Arthritis, Rheumatic & Back Disease Associates, P.A. Greentree Osteoporosis Center
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- Lorin Lester
- 9 years ago
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1 Dear Patient, We are looking forward to seeing you for your upcoming appointment. This time has been set aside especially for you and it includes time for us to answer any questions you may have. Please take a moment to review the enclosed material. We must have certain information before your visit. Fill out the enclosed medical history and insurance forms and bring them with you when you come for your appointment. In addition, if you have had any recent medical tests it will be helpful for you to bring these results with you. If for any reason you are unable to keep this appointment, we would appreciate at least 48 hours notice. This allows us to keep the wait for new patient appointments to a minimum. In addition, we strive to have emergency appointments available or our established patients. Your courtesy in notifying us of any change you need in your appointment day or time enables us to do this. Should a new patient schedule an appointment and miss that appointment without notifying us, there will be a charge of $ Thank you very much for the trust and confidence you have expressed in choosing this practice for your medical care. Sincerely, Sheldon D. Solomon, M.D., F.A.C.P. Brian L. Grimmett, M.D. Kenneth H. Maurer, M.D. James P. Dwyer, D.O. Adrienne R. Hollander, M.D. Arielle S. Silver, M.D. Michael C. Schuster, M.D., Ph.D. Amy M. Evangelisto, M.D. Alicia Weeks, M.D. Joshua Sundhar, M.D Evesham Road Suite 101 Voorhees, NJ Fax Route 38 West Suite 103 Mount Laurel, NJ Fax Hurffville-Crosskeys Road Suite 130 Sewell, NJ Fax
2 PATIENT INFORMATION Patient name: of birth: Gender: Address: Social security #: City: State/Zip: Home phone: M F Cell or business phone: Insurance subscriber name: Subscriber date of birth: Relationship to subscriber (i.e. self, child, spouse): Emergency contact name: Emergency contact phone: Are you required to have a referral from your Primary Care Physician to see a specialist? Yes No Primary Care Physician name and phone: PRIMARY INSURANCE Insurer name: Address and phone: SECONDARY OR SUPPLEMENTAL INSURANCE Insurer name: Address and phone: Patient ID #: Group #: Patient ID #: Group #: Effective date: Effective date: If applicable, what is your copay for specialist office visits? PHARMACY If you have pharmacy benefits, are they covered by your Primary Insurance? Yes No Pharmacy benefit ID #: Effective date: If not, what are the name, address, and phone of your pharmacy insurance carrier? Name, address, and phone of your local pharmacy: Name, address, and phone of your mail order pharmacy: IMPORTANT: Many health insurance policies have specific restrictions as to the health care they cover and where that care can be given. Our office will try to provide to your insurance company information that will maximize your coverage. It is important, however, that you be informed about your coverage. BEFORE YOUR VISIT TO OUR OFFICE please refer to your insurance card and the telephone number on the reverse side, your employer benefits manager, or insurance agent to answer the following questions: 1. Are you limited in your choice of physicians? Yes No 2. If you need lab, x-rays, or other therapy are there only certain places where these can be performed? Yes No 3. Are there only certain hospitals to which you can be admitted? Yes No This will help you, and us better understand any restrictions you may have on your health care coverage. If you are unsure of the answers to these questions please call your employer benefits manager or your insurance company. A phone number for your insurance company appears on the back side of your card.
