member services department of your insurance company (the phone numbers are usually on your insurance card). You are responsible to notify us of your insurance. You are also responsible to notify us immediately of insurance changes, if any. To effectively help you meet this obligation have your current insurance card with you at the time of your visit, as well as a photo ID such as a driver's license, military ID, or government issued ID. It is also your responsibility to know your insurance company's patient responsibilities and procedures. If proper procedures are not followed, your insurer may decline payment and you may be liable for full payment of the bill. If your insurance plan requires a referral and/or prior authorization, let our office know it prior to your visit. If prior authorization is required but not obtained by the time of your visit you either may not be seen for your scheduled visit, or you will be responsible for full payment of your bill at time of service. Check all that Apply: Read Understood and Agreed Signature: Date: (MM/DD/YYYY)

5 Assignment of Insurance Benefits I, the undersigned, agree for the direct payment to RehabXperience, LLC (RehabXperience) of any insurance benefits payable to or on behalf of me including, but not limited to, Medicare, commercial insurer, Personal Injury Protection (PIP), or other auto and liability insurance covering me, or any party liable to me. I further understand that if I receive any insurance payments directly from my insurance carrier or any other liable party covering me for services rendered by RehabXperience, I will immediately (within 5 days) pay over such payments to RehabXperience. (initial) I understand that if I restrict the disclosure of my Protected Health Information (PHI) to insurance companies and other responsible parties, payment for services rendered will be due at the time of service. My PHI means, in part, my demographic information, collected from me and created or received by RehabXperience, other health care providers, health plans and/or my employer. This PHI relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me. I understand that charges not covered by this assignment including, but not limited to, co-pays and deductibles and due RehabXperience are payable at the time of service. Signature: Date: (MM/DD/YYYY)

6 Cancellation and No Show I, the undersigned, recognize that the effectiveness of treatment and the pace of improvement are significantly affected by the consistency and continuity in treatment. I also understand that disruption in treatment may adversely affect the outcomes of my therapy. I understand that I need to make every effort to keep the schedule of treatments as communicated to me by RehabXperience, LLC (RehabXperience). I understand that I am responsible to arrive on time to my scheduled appointments. I further understand that I am responsible to contact RehabXperience at least 24 hours prior to an appointment I cannot make to give a cancellation notice and reschedule my appointment. I am aware that RehabXperience reserves the right to charge me $25 for each noshow or late cancellation should I fail to meet my responsibility to give a notice as described above. While RehabXperience does not desire for me to incur additional expenses, this amount will cover some of RehabXperience resources that are idle as a result of my late cancellation or no-show. I understand that this fee is my responsibility, will not be billed to my insurance company and is payable upon my following visit. Following a no-show, RehabXperience may make a reasonable effort to contact me. Should the effort by RehabXperience to maintain my treatment routine fail, RehabXperience will contact my referring physician and recommend discharge for non-compliance. Relation to Patient (check one): Self Signature: Date: (MM/DD/YYYY)

New Patient Intake Package

New Patient Intake Package CORE Physical Therapy 1255 S State St, Suite 7 Dover, DE 19901-6932 Phone: (302) 734-0100 Fax: (302) 734-0101 New Patient Intake Package - Welcome Letter - Consent Form - Appointment Contact Preference

More information

If you miss 3 consecutive appointments we may have to notify your physician and will require a new referral in order to continue your treatment.

If you miss 3 consecutive appointments we may have to notify your physician and will require a new referral in order to continue your treatment. Welcome to POST Physical Therapy Brookline. We strive to provide our patients with excellent service and quality care. Our commitment to your well-being and health care is something that we at POST Physical

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

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

THE EYE INSTITUTE. Eye Associates of Wayne P.A. 968 Hamburg Turnpike Wayne, NJ 07470 p. 973-696-0300 f. 973-696-0465

THE EYE INSTITUTE. Eye Associates of Wayne P.A. 968 Hamburg Turnpike Wayne, NJ 07470 p. 973-696-0300 f. 973-696-0465 THE EYE INSTITUTE Eye Associates of Wayne P.A. 968 Hamburg Turnpike Wayne, NJ 07470 p. 973-696-0300 f. 973-696-0465 Dear Patient: Welcome to the Eye Institute. Our mission is to provide you with the highest

