:: Member Services Agreement ::
|
|
|
- Spencer Weaver
- 8 years ago
- Views:
Transcription
1 :: Member Services Agreement ::
2 Member Services Agreement Welcome to Nextera Healthcare s direct primary care program for individuals, families and businesses. A monthly membership program centered on creating a meaningful patient experience by caring and coaching patients to optimal health, Nextera Healthcare delivers convenient access to high quality primary health care services for one low monthly fee. Nextera Healthcare is committed to changing the way providers deliver primary care by caring and coaching patients to optimal health. Nextera Healthcare Membership Nextera Healthcare providers offer a wide range of adult and family primary care services, including but not limited to: 1 Acute care and chronic disease management Allergy testing and treatment Bioidentical hormone replacement therapy Dermatology Mental health, including treatment for depression, anxiety and other mood disorders School, sports and workplace physicals Sleep assessments and support Stress management Treatment of sprains, lacerations and broken bones Weight management and health risk assessment Women s health Well checks for infants and children Preventive health care Same-day or next-day appointments based on medical need. Please call 911 in the event of a medical emergency. Maximize Your Nextera Healthcare Membership Nextera Healthcare is not a health insurance plan. While the majority of primary care services are included in the Nextera Healthcare membership, additional costs may be incurred for laboratory, medical imaging, surgery, specialist care, emergency department visits and hospitalization. For this reason, patients are generally best served by combining Nextera Healthcare membership with a high-deductible insurance policy to cover specialist physician and hospital services. Speak with a health insurance broker to determine which plan may best serve you and your family.
3 Member Services Agreement Monthly Membership Fees Adult (18 and older) - $99/month Additional Adult (18 and older) - $79/month *Child, (17 and younger) - $49/month *Children must be enrolled in a plan with at least one adult member There is a one-time registration fee of $29 per person due at the time of enrollment. Eligibility Restrictions Nextera Healthcare is an innovative health care solution serving most men, women and children by providing comprehensive primary health care services. 2 Government Health Programs Due to regulatory restrictions, Nextera Healthcare is not available to those who are eligible for or enrolled in Medicare, Medicaid or other government health programs. Pre-existing Conditions Some medical conditions require specialty care and/or costly prescription medications. In some cases, the cost of required treatment(s) far outweighs the savings traditionally offered through Nextera Healthcare membership. Patients who may not benefit from Nextera Healthcare include those living with and undergoing treatment for medical conditions for which generic and/or less costly medications and drug therapies are not available, including but not limited to: Cancers requiring chemotherapy and/or radiation Hepatitis C requiring antiviral and/or interferon therapy Multiple sclerosis requiring interferon medications Rheumatic diseases such as rheumatoid arthritis or lupus requiring tumor-necrosis-factor alpha (TNF-a) inhibitors Contact us to determine if you may benefit from Nextera Healthcare and to find a physician near you.
4 MEMBERSHIP TERMS & CONDITIONS I acknowledge and agree to the one-time registration fee of $29 per person, due at the time of enrollment. I understand and agree to the scope of coverage, including limitations, of my Nextera Healthcare membership. I understand that Nextera Healthcare is not an insurance plan and DOES NOT PROVIDE COMPREHENSIVE HEALTH INSURANCE COVERAGE, nor is this a contract of insurance. I understand that Nextera Healthcare must abide by all patient privacy rules and regulation mandated by the Health Insurance Portability and Accountability Act (HIPAA). 3 I understand and agree to pay my monthly membership fee by the due date via an ACH, debit or credit card transaction using the payment information on file. I understand that transactions declined due to insufficient funds and expired credit cards will result in an additional fee of $50 and that failure to comply with payment terms may result in termination of my membership. I understand that a 10% discount will be applied if I prepay my Nextera Healthcare membership for an entire year (12 months). I understand that services will not be rendered for patients with past due accounts. I understand that Nextera Healthcare administrators may, at their discretion, terminate my membership by providing written notice 30 days in advance of termination. I understand that I may terminate my Nextera Healthcare membership at any time by providing written notice (mail or ) 30 days prior to the scheduled payment date for the next month. I understand that if I choose to re-enroll in Nextera Healthcare after terminating my membership due to non-payment, I will be expected to pay current balance and a re-enrollment fee in addition to the standard registration fee of $29 per member. I understand that Nextera Healthcare may add, discontinue or otherwise alter membership service offerings and the terms of this contract and fee schedule at any time. However, membership rates will remain fixed per contract for a period of at least 90 days. I will receive written notice at least 60 days in advance of any fee or service changes. I understand that, due to regulatory restrictions, individuals enrolled in or eligible for Medicare, Medicaid and other government health programs are disqualified from enrolling in Nextera Healthcare.
