INSURANCE VERIFICATION FORM - Atco Medical Associates
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- Felicia Philomena Foster
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1 INSURANCE VERIFICATION FORM - Atco Medical Associates Patient Name Date of Birth Social Security # Single Married Separated Widowed Home Phone Cell Phone # 1 Cell Phone # 2 Address Spouse's Name Spouse's Contact Number Emergency Contact / Phone Number LAST PRIMARY CARE PROVIDER Last Primary Care Physician's Office Primary Care Doctor's Name Last Physician's Office Number INSURED PERSON ( if not patient ) Insured Person's Name Date of Birth Social Security Number Relationship to Patient Driver's License OFFICE USE ONLY CHECKLIST Primary Insurance Secondary Insurance Other Insurance Check Guarantor and all of Guarantor's Info rev.date 06/Oct/2010
2 PATIENT REGISTRATION FORM - A : Insurance Information Atco Medical Associates, P.C. rev.date 25/feb/2010 Patient Name Date of Birth (mm/dd/yyyy) Social Security # Single Married Separated Widowed Home Phone Cell Phone # 1 Cell Phone # 2 Address Spouse's Name Spouse's Contact Number Emergency Contact / Phone Number PATIENT EMPLOYMENT INFORMATION Employer's Name Occupation Work Phone INSURED PERSON ( if not patient ) Insured Person'sName Contact Number Relationship to Patient INSURANCE INFORMATION Primary Insurance Company Primary Identification Number / Group Number Primary Contact Number Secondary Insurance Company Secondary Identification Number / Group Number Secondary Contact Number MEDICAL INFORMATION RELEASE and ASSIGNMENT OF BENEFITS I authorize the release of my medical information to process a claim. I permit a copy of this authorization to be used in place of the original. I hereby authorize Atco Medical Associates, P.C. to apply for benefits on my behalf for covered services rendered by Atco Medical Associates, P.C. or ordered by Atco Medical Associates, P.C. I request that payment from my insurance company be made directly to Atco Medical Associates, P.C. (or the party who accepts assignment). I certify that this information that I have reported with regard to my insurance coverage is correct. This authorization may be revoked by either me or my insurance company at any time in writing. X Signature Date The Health Insurance Portability and Accountability Act (HIPAA) prevents the release of your Protected Health Information (PHI) to family members, friends of family members, and certain institutions without your written approval. Your signature and initials below confirm you understand these rules regarding the release of your PHI. Please check one box only, sign and date this form. I DO NOT permit the release of information to my family members / friends I PERMIT the release of information to the following person (s) : X Signature Date
3 PATIENT REGISTRATION FORM - B : MEDICAL INFORMATION SHEET Atco Medical Associates, P.C. rev.date 25/feb/2010 Patient Name Date of Birth (mm/dd/yyyy) Contact Phone Number 1. Describe the reason for your initial visit : 2. Please list current medical conditions : 3. Please list any past surgical procedures : 4. Please list your present medications : 5. List allergies please : 6. Are you a smoker? Yes No PERSONAL MEDICAL INFORMATION - Do you have any of the following (please check below): Anxiety Diabetes Hepatitis Stroke Asthma Difficulty Hearing Hypertension Thyroid Disease Blood in Stool Dizzy Spells Joint Pain/Arthritis Ulcers of the Stomach Cancer Glaucoma Kidney Stones Urinary Tract Infections Catarracts Headaches Memory Loss Urinary Difficulty Chest Pain Heart Attack Shortness of Breath O T H E R Depression Hemorrhoids Skin Disorders Please list or explain any other diseases : FAMILY MEDICAL HISTORY - Please check all that apply : FATHER MOTHER UNCLE AUNT SIBLINGS CHILDREN ASTHMA BREAST CANCER COLON CANCER DIABETES HEART ATTACK / DISEASE HIGH BLOOD PRESSURE HIGH CHOLESTEROL STROKE