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

Patient Information Form Trinity Wellness Center. Insurance Information

Patient Information Form Trinity Wellness Center. Insurance Information Patient Information Form Trinity Wellness Center Last Name, First Name, MI* Date of Birth* / / Social Security # -- -- Sex* : Female / Male Student Status (circle one): Full-time / Part-time / not a student

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

Advanced Solutions Pain Management

Advanced Solutions Pain Management Joseph Ho, M.D. Sabrina Shue, M.D. Patient Information Name: M F Age: Last, First, Middle (Circle One) DOB: SSN: Single Married Divorced Separated Widowed Address: City: State: Zip: Home Phone: Cell: Work:

More information

Today s Date: / /! / / Full Legal Name (First, Middle, Last) Date of Birth Age. Address City State Zip

Today s Date: / /! / / Full Legal Name (First, Middle, Last) Date of Birth Age. Address City State Zip Today s Date: / / / / Full Legal Name (First, Middle, Last) Date of Birth Age Social Security Number Marital Status Address City State Zip Out of State Address Phone: Home ( ) - Cell ( ) - Email: PREFERRED

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

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

If physical therapy is being sought due to an accident, please indicate the and of the accident

If physical therapy is being sought due to an accident, please indicate the and of the accident 2919 S. 120 th St. Omaha, NE 68144 Office Phone: (402) 504-3535 Cell Phone: (402) 630-9756 Fax: (402) 934-3866 OUTPATIENT THERAPY TREATMENT AGREEMENT If physical therapy is being sought due to an accident,

More 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

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

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

Betsy Houser Counseling LLC Betsy Houser, LCSW PIP

Betsy Houser Counseling LLC Betsy Houser, LCSW PIP Betsy Houser Counseling LLC Betsy Houser, LCSW PIP IMPORTANT-PLEASE READ Important Notices Contained in Attached Policies and Procedures Appointments: Reminder emails are provided as a courtesy by this

More information

MIGUEL GONZALEZ, MD, FCCP, FACP 303 S. Moorpark Rd. Thousand Oaks, Ca 91361 805-497-7508 Phone 805-495-6834 Fax PATIENT INFORMATION

MIGUEL GONZALEZ, MD, FCCP, FACP 303 S. Moorpark Rd. Thousand Oaks, Ca 91361 805-497-7508 Phone 805-495-6834 Fax PATIENT INFORMATION MIGUEL GONZALEZ, MD, FCCP, FACP 303 S. Moorpark Rd. Thousand Oaks, Ca 91361 805-497-7508 Phone 805-495-6834 Fax PATIENT INFORMATION DATE: REFERRED BY: NAME: SEX: M / F MARITAL STATUS: BIRTHDATE: DRIVERS

More information

LAS VEGAS PAIN INSTITUTE & MEDICAL CENTER, L.L.C.

LAS VEGAS PAIN INSTITUTE & MEDICAL CENTER, L.L.C. LAST NAME: FIRST NAME: DOB: / / AGE: MARITAL STATUS: SEX: M F SSN: - - HOME#: CELL#: WORK#: STREET ADDRESS: CITY: STATE: ZIP: EMPLOYER NAME & ADDRESS: SPOUSE S NAME: DOB: / / SSN: - - WORK#: EMPLOYER NAME

More information

PATIENT INFORMATION. Patient: S.S.# Address: D.O.B. Home Phone: Bus Phone: Male Female. Emergency contact: Relation to Patient: PH#

PATIENT INFORMATION. Patient: S.S.# Address: D.O.B. Home Phone: Bus Phone: Male Female. Emergency contact: Relation to Patient: PH# Massage 258 West 91 st Street, Suite 1-B Physical THERAPY EXPERTS, PLLC WELCOME 212-875-8345 T PLEASE FILL IN FORM COMPLETELY TO AVOID INSURANCE PAYMENT DELAY! PATIENT INFORMATION Patient: S.S.# Address:

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

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

MVA New Patient Paperwork

MVA New Patient Paperwork Please Complete Entire Form MVA New Patient Paperwork Patient Name: M F Today s Date / / Address: Employer: _ City, State, Zip: Address: Home Phone: ( ) City, State, Zip: Cell Phone: ( ) Work Phone: (