5 PATIENT RIGHTS AND RESPONSIBILITIES I understand that while I can designate a primary care provider, there may be instances when said provider is unavailable. In such cases, I will be offered care by another Nextera Healthcare provider. I understand that I have the right to accurate, up-to-date and easy-to-understand information about Nextera Healthcare programs and services. I understand that pre-existing medical conditions do not disqualify me from enrolling in Nextera Healthcare. I understand that I have the right to know my treatment options and actively participate in my health care decisions. 4 I understand that I have the right to a fair, expedient and objective review of any complaint I may have against Nextera Healthcare and its providers by Nextera Healthcare administrators. All suggestions and patient feedback should be directed to memberservices@nexterahealthcare.com. I understand that in the event of a life-threatening medical condition, I should always call 911 or proceed to the nearest emergency department. Note: Emergency department services are not included in Nextera Healthcare membership. I understand that on-call physicians and other health care providers are available for telephone consultations in the event of a urgent medical matter. Please call 911 or proceed to the nearest emergency department if immediate medical attention and/or treatment is required. PATIENT NAME (Please Print): SIGNATURE: DATE:
6 PATIENT INFORMATION PATIENT REGISTRATION LAST NAME FIRST NAME DOB SSN ADDRESS CITY STATE ZIP BILLING ADDRESS CITY STATE ZIP HOME PHONE CELL PLACE OF EMPLOYMENT WORK PHONE EMERGENCY CONTACT PHONE RELATIONSHIP MEMBERSHIP MEMBERSHIP START DATE: PREFERRED CLINICIAN: MONTHLY MEMBERSHIP FEE $ BILLING CYCLE (MONTHLY/QUARTERLY/ANNUALLY PAYMENT DUE DATE): PAYMENT DUE ON THE 1st OF THE MONTH 5 LAST NAME OF PRIMARY MEMBER: NAME OF ADDITIONAL ADULT UNDER THIS MEMBERSHIP DOB SSN Name of child #1: DOB Name of child #2: DOB Name of child #3: DOB Name of child #4: DOB PAYMENT OPTION A: ELECTRONIC FUNDS TRANSFER (Preferred) NAME OF ACCOUNT HOLDER: BANK NAME: ACCOUNT NUMBER: ROUTING NUMBER: ACCT TYPE: (CHECKING / SAVINGS) OPTION B: CREDIT OR DEBIT CARD NAME ON CARD: CARD TYPE: VISA, MASTERCARD, AMEX CC NUMBER: EXP: CSC: Nextera Healthcare membership includes services described in the Member Services Agreement. By signing below, you acknowledge that you have read and agree to the membership terms, conditions, limitations and fee schedule and that you authorize Nextera Healthcare to receive recurrent payments as outlined above. Services NOT included in Nextera Healthcare membership, including any tests, treatments, consultations or procedures provided and/ or administered by specialist physicians or hospitals will be billed separately by those providers/institutions. Nextera Healthcare is not responsible for any and all specialist physician and/or hospital fees. Participation in Nextera Healthcare is continuous. Nextera Healthcare is authorized to withdraw membership fees as outlined above (Electronic Funds Transfer or Credit/Debit Card) until notification of membership termination is received by Nextera Healthcare administrators. PRINTED NAME: SIGNATURE: DATE:
7 CORRESPONDENCE AND CONTACT INFORMATION MAILING ADDRESS: Nextera Healthcare 4943 State Highway 52, Suite 240 Frederick, CO PHONE: (303) FAX: (303) WEBSITE: Member Services: MemberServices@NexteraHealthcare.com Billing Inquiries: Billing@NexteraHealthcare.com Web Technical Support: WebSupport@NexteraHealthcare.com
Nearest Relative Information (Not in same household)
Patient Information Name Male Female Address City State Zip Birth Date Age Responsible Party Information Name: Self Parent/Guardian Birth Date SSN# Drivers License# Email Employer Employer Phone# Employer
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
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