3 Patient or other authorized person: Please sign the appropriate insurance authorization below so that we can process your claim. Thank you! MEDICARE (Policy #: ) or MEDIGAP (Policy #: ) I request that payment of authorized Medicare benefits be made, on my behalf, to Sheldon D. Solomon, M.D., Brian L. Grimmett, M.D., Kenneth H. Maurer, M.D., James P. Dwyer, D.O., Adrienne Hollander, M.D., Arielle Silver, M.D., Stephen Burnstein, D.O., Michael Schuster, M.D., Amy Evangelisto, M.D, Alicia Weeks, M.D., Joshua Sundhar, M.D. of Arthritis, Rheumatic & Back Disease Associates for any services furnished to my by that physician or supplier. I authorize any holder of medical information about me to release to the Health Care Financing Administration and it s agents or to my Medigap insurance, any information needed to determine these benefits or the benefits payable for related services. Beneficiary Signature OTHER HEALTH INSURANCE (Name of insurance: ) I authorize the release of any medical information necessary to process my health insurance claim and authorized payment of medical benefits, on my behalf, to Sheldon D. Solomon, M.D., Brian L. Grimmett, M.D., Kenneth H. Maurer, M.D., James P. Dwyer, D.O., Adrienne Hollander, M.D., Arielle Silver M.D., Stephen Burnstein, D.O., Michael Schuster, M.D., Amy Evangelisto, M.D., Alicia Weeks, M.D., Joshua Sundhar, M.D. of Arthritis, Rheumatic & Back Disease Associates for any services furnished me by that physician/supplier. Beneficiary Signature IF WE ARE AN OUT OF NETWORK PROVIDER FOR YOU I am currently enrolled in health insurance.. I understand that I am being treated at Arthritis, Rheumatic & Back Disease Associates by Dr., who is not a participating provider for this health insurance plan. My fees for services will be submitted to my insurance carrier, but I understand that any and all fees not covered by my plan, including but not limited to co-pays and deductibles, as a result of Dr. s non participation are my responsibility. I may request, at any time, a list of charges incurred for my care. Beneficiary Signature ALL PATIENTS WHOSE INSURANCE REQUIRES REFERRALS MANAGED CARE HEALTH INSURANCE (ALL CARRIERS) I am currently enrolled in, which requires a current and valid referral prior to receiving medical services. I have been informed by Arthritis, Rheumatic & Back Disease Associates, P.A., that if I do NOT have a current, valid referral on file the day my services are rendered my insurance will not pay Arthritis, Rheumatic & Back Disease Associates or reimburse me for the cost of those services. I assume full financial liability for any services provided to me by Arthritis, Rheumatic & Back Disease Associates today, or any day, when a current, valid referred has not been received by Arthritis, Rheumatic & Back Disease Associates. Beneficiary Signature
4 CONSENT TO OBTAIN MEDICATION HISTORY With your consent, we may request and use your prescription medication history information using the e- prescription feature of our electronic medical records. This is only for informational purposes so that an up to date record of your medication is available for your treatment and safety. Yes, I give my consent to obtain my medication history using the e- prescribing feature. No, I do not give my consent to obtain my medication history using the e-prescribing feature. I understand that my mediation information my not be complete when making treatment decisions. RECEIPT OF NOTICE OF PRIVACY PRACTICE WRITTEN ACKNOWLEDGEMENT FORM I,, have been advised that Arthritis, Rheumatic & Back Disease Associates complies with required privacy regulations regarding my Individually Identifiable Health Information created as a result of the Health Insurance Protability and Accountability Act of 1996 (HIPAA). A copy of the Practice Notice of Privacy Practices in available for me should I want one. Patient Signature
5 OFFICE POLICY REGARDING LEGAL CASES AND TESTIMONY Dear Patient, This statement is to acquaint you with our policy in regard to accepting cases with legal involvement or those requiring testimony. Because of our heavy clinical research and teaching responsibilities, and the ongoing requirements of good patient care, we find it impossible to accept any new patients with legal involvement or cases requiring testimony. It is frequently impossible to predict which cases with legal involvement will require testimony and which will not. With this in mind it has been our decision to accept no cases of this nature and refer patients who need this type of advice and assistance to other physicians for their care. The main reason we choose not to participate in the medical component of litigation is that it requires an extensive commitment in time and energy. We feel our primary obligation is to render medical care and treatment, rather than testimony and assistance in the area of litigation. We appreciate your understanding and ask you to sign this statement as acknowledgement of your understanding of this policy. Sincerely, Sheldon D. Solomon, M.D., F.A.C.P. Brian L. Grimmett, M.D. Kenneth H. Maurer, M.D. James P. Dwyer, D.O. Adrienne R. Hollander, M.D. Arielle S. Silver, M.D. Stephen L. Burnstein, D.O. Michael C. Schuster, M.D., Ph.D. Amy M. Evangelisto, M.D. Alicia Weeks, M.D. Joshua Sundhar, M.D. Patient Signature Witness Signature
6 IMPORTANT INFORMATION FOR OUR PATIENTS REGARDING DISABILITY FORMS If you are under the care of our physicians at Arthritis, Rheumatic & Back Disease Associates you need to be aware that it is our office policy not to fill out disability claims, temporary or permanent, initiated by yourself, an attorney, employer, other health care provider, etc. It has been our experience that being asked to do so significantly interferes with the doctor-patient relationship. In our judgment, certification of disability status is properly determined by independent examination. We are, of course, always able to forward your office records to requesting parties approved by you in support of your claim. Should you have any questions regarding this policy please feel free to discuss them with us.