More information

The Healthy Mind PSYCHIATRIC SERVICES

The Healthy Mind PSYCHIATRIC SERVICES The Healthy Mind PSYCHIATRIC SERVICES 900 Straits Tpk Suite D Middlebury, CT 06762 New Patient Registration: Patient s First Name Last Name Patient s Telephone: Home Cell Email: Patient s Date of Birth:

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

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

DAVID LAWRENCE CENTER Restoring & Rebuilding Lives

DAVID LAWRENCE CENTER Restoring & Rebuilding Lives Restoring & Rebuilding Lives Health Insurance Portability & Accountability Act (HIPAA) Notice of Privacy and Security Practices & Notice of Client Rights Abbreviated Statement For more than 40 years David

More information

PATIENT S NAME: DOB: PHONE: (HOME) (WORK) (CELL) (EMERGENCY) PATIENT SS#: PATIENT DRIVER LIC# PATIENT S/GUARDIAN S EMPLOYER: SCHOOL: CONTACT: GRADE:

PATIENT S NAME: DOB: PHONE: (HOME) (WORK) (CELL) (EMERGENCY) PATIENT SS#: PATIENT DRIVER LIC# PATIENT S/GUARDIAN S EMPLOYER: SCHOOL: CONTACT: GRADE: FAMILY PSYCHOLOGY ASSOCIATES NEW PATIENT INFORMATION SHEET PATIENT S NAME: DOB: ADDRESS: (street) (apt#) (city) (zip) PHONE: (HOME) (WORK) (CELL) (EMERGENCY) PATIENT SS#: PATIENT DRIVER LIC# PATIENT S/GUARDIAN

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

Welcome and thank you for choosing eriver Neurology of New York, LLC Phone: (845) 452-9750 Fax: (845) 452-9751. Office Policies

Welcome and thank you for choosing eriver Neurology of New York, LLC Phone: (845) 452-9750 Fax: (845) 452-9751. Office Policies Welcome and thank you for choosing eriver Neurology of New York, LLC Phone: (845) 452-9750 Fax: (845) 452-9751 eriver Neurology of New York, LLC does not discriminate against any person on the basis of

More information

INJURY INFORMATION WORSHEET

INJURY INFORMATION WORSHEET APPENDIX A INJURY INFORMATION WORSHEET PATIENT INFORMATION Patient Name Contact Phone Today s DOB DOI HEALTH INSURANCE - PRIMARY Insurance Co. Name of Insured Benefits Phone# Insured SS# Insured DOB Policy

More information

The Orthopedic and Sports Medicine Institute Michael Boothby M.D. Richard Wilson M.D. Bret Beavers M.D. William J Shaw IV-PA-C Jeff Curtis PA-C

The Orthopedic and Sports Medicine Institute Michael Boothby M.D. Richard Wilson M.D. Bret Beavers M.D. William J Shaw IV-PA-C Jeff Curtis PA-C Today s Date: Patient Name: Last First Middle Initial Date of Birth: Age: Social Security Number: Gender: M F Preferred Phone: Secondary Phone: Home Address: City: State: Zip: Email Address: Employer:

More information

PRO SPORTS THERAPY, INC. (P.S.T.)

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

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

BILLING INFORMATION AND ASSIGNMENT OF BENEFITS

BILLING INFORMATION AND ASSIGNMENT OF BENEFITS BILLING INFORMATION AND ASSIGNMENT OF BENEFITS Facility: Northpoint Radiation Center Pro Physicians Clinic PA Physician: Timothy D. Nichols, M.D. PA, Board Certified Radiation Oncology Wilhelm J. Lubbe,

More information

PATIENT INFORMATION EMERGENCY CONTACT LAST FIRST RELATIONSHIP REFERRAL SOURCE DOCTOR / REFERRING CLINICIAN: FAMILY MEMBER/FRIEND: INSURANCE:

PATIENT INFORMATION EMERGENCY CONTACT LAST FIRST RELATIONSHIP REFERRAL SOURCE DOCTOR / REFERRING CLINICIAN: FAMILY MEMBER/FRIEND: INSURANCE: PATIENT INFORMATION LAST FIRST MI GENDER M F BIRTHDATE MO./ DAY/ YEAR SS# - - ADDRESS CITY ST ZIP PHONE (CELL) PHONE (HOME) EMAIL MARITAL STATUS EMPLOYER ADDRESS OCCUPATION WORK PHONE EXT WHO IS YOUR PRIMARY

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

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 4765 Carmel Mountain Rd. Ste 202, San Diego, CA 92130 Phone (848) 847-0055 Fax (858) 847-9944 Dear Patient, Your insurance may pay your total bill for services rendered by Pilates People Torrey Hills.