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
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
Patient History Information
Date: Body Technic Systems, Inc. 33790 Bainbridge Rd. Ste. 205 Solon, Ohio 44139 440-248-9255 phone 440-248-3608 fax Patient History Information Name: Date of birth: Address: City: State: Zip: Home phone:
Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D
Be Fit Physical Therapy & Pilates, LTD Patient Registration Form Date: Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D Secondary Phone# (Home)(Cell)(Work):
ADA-Sponsored Disability Income Protection Plan Application for Insurance
Members Insurance Plans ADA-Sponsored Disability Income Protection Plan Application for Insurance IPWS15 Read all forms Complete sections 1 thru 9 Mail or Fax ALL completed forms Questions? 866.607.5334
Horizon Eye Care, P.A. Patient Information Sheet. For your convenience, please print and complete the pre-registration forms before your visit.
Patient Information Sheet For your convenience, please print and complete the pre-registration forms before your visit. Section 1: Patient's Legal Name: (First, MI, Last) Parent / Guardian: (If applicable)
How did you hear about our services? (Check ONE only)
Name: of Visit: Is your visit a MEDICAL or COSMETIC visit? (Check one) How did you hear about our services? (Check ONE only) 1. Newspaper Ad Name of Newspaper: 2. Internet via: Banner Ad Search via pdskin.com
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
How To Write A Medical History Questionnaire For An Aransas Plastic Surgery
Arkansas Plastic Surgery O David H. Bauer, M.D. O Gary E. Talbert, M.D. Appointment Date Patient Information INFORMATION FOR CASE HISTORY FILE Patient s Name: SS# First Middle Last Date of Birth: Patient
Orthopedic Initial Questionnaire
Orthopedic Initial Questionnaire Name: Date: Height: Weight: In order to allow the therapist to have a better understanding of the nature of your injury and evaluate your condition fully, please complete
1455 West Fair, Marquette, MI 49855 Phone - 906.226.0574 // Fax - 1.888.347.1135 // info@mqtrehab.com
To our valued patients, In order to speed up the registration process and begin your treatment as soon as possible, please complete the forms listed below and bring the proper documentation to your first
Professional Practice Medical Record Documentation Guidelines
Professional Practice Medical Record Documentation Guidelines INTRODUCTION Consistent and complete documentation in the medical record is an essential component of quality patient care. All Participating
SUPPORT PATH PROGRAM INTAKE FORM PHONE: 1-855-769-7284 FAX: 1-855-298-8700
SUPPORT PATH PROGRAM INTAKE FORM PHONE: 1-855-769-7284 FAX: 1-855-298-8700 1 REQUESTED SERVICE(S) (REQUIRED) CHECK ALL BOXES THAT APPLY Benefits Investigation Prior Authorization and Appeals Support Patient
Patient Resource Guide for Billing and Insurance Information
Patient Resource Guide for Billing and Insurance Information 17 Patient Account Payment Policies July 2012 Update Lexington Clinic Central Business Office Payment Policies Customer service...2 Check-in...2
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
Medicare Supplement plan application
Medicare Supplement plan application SECTION 1 Personal information Last name First name Middle initial Social Security number - - Primary Street address City State ZIP code Mailing Street address (if
Application for Blue Shield of California Medicare Supplement plans
Application for Blue Shield of California Medicare Supplement plans FOR OFFICE USE ONLY Here's how to apply Accept. code Plan type Market code 1 Provide ALL requested information and print clearly in blue
New Patient Information Form
PATIENT INFORMATION New Patient Information Form Patient s Patient s Preferred Name Middle Initial Date of Birth SSN# Primary Language YES NO Email Address Race/Ethnicity Is patient of Hispanic Origin?