7 PATIENT HISTORY - Arthritis, Rheumatic & Back Disease Associates, P.A. Please complete and bring to your appointment Today s date: Last Name First Middle Birth Birth Place Gender M Race: American Indian or Alaska Native Asian Address Black or African American Native Hawaiian or other Pacific Islander White F Ethnicity: Hispanic or Latino Not Hispanic or Latino Language(s) spoken Marital Status Home Phone # Other Phone # Occupation Emergency Contact Name E.C. Relationship E.C. Phone # of Last Physical Exam Referring Doctor Doctor Referring Doctor s Address Have you been diagnosed as having (circle all that apply): Stroke Psoriasis Osteopenia Osteoporosis Cancer High blood pressure Heart Attack Angina Tuberculosis Ulcers Congestive Heart Failure Venereal Disease AIDS Kidney Disease Sinusitis Enlarged Prostate Diabetes Kidney Stone Thyroid Disease Anxiety Leukemia Phlebitis Arthritis Depression Seizures Colitis Gout Mental Illness Migraines Diverticulitis Rheumatoid Arthritis Nervous Breakdown Asthma Irritable Bowel Disease Osteoarthritis Suicide Attempt Bleeding Tendency Rheumatic heart disease Systemic Lupus Spinal Stenosis Hepatitis Congential heart disease Psoriatic Arthritis Herniated Disc Have you had other prior medical problems not mentioned above? List any operations you have had and the years in which you had them. List any drugs to which you are allergic. List all current or recent medications (including eye drops). List any prior arthritis drugs.
8 Do you currently smoke? If no, have you smoked in the past? Do you currently use, or have you used in the past, IV drugs, marijuana, heroine or cocaine? Do you currently drink alcohol? If no, did you drink in the past? If yes, how much alcohol do you consume daily? Do you have a living will or advanced directives? Have you recently noticed any of the following problems? (Circle Y or N) Headache Dizziness Ringing in Ear Numbness in hands Mouth Sores Dry Mouth Other skin condition Trouble Swallowing Rash from the sun Psoriasis Wheezing Shortness of breath Cough Cough up blood Rapid heart beat Diarrhea Hoarseness Chest pain Weight loss Black or bloody stool Stomach pain Loss of appetite Blood in urine Color change in fingers Constipation Burning when urinate Nosebleeds when exposed to cold To be answered by women only Are you having regular menstrual periods? of last menstrual period: Are you post menopausal How many children born alive? Are you currently taking oral contraceptives? How many miscarriages? Have you ever had any complications of pregnancy? Family history Father Mother Siblings Spouse Children Name Gender M F If living If deceased Age Medical issues Age at death Cause/Prior medical issues Describe briefly the problems for which you are being seen at this office. Is there additional information you feel is important and may impact your medical care? Are you interested in participating in relevant Clinical Trials that could provide new treatments for your disease?
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Information as of (enter today s date) (Please Print Legibly & Fill In or Correct All Fields) s Name Address First Middle Last Street & Apt # City State Zip Home Phone Cell Phone Other Phone Any restrictions
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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
(928) 854-4307 MEDICAL HISTORY. Weight: _ Shoe size: _
2302 N. Stockton Hill Rd Ste. G 1731 Mesquite Ave Ste 4 1200 Mohave Rd MEDICAL HISTORY Weight: Shoe size: ~~~~~~~~~~~~~~~~~~~~~~~~~~PLEASECIRCLE: RIGHT or LE~ Is your problem due to an accident? YES or
WELCOME Thank you for taking the time to fill out this form. It will enable us to provide quality, personalized dental care for you.
HIRSHFIELD DENTAL CARE 50 NORTH ST. MEDFIELD, MA 02052 Today s date WELCOME Thank you for taking the time to fill out this form. It will enable us to provide quality, personalized dental care for you.