More information

Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,,

Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Medical History Existing or Relevant Previous Conditions Allergies Yes No Dizzy Spells Yes No MRSA Yes No Anemia Yes No Emphysema/Bronchitis Yes No Multiple Sclerosis Yes No Anxiety Yes No Fibromyalgia

More information

Orthopedic Specialty Associates, P.A.

Orthopedic Specialty Associates, P.A. Orthopedic Specialty Associates, P.A. TEL 817.878.5300 FAX 817.878.5307 Keith C. Watson, M.D. Reconstructive Surgery of the Shoulder and Elbow John E. Conway, M.D. Reconstructive Surgery of the Shoulder,

More information

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: 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

More information

ASSIGNMENT OF BENEFITS / ERISA AUTHORIZED REPRESENTATIVE FORM

ASSIGNMENT OF BENEFITS / ERISA AUTHORIZED REPRESENTATIVE FORM ASSIGNMENT OF BENEFITS / ERISA AUTHORIZED REPRESENTATIVE FORM Financial Responsibility I have requested professional services from Diamond Sport & Spine Clinic ( Provider ) on behalf of myself and/or my

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

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

Conroe Physician Associates. Patient Consent Form. I fully understand that this is given in advance of any specific diagnosis or treatment.

Conroe Physician Associates. Patient Consent Form. I fully understand that this is given in advance of any specific diagnosis or treatment. Conroe Physician Associates Patient Consent Form Please Read and Sign I, undersigned, hereby consent to the following: Administration and performance of all treatments Administration of any needed anesthetics

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

IRVING & ASSOCIATES IN BEHAVIORAL HEALTH, P.C. 5151 Mochel Drive, Suite 307 Downers Grove, IL 60515

IRVING & ASSOCIATES IN BEHAVIORAL HEALTH, P.C. 5151 Mochel Drive, Suite 307 Downers Grove, IL 60515 : / / Client Name: _ SSN: / / of Birth: Age: Sex: Male Female Address: City/State/Zip: Home Phone Number Is it okay to leave a message here? Y/N Work Number Is it okay to leave a message here? Y/N Cell

More information

Patient Information. Claims Address: Please also provide Health Insurance information in addition to Work Comp /Auto

Patient Information. Claims Address: Please also provide Health Insurance information in addition to Work Comp /Auto For Office Use Updated By (Initial Here): Mailing Address: Patient Information City, State & Zip: Primary Home Cell Permission to Leave Messages: Yes No Secondary Home Cell Permission to Leave Messages:

More information

Devine Chiropractic & Rehab Center P.S. 1205 2 nd Avenue - Seattle, WA 98101 (206) 623.2225

Devine Chiropractic & Rehab Center P.S. 1205 2 nd Avenue - Seattle, WA 98101 (206) 623.2225 1205 2 nd Avenue - Seattle, WA 98101 Office Policies A clear definition of our policy allows us to concentrate on the big issue--restoring and maintaining your health. We are always happy to answer any

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

FAMILY PRACTICE CENTER 2016 Patient Information Update

FAMILY PRACTICE CENTER 2016 Patient Information Update FAMILY PRACTICE CENTER 2016 Patient Information Update Patient s Legal Name: Name you prefer to be called: First Last MI Address: Street City State Zip Cell Phone: Alt. Phone: Email: SS# Best way to contact

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

ADVANCED GASTROENTEROLOGICAL ASSOCIATES M. Badar Anwer, M.D. Welcome To Our Practice!