Dr. David Y. Liao, D.O. Orthopedic Center, LLC. Release of Information
Release of Information The purpose of this form is to alert our office as to those family members and/or friends who may be scheduling or canceling appointments on your behalf and/or will need to have
How Much Does a Cool Springs Eye Care Business Cost?
Welcome to Cool Springs EyeCare and Donelson EyeCare! We are looking forward to seeing you and helping you with your eye health and vision. As a comprehensive primary care practice we provide a full range
Minnesota Comprehensive Health Association. Summary of Benefits and Plan Options
Minnesota Comprehensive Health Association Summary of Benefits and Options www.mchamn.com MCHA Customer Service 1-866-894-8053 TTY: 952-992-3190 or toll-free at 1-800-841-6753 Monday Friday: 7 a.m. 6 p.m.
Last Name First Name Middle Initial Address Apt # City State Zip Home Phone ( ) Mobile Phone ( ) Work Phone ( )
Patient Registration A. P A T I E N T Please Print Legibly on Form Account # Address Apt # City State Zip DOB (mm/dd/yy) Gender Male Female SSN # Preferred Contact Method: Home Ph Mobile Ph Text E-mail
PATIENT INFORMATION - Please complete and/or verify all information and make changes as necessary.
PATIENT INFORMATION - Please complete and/or verify all information and make changes as necessary. Today s : Are you here for an injury that is work-related? YES NO N/A Patient Name (First-Middle-Last)
Orthopedic Initial Questionnaire. Date: Weight:
Orthopedic Initial Questionnaire Name: Height: Date: Weight: In order to allow the therapist to have a better understanding of the nature of your injury and evaluate your condition fully, please complete
Good health happens together
Good health happens together CITY OF BALTIMORE 2016 HEALTH CARE OPTIONS WHAT S INSIDE BENEFITS OVERVIEW WELLNESS RESOURCES ONLINE TOOLS Thank you for considering UnitedHealthcare. We are proud to again
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:
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
!"#$%$&!"'()*+,-".-,/ &01*+("12"31+4156"$,+0"!*7("819".5(<(/4*<("&,5( :(()";(,-40"&,5( !"#$%$&!",/)"'()*+,5(
submitted anytime during the year to your institution HR/Benefits Office, and the tobacco premium will be waived beginning the first of the month following submission of the form. Important: A member is
WAKEMED DONOR MILK PROGRAM AGREEMENT
WAKEMED DONOR MILK PROGRAM AGREEMENT Dear Sir/Madam, To begin your participation in the program please read the following Donor Milk Program Fact Sheet (page 2). Keep this for your records. A prescription
INTEGRATED PHYSICAL THERAPY a whole- istic 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: Referring Physician? _ How do you hear about us: Dr. Referral
Blue Cross and Blue Shield of Georgia Medicare Supplement Application
Blue Cross and Blue Shield of Georgia Medicare Supplement Application o New Enrollment o Change to Enrollment Send no money now! For assistance, please contact us at 1-888-211-9817 or contact your Blue
New Patient Information
New Patient Information LAST FIRST NAME NAME M.I. DATE OF SOC. MARITAL BIRTH SEC. SEX STATUS PRIMARY ADDRESS PHONE CELL CITY STATE ZIP PHONE WORK EMPLOYER PHONE REFERRING/ YOUR PRIMARY PHYSICIAN E-MAIL
920 NE 112 th Avenue, Suite 103, Vancouver, WA 98648 Phone: 360-567-2002 Fax: 360-567-2005 www.timberlinept.com
920 NE 112 th Avenue, Suite 103, Vancouver, WA 98648 Phone: 360-567-2002 Fax: 360-567-2005 www.timberlinept.com Thank you for selecting Timberline to be a part of your rehabilitation. Below we have condensed
BORIS RUBASHKIN, MD DONNA EDWARDS, RN, MSN, PMH- NP BERNADATTE WILLIAMS, PMH-NP
BORIS RUBASHKIN, MD DONNA EDWARDS, RN, MSN, PMH- NP BERNADATTE WILLIAMS, PMH-NP 9525 Katy Freeway, Suite 312 Houston, Texas 77024 Phone (713) 463-9449 Fax (713) 463-7181 www.bhchouston.com Welcome! Thank
11120 New Hampshire Ave., Suite 411 Silver Spring MD 20904 Office (301)754-0505 Fax (301)754-0509
PATIENT REGISTRATION FORM (PLEASE PRINT) PATIENT S LAST FIRST MIDDLE DATE OF BIRTH / / AGE: SEX: M F SOCIAL SECURITY # STREET ADDRESS APT # CITY STATE ZIP HOME CELL EMAIL MARITAL STATUS: SINGLE / MARRIED
Specialty Drug Care: Case management services in Quebec
Specialty Drug Care: Case management services in Quebec QUEBEC SUPPORTING HEALTHIER OUTCOMES Your health benefit plan is designed to provide you and your family with financial protection for a variety
Welcome to Happy Teeth Dental Care!