Orthopaedic Institute of Ohio Demographic Information Date:
Orthopaedic Institute of Ohio Demographic Information Date: Patient Name Home Phone Cell Phone Employer Phone Mailing Address (include PO Box and Apt. #) Family Doctor Name and Phone Number City, State,
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
Please bring the following with you to your appointment: Completed New Patient forms A list of all prescribed medications with dosages and quantity
Mark E. Hollingshead, M.D. Cataract & Refractive Surgeon Welcome: We look forward to being of assistance to you on your first visit with Hollingshead Eye Center. In order to provide the best possible service,
PATIENT REGISTRATION
PATIENT REGISTRATION Patient s Last Name: Patient s First Name: MI: Address: City, State Zip code: Patient s Date of Birth: Patient s Social Security: Best Number to contact: Secondary Number: Marital
PLEASE COMPLETE PRIOR TO VISIT***Place your name at the bottom of each sheet
PLEASE COMPLETE PRIOR TO VISIT***Place your name at the bottom of each sheet GASTROINTESTINAL ASSOCIATES, INC. PATIENT REGISTRATION Welcome to our practice. Please complete all sections of this registration
Electronic Health Records Intake Form
Dr. Sam Yoder, D.C. 101 Winston Way Ste B Campbellsville, KY 42718 Electronic Health Records Intake Form In compliance with requirements for the government EHR incentive program First Name: Address: Last
Please review, complete, and return all paperwork included in this packet. If you have any questions or concerns please feel free to contact us at
Your child has been referred to the Health4Life Program at Children's Healthcare of Atlanta. We are located at the Scottish Rite Campus in the Medical Office Building. In order to serve you and your child
St. Luke s MS Center New Patient Questionnaire. Name: Date: Birth date: Right or Left handed? Who is your Primary Doctor?
St. Luke s MS Center New Patient Questionnaire Name: Date: Birth date: Right or Left handed? Who is your Primary Doctor? Who referred you to the MS Center? List any other doctors you see: Reason you have
Health Information Form for Adults
A. Identification B. Emergency Contacts Name (Last) (First) (Middle) Maiden Name In Case of Emergency, Notify: Primary Contact Name (Last) (First) (Middle) Primary Alternate Relationship Home Work Home
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
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.
PATIENT INFORMATION SHEET. Last Name: First Name: MI: Home Address: Apt# City: State: Zip Code: Home Phone #: Cell Phone #:
PATIENT INFORMATION SHEET PATIENT Last Name: First Name: MI: Gender: M F Date of Birth: / / SS# Home Address: Apt# City: State: Zip Code: Home Phone #: Cell Phone #: Employer Name: Work Phone #: Email
Accident / Injury Report
Accident / Injury Report Name Date Date of birth Date of accident Time of accident am / pm. auto injury Were you: Driver Passenger Pedestrian Were you struck from: Behind Right Side Left Side Front Parked
Patient Information. If Patient is child, Parent s Name. City State Zip Cell# SS# of Patient Driver s License #
Patient Information Patient Name Date of Birth If Patient is child, Parent s Name Street Address Male or Female City State Zip Cell# Home# Work# Name of Employer Email Address SS# of Patient Driver s License
Integrated Medical Services (IMS) New Patient Registration Sheet
Personal Information Today s Date: Patient First Name: Initial: Last Name: DOB: Age: Social Security #: Email: Address: Street Apt # City/State/Zip Home Phone: Work Phone: Cell phone: Gender : M F Language:
Agnes Ju Chang, M.D., F.A.A.D.
Agnes Ju Chang, M.D., F.A.A.D. Dear Valued Patient: Thank you for choosing Integrated Dermatology of K Street, the office of board certified dermatologists, Dr. Agnes Ju Chang, Dr. David A. Lee, Allison
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM PATIENT INFORMATION Patient s Name: First Middle Initial Last DOB: / / Address: City: State: Zip: Primary Phone: - - Secondary Phone: - - Email: (for patient portal purposes only)
Westoaks Orthopaedic Associates
Westoaks Orthopaedic Associates Name: Address: Patient ID #: Sex: M [ ] F [ ] Date of Birth: Social Security #: City, State, Zip: Email: [ ] Home [ ] Work [ ] Mobile [ ] Married [ ] Single Referring Physician:
Patient Information. Name: Soc Security #: Date of Birth: Age: Male / Female. LOCAL Address: Street City State Zip. Phone: Home: Cell / Work:
Patient Information PERSONAL INFORMATION (Please Print Clearly) Name: Soc Security #: Date of Birth: Age: Male / Female LOCAL Address: Street City State Zip Phone: Home: Cell / Work: Email Address: Out
In order to bill your Insurance, Please fill out the following information completely. PLEASE PRINT AND BRING TO YOUR APPOINTMENT
In order to bill your Insurance, Please fill out the following information completely. PLEASE PRINT AND BRING TO YOUR APPOINTMENT 1) PATIENT REGISTRATION ACCT #: DR.: APPT. DATE: FIRST NAME MIDDLE LAST
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
Full name DOB Age Address Email Phone numbers (H) (W) (C) Emergency contact Phone
DEMOGRAPHIC INFORMATION Full name DOB Age Address Email Phone numbers (H) (W) (C) Emergency contact Phone CARE INFORMATION Primary care physician: Address Phone Fax Referring physician: Specialty Address