4 Office Policy Form Regarding Missed Appointments Atco Medical Associates endeavors to provide services to our loyal patients as promptly and as close to their scheduled appointment time as possible. Our office strives to provide superior medical care to all of our patients and this does cause delays in keeping accurate appointment times. We apologize for any delay in your scheduled appointment time. Unfortunately there have been numerous patients of Atco Medical Associates, both new and established, that do not show for their scheduled appointment. This is unfair to our patient population that needs to be seen by our staff and it is unfair to our practice. We unfortunately find it necessary to implement a new policy concerning missed and cancelled appointments. It is expected that appointments be kept as scheduled. However, circumstances may occasionally arise that might necessitate rescheduling of an appointment for another date or time. If an appointment does need to be rescheduled, it is expected that the patient will contact the office at least twentyfour (24) hours in advance. In the event a patient misses a scheduled appointment and has neither attempted to contact the office nor rescheduled their office visit, then a $40 no-show fee will be assessed. These fees are the responsibility of the patient and are not billable to the insurance company. We truly appreciate your cooperation with this policy. Thank You. Patient signature Date
5 Controlled Substances Policy Contract (rev.date 7/4/2011) Medications for anxiety (Xanax, Klonopin, Valium, etc.) as well as medications for pain (Percocet, OxyContin, Roxicodone, etc.) are considered controlled substances by federal and state law. The purpose of this controlled substances policy contract is to ensure that all patients of Atco Medical Associates that may be prescribed any of these substances are completely aware of the policies of Atco Medical Associates regarding these medications. All patients of Atco Medical Associates are to read this form carefully and sign their name to this contract, which will be placed in each patient's medical record. 1. All new patients of Atco Medical Associates must provide medical documentation and/or medical testing outlining the necessity for pain medications. This includes, but not limited to, medical imaging, previous physician's office notes, current pharmacy medication log, etc. This prior medical documentation is required for all new patients and there will be no exceptions or refunds for office visits if medical documentation is not provided. 2. The prescription writing of controlled substances is solely up to the physician's discretion of Atco Medical Associates, regardless of what prior medication any patient has been taking in the past or is currently taking. There will be no refunds for office visits from which patients are dissatisfied with the medication they may or may not have received at their office visit with Atco Medical Associates. 3. All patients receiving controlled substances may be subject to random urine drug screen at the patient's expense. Failure to comply with random urine drug screen, obtaining positive urine drug screen for unexpected substances, or lack of a positive urine drug screen for expected substances will be grounds for immediate dismissal from Atco Medical Associates. 4. It is the responsibility of all patients of Atco Medical Associates to take their medications as prescribed by the directions printed on the bottle. If a patient of Atco Medical Associates runs out of their medication(s) because they were taking the medications too frequently, despite the directions on the bottle, the medications will not be replaced until the next cycle when a patient is due to receive his or her medications again. Patients of Atco Medical Associates who take their medications at their own discretion, regardless of the directions, will be subject to review and may be dismissed from Atco Medical Associates. 5. Patients of Atco Medical Associates who are prescribed controlled substances are to receive these types of medications only from physicians at Atco Medical Associates. Patients of Atco Medical Associates who are receiving prescriptions for controlled substances from physicians in other medical practices (also known as double dipping ), will not have their medications filled and will be dismissed from this practice. Patients who are currently prescribed controlled substances from Atco Medical Associates and obtain controlled substance prescriptions from the emergency department physician at a hospital may also be subject to dismissal from this practice.