Happy Teeth Dental Care Registration Packet Welcome to Happy Teeth Dental Care! Thank you for choosing our office for your dental needs. We look forward to meeting and working with you! Happy Teeth Dental
You can relax, knowing your final wishes will be respected.
Memorial Fund You can relax, knowing your final wishes will be respected. Humana Financial Protection Products GNA06XOHH 11/09 MI Memorial Fund Ensure financial peace of mind for you and your family. You
Welcome to Seattle Smiles Dental
Welcome to Seattle Smiles Dental The Puget Sound Plaza 1325 4 TH Avenue, Suite 1230 Seattle, Washington 98101 TEL: 206.624.1773 FAX: 206.624.2268 info@seattlesmilesdental.com MISSION Our mission is to
Advanced Rheumatology of Houston Offices of Dr. Tamar F Brionez
Advanced Rheumatology of Houston Offices of Dr. Tamar F Brionez New patient history form Patient name DOB Allergies to Medicines: Current Medications Name Dose Times/day taken Social History Married/single/widowed/divorced
New River Health will bill private insurance, Medicaid, and CHIP for eligible students. No child will be denied services due to inability to pay.
The Richwood School-Based Health Center is pleased to offer medical, mental health counseling, health education, and on site dental services to all Richwood Middle School and Richwood High School students.
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
FAMILY CONTACT INFORMATION
FAMILY CONTACT INFORMATION -------------------- PLEASE COMPLETE THIS FORM IN BLACK INK ONLY -------------------- Date Account # Children Names DOB Gender School Goes By Cell Phone # Email Address Please
How To Pay For Care At A Clinic
WELCOME TO THE HUMAN PERFORMANCE AND REHABILITATION CENTERS, INC. Welcome to Human Performance and Rehabilitation Centers, Inc. The following information will give you a better understanding of our payment
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
Health First Insurance, Inc. Medicare Supplement Application 2013
6450 US Highway 1, Rockledge, FL 32955 Customer Service: 321.434.4822 Toll-free 1.855.443.4735 TTY relay 1.800.955.8771 Monday through Friday from 8 am to 8 pm, Saturday from 8 am to noon A. General 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
Hospitals and Health Systems:
Hospitals and Health Systems: An Inside Look at Employee Health Plan Strategies To Control Costs and Provide Access to Healthcare August 2010 Highlights Because of their dual role as benefit plan sponsor
REHAB RESOURCES, INC. CONSENT FOR TREATMENT ASSIGNMENT OF BENEFITS BILLING AUTHORZATION ADULT (18 years and over)
CONSENT FOR TREATMENT ASSIGNMENT OF BENEFITS BILLING AUTHORZATION ADULT (18 years and over) Rehab Resources, Inc. is a certified agency that provides outpatient therapy services. Occupational, Physical,
WELCOME TO MY PRACTICE Thank you for choosing me as your therapist. I am looking forward to our work together and providing you with assistance.