ADVANCED GASTROENTEROLOGICAL ASSOCIATES M. Badar Anwer, M.D. Welcome To Our Practice! ADVANCED GASTROENTEROLOGICAL ASSOCIATES M. Badar Anwer, M.D. 210 E. Monument Ave, Suite A Kissimmee, FL 34741 Phone: 407-870-9992 Fax: 407-870-5153 W 410 Celebration Place, Suite 400 Celebration, FL 34747

More information

Physical Occupational and Speech Therapy Patient Information Sheet

Physical Occupational and Speech Therapy Patient Information Sheet Physical Occupational and Speech Therapy Patient Information Sheet FIRST NAME: MI: LAST NAME: ADDRESS: HOME PHONE: WORK PHONE: MALE FEMALE CELLPHONE: DOB: SS# EMERGENCY CONTACT: PHONE: RELATIONSHIP: PRIMARY

More information

The Clarity Psychological Group 3915 Cascade Rd. SW Suite 250 Atlanta, GA 30331 P. (404) 699-3170 F. (404) 699-5680

The Clarity Psychological Group 3915 Cascade Rd. SW Suite 250 Atlanta, GA 30331 P. (404) 699-3170 F. (404) 699-5680 The Clarity Psychological Group 3915 Cascade Rd. SW Suite 250 Atlanta, GA 30331 P. (404) 699-3170 F. (404) 699-5680 Dear Client: It is a pleasure to have you in our practice. We appreciate the opportunity

More information

Intake for Services. Birth date: Age: Gender: Name of Spouse: Years Married: Spouse's Age:

Intake for Services. Birth date: Age: Gender: Name of Spouse: Years Married: Spouse's Age: Intake for Services Today's Date Last name: First name: Birth date: Age: Gender: Address: City/State/Zip Email: Home Phone: Cell phone: Marital Status: No. of Children & ages: If presently married: Name

More information

Wayne Physical Medicine & Rehabilitation Associates 401 Hamburg Turnpike, Suite 105 Wayne, NJ 07470

Wayne Physical Medicine & Rehabilitation Associates 401 Hamburg Turnpike, Suite 105 Wayne, NJ 07470 PLEASE FILL OUT THIS SHEET COMPLETELY AND CORRECTLY. PLEASE PROVIDE ALL INSURANCE CARDS TO THE RECEPTIONIST TO COPY. Name Social Security # Address City, State & Zip Code Home Phone No. ( ) Cell Phone

More information

Welcome To Our Physical Therapy Department

Welcome To Our Physical Therapy Department Welcome To Our Physical Therapy Department Our entire staff is dedicated to providing our patients with the best possible care and service while keeping the costs to you from increasing at an unreasonable

More information

Optimum Performance Physical Therapy, LLC

Optimum Performance Physical Therapy, LLC Optimum Performance Physical Therapy, LLC Patient Information: Name: DOB: SS# Address: Phone: (H) (W) (C) Sex: Male Female Marital Status: M S D W Email: Employer Name/ Address: Referring Physician: (P)

More information

ADULT REGISTRATION FORM. Last Name First Name Middle Initial. Date of Birth Age Identified Gender. Street Address. City State Zip Code

ADULT REGISTRATION FORM. Last Name First Name Middle Initial. Date of Birth Age Identified Gender. Street Address. City State Zip Code ADULT REGISTRATION FORM Last Name First Name Middle Initial Date of Birth Age Identified Gender Street Address City State Zip Code Home Phone Cell Phone FINANCIALLY RESPONSIBLE PARTY (If different from

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

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

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

The Providers & Staff of the Women s Institute for Gynecology & Minimally Invasive Surgery

The Providers & Staff of the Women s Institute for Gynecology & Minimally Invasive Surgery Julie Drolet, MD, FRCSC, FACOG Deborah Gobel, CRNP Sybil Mudloff, MSN, CRNP Sixth Avenue Professional Center 1600 Sixth Avenue, Suite 117 York, Pennsylvania 17403 Phone: 717-840-9885 Fax: 717-840-9313

More information

Single Married Divorced Widowed Student Minor African American Asian Caucasian Hispanic Other:

Single Married Divorced Widowed Student Minor African American Asian Caucasian Hispanic Other: At both New Tampa Foot & Ankle AND South Tampa Foot & Ankle, we are committed to getting you back on your feet free of pain and injury so that you can get back to your activities and back into life! We

More information

INTEGRATED PHYSICAL THERAPY A Holistic Approach to Physical Therapy

INTEGRATED PHYSICAL THERAPY A Holistic Approach to Physical Therapy Patient s Name: D.O.B.: Age: Address: City: State: Zip Code: Home Phone #: Cell #: Business #: Social Security Number: E-mail Address: Height: Weight: Referring Physician? Status: Married/Single/Other/Full