6 6. The alteration of any written paper prescription by a patient (changing the date, changing the quantity, changing the dosage frequency, etc.) is a violation of federal and state law. Any patient of Atco Medical Associates that alters a prescription blank will not have the medications filled by the pharmacy, will immediately be dismissed from this practice, and could possibly be arrested by local authorities for violating the law. 7. It is the responsibility of all patients of Atco Medical Associates that have been prescribed controlled substances to make sure that their medications are not lost or stolen, either the prescription paper or the bottles of the medications themselves. Lost medications or stolen medications, regardless of a police report, will not be replaced under any circumstances. If the medications are lost or stolen they will only be replaced at the next cycle when a patient is due to receive his or her medications again. 8. Controlled substances prescribed by Atco Medical Associates are to be filled at one pharmacy only, at the discretion of the patient, which will be documented on the patient's medical record and/or the written prescription itself. The use of a different pharmacy, or pharmacies, other than the agreed upon pharmacy between the patient and Atco Medical Associates, requires prior notification to Atco Medical Associates. Lack of notification of using a different pharmacy may result in a medication not being approved for refill. 9. Controlled substances require close monitoring and patients receiving controlled substances are to be seen on a monthly basis. Written prescriptions for controlled substances must be obtained during normal business hours during an office visit. Prescriptions will not be mailed to patients. Dispensing controlled substance prescriptions will not occur on weekends, holidays or any other time that the office is closed since it is essential that each patient's chart be accessed to ensure appropriate controlled substance prescription dispensation. All of the policies stated within this Controlled Substances Policy Contract are nonnegotiable. Violation of office policies within this contract will result in dismissal from Atco Medical Associates without exception. Your signature on this form states that you fully understand the above mentioned policies of Atco Medical Associates regarding controlled substances. Your signature on this form signifies that you will adhere to the rules and regulations of Atco Medical Associates in regards to the prescribing and continued use of controlled substances. Print Your Name Here Your Signature Here Today s Date 2
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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:
DATE OF BIRTH SOCIAL SECURITY (Last 4 digits): SEX: Male Female
PATIENT DATA SHEET PATIENT INFORMATION Please complete this form in its entirety prior to your first visit. Also, please bring your insurance information and/or cards to our office at your first visit.
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
Patient Demographic Form
Patient Demographic Form New Patient Returning Patient Primary Care Physician (PCP) Name: Patient Name: Last Name First Name MI Address: P.O. Box City: State: Zip: Cellular Number: Home Number: Work Number:
VEIN CLINIC OF NORTH CAROLINA 3318 HEALY DR. WINSTON SALEM, NC 27103 PH. 336-768-3530 FAX- 768-1329. Scott W. Baker, MD. Patient Instructions
18 HEALY DR. WINSTON SALEM, NC 710 PH. 6-768-50 FAX- 768-19 Scott W. Baker, MD Patient Instructions 1. Bring a list of all regular medications and dosages.. Bring your insurance card and all necessary
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:
Copayment 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.
Home Phone#: Mobile #: Email Address: Sex: M F Date of Birth (mm/dd/yyyy): / / Name of Emergency Contact: Relationship: Home Phone: ( )
Patient Information Date: First Name: Address: Surname: City: Postal Code: Home Phone#: Mobile #: Email Address: Sex: M F Date of Birth (mm/dd/yyyy): / / Name of Emergency Contact: Relationship: Home Phone:
6. Do you have an Advance Directive or Living Will? Yes No These are written statements about how you want to be treated if you get very sick.
Adult Health History Name: First Last Name you like to be called: Today s Date: Date of Birth: Male Female Transgender Male to Female Transgender Female to Male Other Filling out this form Answering these
LOW T NATION TESTOSTERONE INTAKE FORM NAME: DATE: ADDRESS: CITY: STATE: ZIP: CELL #: HOME #: SOC SECURITY #: DATE OF BIRTH:
LOW T NATION TESTOSTERONE INTAKE FORM NAME: DATE: ADDRESS: CITY: STATE: ZIP: CELL #: HOME #: SOC SECURITY #: DATE OF BIRTH: DRIVERS LICENSE NUMBER: STATE: EMAIL ADDRESS: MARITAL STATUS: ( ) SINGLE ( )
Princeton 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 #: /
Associates 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
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
Insurance card Picture ID MRI/X-ray reports Therapy referral from referring physician Insurance referral if required from your insurance carrier
Welcome to the Rehabilitation Center of Southern Maryland. Thank you for giving us the opportunity to care for your Physical/Occupational therapy needs. We look forward to helping you in every way we can.
PREMIER PAIN CARE PA Carlos J Garcia MD 2435 W. Oak Street # 103 Denton, TX 76201 Phone 940-323-9404 Fax 940-323-9422 PATIENT REGISTRATION
PREMIER PAIN CARE PA Carlos J Garcia MD 2435 W. Oak Street # 103 Denton, TX 76201 Phone 940-323-9404 Fax 940-323-9422 PATIENT REGISTRATION Last Name First Name MI Mailing Address City Zip code Home Phone
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