Lorie Jenddryka, MS, LCPC, CH 800 E. Northwest Highway, Suite 500 Palatine, IL 60074 (847) 794-8836 WELCOME TO MY PRACTICE Thank you for choosing me as your therapist. I am looking forward to our work
3 Emergency Contact. Eaton Chiropractic & Rehab Center. 1 Patient Information. 2 Insurance / Guarantor. 4 Accident Information. Emergency Contact:
Eaton Chiropractic & Rehab Center 1 Patient Information Name: First Initial Last Address: Home: Work: Cell: DOB: Male Sex: Female SSN: Email: Single Divorced Marital Status: Married Separated Widowed Full
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:
Copayment: The amount you must pay for each medical visit to a participating doctor or other healthcare provider, usually at this time service.
Basic Terms How to calculate Out of Pocket Costs on a Hospital Stay: If you have a $2000 deductible and 30% coinsurance health insurance plan. If you have a $10,000 emergency room or hospital stay your
Application for Senior Medicare Supplement Plans BLUE CROSS AND BLUE SHIELD OF MONTANA P.O. BOX 4309 HELENA, MT 59604
Application for Senior Medicare Supplement Plans BLUE CROSS AND BLUE SHIELD OF MONTANA P.O. BOX 4309 HELENA, MT 59604 SENIORAPP062010 FLD New Enrollment Change Benefit Plan (e.g., Plan F to Plan C) Transfer
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
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:
Understanding the ObamaCare Health Insurance Plans in North Carolina Understanding Insurance and Affordable Care Act Terminology: ACA- Marketplace
Understanding the ObamaCare Health Insurance Plans in North Carolina As a result of the Affordable Care Act (a.k.a. ObamaCare) the following provisions are now in place for health insurance policies with
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
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)
Praxis Physical Therapy and Human Performance 935 Lakeview Parkway Suite #195 Vernon Hills, IL 60030 Phone: 847-247-7200 Fax: 847-247-4340
Medical Registration Form (Page 1) Welcome to our Office: By completing this patient information form, you will help us to serve you more efficiently. Should you have any questions concerning our professional
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
PATIENT INFORMATION. Office Location:
Date: PATIENT NAME (Last, First M.I.): PATIENT INFORMATION (Please complete all sections) Office Location: DATE OF BIRTH: / / NAME OF PARENT(S) OR GUARDIAN(S): SSN#: SEX: (_) Male (_) Female MARITAL STATUS:
FAIRBANKS PHYSICAL THERAPY
REGISTRATION PAPERWORK CHECKLIST If you wish, you can save time and simplify the registration process by completing the registration paperwork before you arrive. This checklist will help make sure you
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:
Lanier Chiropractic and Rehabilitation Information 4530 Nelson Brogdon Blvd., Suite B, Sugar Hill, GA 30024 770-271-8949
Lanier Chiropractic and Rehabilitation Information 4530 Nelson Brogdon Blvd., Suite B, Sugar Hill, GA 30024 770-271-8949 Thank you for choosing Lanier Chiropractic and Rehabilitation! It is our desire
AGREEMENT AND INFORMATION
AGREEMENT AND INFORMATION We would like to welcome you to our office. Please review this Agreement and Information sheet to assist you in understanding our office policies. Our therapists are private practitioners.
Policy Holder Name Relationship to Patient SSN DOB
Orthopedic Today s Date Patient s SSN# Legal First Name Last Name M.I. DOB Gender Parent/Guardian Name (for pediatrics) DOB Address City State Zip Home Phone Cell Phone Work Phone Email Have any members
Your Retiree Health Care Travel Guide
SPECIAL EDITION for Individuals Not Yet Eligible for Medicare Your Retiree Health Care Travel Guide 2010 Enrollment for BorgWarner Pre-Medicare Health Care Coverage Welcome to 2010 Pre-Medicare enrollment!