More information

2015 Annual Patient Paperwork Update for Existing Patients

2015 Annual Patient Paperwork Update for Existing Patients 2015 Annual Patient Paperwork Update for Existing Patients DATE: ͺͺͺͺ ŚĞĐŬ WƌĞĨĞƌƌĞĚ ůŝŷŝđ &ƚ tăljŷğ 'ƌğğŷǁžžě

More information

Medical History Questionnaire

Medical History Questionnaire Medical History Questionnaire Name: Date: Allergies (including latex): List all medications that you are currently taking, either prescription or non- prescription. Please specify dosage and length of

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

Referring Physician: Type (Circle): Insurance Fitness Work/Comp Personal Injury Auto D/A:

Referring Physician: Type (Circle): Insurance Fitness Work/Comp Personal Injury Auto D/A: Patient Information Referred By: Referring Physician: Patient Name: Appointment Date: Time: Last First Middle Int. Date of Birth: SS#: Street Address: City/State/Zip: Phone Numbers: Home: Work: Cell: Email:

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

Welcome to Tri-State Rehab Services

Welcome to Tri-State Rehab Services Welcome to Tri-State Rehab Services Ashland Ironton Jackson Louisa New Boston Westmoreland Thank you for choosing our facility. To help us meet all your physical therapy needs, please fill out forms completely

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

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

Reason(s) For Referral: Current medications:

Reason(s) For Referral: Current medications: 1540 Sunday Drive Suite 200Raleigh, NC 27607 Office: 919-859-9040FAX: 919-859-9030 Name: Date Examined: Responsible Person: _ Birth Date: Address: Age: Sex: M F Marital Status: S M D W SSN: Home Phone:

More 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

Did the motor vehicle accident in which you were injured or personal injury occur in Maricopa County? Yes No

Did the motor vehicle accident in which you were injured or personal injury occur in Maricopa County? Yes No Welcome to Spooner Physical Therapy! We understand that you have been injured in a motor vehicle accident or other 3 rd party responsible personal injury situation. It is our goal at Spooner Physical Therapy

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 Patient Information Street Address City State Zip Home Phone SSN of Birth Gender Male Female Work Phone Cell Phone Marital

More information

WELCOME TO SHEA PHYSICAL THERAPY 5440 Everhart, Suite 1 Corpus Christi, TX Telephone (361) Fax (361)

WELCOME TO SHEA PHYSICAL THERAPY 5440 Everhart, Suite 1 Corpus Christi, TX Telephone (361) Fax (361) WELCOME TO SHEA PHYSICAL THERAPY 5440 Everhart, Suite 1 Corpus Christi, TX 78411 Telephone (361) 994-5224 Fax (361) 992-1933 Patient s Name: Today s : of Birth: Age: Male/Female Address: City/State/Zip:

More information

Diabetes & Glandular Disease Clinic, P. A. Patient Financial Responsibility Policy and Acknowledgement Form

Diabetes & Glandular Disease Clinic, P. A. Patient Financial Responsibility Policy and Acknowledgement Form At Diabetes & Glandular Disease Clinic, P. A. (DGD Clinic, P.A.) the Providers and staff are dedicated to providing the best possible care and service to patients. In order for DGD Clinic, P.A. to continue

More information

PATIENT INFORMATION. Patient s Last Name First Name Middle Name

PATIENT INFORMATION. Patient s Last Name First Name Middle Name PATIENT INFORMATION Patient s Last Name First Name Middle Name Suffix Gender: q Male q Female Social Security Number Date of Birth Race Ethnic Group: q Hispanic q Non-Hispanic q Unknown Preferred Language

More information

Dear Patient, If you have any questions about your appointment, please do not hesitate to call us at (910) 791-4755. Welcome to our practice!