ADULT MEDICAL SERVICES PC 6645 Main St. Suite A, Williamsville, NY 14221 (716) 276-8726 (Office) (716) 276-8730 (Fax)
I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information
2015 Medicare Supplement Program
2015 Medicare Supplement Program NUSCO Retiree Health Plan Medicare Eligible Retirees and Surviving Spouses Your Medicare Supplement Program This guide can help you better understand your Medicare Supplement
UNIVERSITY OF WISCONSIN MADISON BADGER SPORTS CAMP HEALTH FORM
UNIVERSITY OF WISCONSIN MADISON BADGER SPORTS CAMP HEALTH FORM Event Name: Dates: Participant Name: Participant cell phone with area code: Custodial Parent/Guardian Name: Phone number: Cell phone: Home
MEDICARE SUPPLEMENT APPLICATION - NEVADA Please complete entire application.
MEDICARE SUPPLEMENT APPLICATION - NEVADA Please complete entire application. Select a plan: Plan A Plan B Plan F Plan I Plan J Section 1 Applicant Information This complete original application will be
WELCOME TO AMOSKEAG CHIROPRACTIC, INC. SPINAL CORRECTIVE CARE FOR THE ENTIRE FAMILY ADULT. Full Name: What would you prefer to be called?
Today s Date: / / WELCOME TO AMOSKEAG CHIROPRACTIC, INC. SPINAL CORRECTIVE CARE FOR THE ENTIRE FAMILY ADULT Full Name: What would you prefer to be called? Street Address (If P. O. Box, provide street address
Welcome MHBP Value Plan Members
Welcome MHBP Value Plan Members Welcome to the Mail Handlers Benefit Plan. We are delighted that you chose to enroll in our newest health plan option. We are proud of our long heritage in serving federal
Prior Authorization, Pharmacy and Health Case Management Information. Prior Authorization. Pharmacy Information. Health Case Management
Prior Authorization, Pharmacy and Health Case Management Information The purpose of this information sheet is to provide you with details on how Great-West Life will be assessing and managing your claim
! 1220 Howell Street Ste. 110, Seattle, WA 98101 (206) 464-9002
! 1220 Howell Street Ste. 110, Seattle, WA 98101 (206) 464-9002 PATIENT INFORMATION PATIENT NAME (Last, First, Middle Initial) DATE OF BIRTH AGE ADDRESS SOCIAL SECURITY NUMBER CITY, STATE, ZIP Male GENDER
What is HCC Life Short Term Medical (HCC Life STM ) What are my coverage options with HCC Life STM?
What is HCC Life Short Term Medical (HCC Life STM ) HCC Life STM provides affordable temporary health insurance to protect you and your family. You should consider purchasing HCC Life STM if you are concerned
Enrollment Application
Enrollment Application Information About You 840 Carolina Street Sauk City, Wisconsin 53583-1374 (800) 926-8227; Fax (608) 836-0092 www.unityhealth.com Effective Date: / / Name (Last, First, Middle Initial):
Choptank Community Health System School Based Dental Program Healthy Children Are Better Learners DENTAL
School Based Dental Program Healthy Children Are Better Learners DENTAL Dear Parent/Guardian: As a student in the Caroline, Dorchester and Talbot County Public School system, your child has access to the
BOWLING GREEN INTERNAL MEDICINE AND PEDIATRICS ASSOCIATES TREATMENT AUTHORIZATIONS AND FINANCIAL POLICIES
BOWLING GREEN INTERNAL MEDICINE AND PEDIATRICS ASSOCIATES TREATMENT AUTHORIZATIONS AND FINANCIAL POLICIES Patient Name: Date: FINANCIAL POLICY FOR PATIENTS Effective July 10, 2000 our office has established
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:
Effective Jan. 1, 2016. STRS Ohio Health Care Program Guide
Effective Jan. 1, 2016 2016 STRS Ohio Health Care Program Guide 2 www.strsoh.org Welcome Thank you for your interest in the STRS Ohio Health Care Program. We understand choosing a health care plan is an
UnitedHealthcare Injectable Chemotherapy Prior Authorization (PA) Program Frequently Asked Questions
UnitedHealthcare Injectable Chemotherapy Prior Authorization (PA) Program Frequently Asked Questions Q1. What members are impacted by the UnitedHealthcare Injectable Chemotherapy PA Program? A. Beginning
Florida Neurology, P.A.