Dear Patient, If you have any questions about your appointment, please do not hesitate to call us at (910) 791-4755. Welcome to our practice! Dear Patient, Thank you for choosing Wilmington Hearing Specialists for your audiology care! We are excited to welcome you to our practice and provide the high quality services, products, and attention

More information

Personal Injury Intake Form

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

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

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

Primary Care Internal Medicine in Evans

Primary Care Internal Medicine in Evans Zhenrong Zhang, M. D. Thank you for choosing Primary Care. We are delighted to welcome you and will make every effort to serve you in a manner that will meet your expectations. Please assist us by completing

More information

San Antonio Arthritis Care Centers

San Antonio Arthritis Care Centers Thank you for choosing San Antonio Arthritis Care Centers. We look forward to seeing you on: Day: Date: Time: With: Dr. Stolow Dr. Feinstein Dr. Des Rosier At this location: 8527 Village Dr., Suite 104,

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

Physical Therapy Services Medical History Form

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

More information

Name: Sex: Male Female. Address: Apt#: Home #: ( ) Cell #: ( ) Other: ( ) DOB: Age: S.S. No. E-mail: Employer: Business # ( ) Occupation:

Name: Sex: Male Female. Address: Apt#: Home #: ( ) Cell #: ( ) Other: ( ) DOB: Age: S.S. No. E-mail: Employer: Business # ( ) Occupation: You deserve to be healthy. Life is a miracle and so are you. When you were created, you were given all the blue-prints, intelligence, tools, and systems to live an active healthy life. Unfortunately, your

More information

NOTICE OF PRIVACY PRACTICES

NOTICE OF PRIVACY PRACTICES FRANKLIN SQUARE EYE CARE 918 HEMPSTEAD TPKE FRANKLIN SQUARE, NY 11010 TEL #: (516) 354-4242 FAX #: (516) 354-7788 E-mail: franklineyecare@gmail.com OFFICE CONTACT PERSON: SHERIN GEORGE O.D. NOTICE OF PRIVACY

More information

Dear Parents: We appreciate the opportunity to work with your child and look forward to getting to know your family. Sincerely,

Dear Parents: We appreciate the opportunity to work with your child and look forward to getting to know your family. Sincerely, Dear Parents: Thank you for considering Mobile Therapy Centers of America, LLC (MTC) for your child s therapy needs. At MTC, we strive to provide the highest quality of therapeutic intervention. Our services

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

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

123 W. Washington St., Suite 321 Oswego, IL 60543 Phone: 630-383-2077

123 W. Washington St., Suite 321 Oswego, IL 60543 Phone: 630-383-2077 123 W. Washington St., Suite 321 Patient Information: : First Name: Middle Initial: Last Name: Address: City: State: Zip Code: S.S.#: Sex: Birth : Email Address: Primary Phone: (circle one) HOME CELL WORK

More information

!!!! Infectious Disease Center of New Jersey, LLC! Any Allergies: Family History:! Mom:! Dad: Your Medical History:

!!!! Infectious Disease Center of New Jersey, LLC! Any Allergies: Family History:! Mom:! Dad: Your Medical History: Infectious Disease Center of New Jersey, LLC 22 Old Short Hills Road P: 973-535-8355 Suite 106 F: 973.535.8353 Livingston NJ 07039 IDCOFNJ@gmail.com Patient Name Any Allergies: Family History: Mom: Dad:

More information

Volland & Associates, Inc. Signature on File and Assignment of Benefits Agreement

Volland & Associates, Inc. Signature on File and Assignment of Benefits Agreement Signature on File and Assignment of Benefits Agreement Kindly accept a photocopy of this authorization as if it were an original executed authorization. I understand that Volland & Associates, Inc. utilizes

More information

Sample Patient Payment Policy

Sample Patient Payment Policy Sample Patient Payment Policy Thank you for choosing our practice! We are committed to the success of your medical treatment and care. Please understand that payment of your bill is part of this treatment

More information

J. Gary Dolinsky, Ph.D. 161 South Main Street, Suite 309 Licensed Psychologist Provider Middleton, MA 01949 (978) 750 1990 phone (978) 739 4042 fax

J. Gary Dolinsky, Ph.D. 161 South Main Street, Suite 309 Licensed Psychologist Provider Middleton, MA 01949 (978) 750 1990 phone (978) 739 4042 fax J. Gary Dolinsky, Ph.D. 161 South Main Street, Suite 309 Licensed Psychologist Provider Middleton, MA 01949 (978) 750 1990 phone (978) 739 4042 fax jgdol@aol.com www.jgarydolinskyphd.com Psychologist-Patient

More information