Florida Neurology, P.A. Sam Shanmugham, MD Elias Gizaw, MD Nitesh Shekhadia, MD Ramit Panara, MD Robert Rahe, PA-C Lake Mary Orange City Tavares 755 Stirling Center Place Lake Mary, FL 32746 (407) 333-1718
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,
Healthcare Associates Caring for You
Healthcare Associates Caring for You Welcome to Healthcare Associates Dedicated to You At Healthcare Associates (HCA), patients come first, and caring for you is what we do best. We are pleased to offer
BARNIDLL SPORTS MEDICINE 7000 W. 9th Ave. Amarillo, TX 79106 (806) 350-3500 www.barnhillsportsmed.com
BARNIDLL SPORTS MEDICINE 7000 W. 9th Ave. Amarillo, TX 79106 (806) 350-3500 www.barnhillsportsmed.com ACKNOWLEDGMENT OF RECEIPT OF PRIVACY NOTICE I acknowledgement that I have received a copy of Barnhill
[TRANSITIONS ] Short Term Recovery Care Application TRS-336-XX [ER/ASSOC#: ] Applicant Name (First, MI, Last) Social Security Number Email Address
![[TRANSITIONS ] Short Term Recovery Care Application TRS-336-XX [ER/ASSOC#: ] Applicant Name (First, MI, Last) Social Security Number Email Address](/thumbs/31/14787247.jpg "[TRANSITIONS ] Short Term Recovery Care Application TRS-336-XX [ER/ASSOC#: ] Applicant Name (First, MI, Last) Social Security Number Email Address")
I. APPLICANT INFORMATION: 1. IDENTIFYING INFORMATION: [TRANSITIONS ] Short Term Recovery Care Application TRS-336-XX [ER/ASSOC#: ] [Administrative Offices:] [165 Court Street] [Rochester, NY 14647] [1-800-544-0327]
PATIENT INFORMATION INSURANCE INFORMATION
(mm/dd/yyyy): Have you been to Physicians Urgent Care before? Yes No Arrival Time: If yes, when? Is this a follow-up to a previous visit: Yes No PATIENT INFORMATION Patient s First Name: Middle Name: Last
Your guide to better health Grow healthy. Live well.
Your guide to better health Grow healthy. Live well. FREDERICK COUNTY PUBLIC SCHOOLS Look Inside Where do I go for health tools and resources? How can I get and stay healthy? What mobile applications are
WELCOME TO TRI-COUNTY EYE CLINIC
WELCOME TO TRI-COUNTY EYE CLINIC Thank you for choosing Tri-County Eye Clinic as the provider for your eye care. You have an appointment at one of the following two locations: 15122 Dedeaux Road, Gulfport,
FAQs: Health Savings Accounts
What is a Health Savings Account? A Health Savings Account (HSA) is a savings product that allows individuals to pay for current qualified medical expenses and save toward future medical expenses on a
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
Provider Handbooks. Telecommunication Services Handbook
Provider Handbooks January 2016 Telecommunication Services Handbook The Texas Medicaid & Healthcare Partnership (TMHP) is the claims administrator for Texas Medicaid under contract with the Texas Health
*WELCOME TO OUR OFFICE*
*WELCOME TO OUR OFFICE* WE FIND THAT COMMUNICATION WITH OUR PATIENTS REGARDING OUR BUISNESS OFFICE POLICIES ASSISTS US IN PROVIDING YOU THE BEST SERVICE. THEREFORE WE HAVE PROVIDED A HIGHLIGHT OF SOME
Eligibility, Enrollment, Disenrollment & Grace Period
Section 2. Eligibility, Enrollment, Disenrollment & Grace Period Enrollment Enrollment in Ohio s Marketplace Program The Centers for Medicare and Medicaid Services (CMS) is the program which implements
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