Litchfield Family Practice Center FAQ s
|
|
- Jasper Lane
- 7 years ago
- Views:
Transcription
1 Litchfield Family Practice Center FAQ s 1. How long will it take to see my doctor? Each provider has their own staff that manages appointments. Making appointments as far in advance as foreseeable is the best way to get the exact time and date you want to come in. Our staff will make every effort to accommodate our patient's schedule and needs. 2. If I come in earlier than my scheduled appointment time, can I get in to see my doctor earlier? We try our best to stay on schedule. Even though you came in earlier, those times may be scheduled for other patients. However, if there is an unexpected opening, your doctor will work on seeing you earlier. 3. What time should I arrive for my appointment? If possible, patients should arrive 15 minutes prior to their scheduled time. This allows our check in staff to fully update all patient information and allows time for you to fill out any necessary forms. 4. Can I be seen without an appointment? Litchfield Family Practice Center patients are seen on an appointment basis. We encourage you to call to schedule an appointment with your provider. If a provider s schedule allows, we do occasionally make same day appointments. In case of a medical emergency, go directly to the nearest hospital. Page (1)
2 5. Do I have to sign in every time for an appointment? When you sign in, the nursing staff is notified that you are in the building, waiting to be seen. It is necessary for the nursing staff to know who is waiting and it is a good time for you to verify and update your information to guarantee it is accurate. 6. What do I do if I need a refill on a medication? You can either notify your pharmacy or call your provider s staff on their direct dial. 7. Can you call in a prescription without an appointment? It is our policy to fill routine prescriptions during scheduled office visits. However, factors can vary and this decision will be left to your doctor s discretion. Only he or she knows what is in your best medical interest. Your doctor will want to see you are receiving the correct medications for your medical needs. Please, be advised that there may be a charge for phone prescription service. 8. Where do I pick up my samples or written prescriptions? If you called your doctor for a written prescription or samples, you can pick them up at the front desk. Sometimes identification is requested, so please have your photo ID available. 9. How do I get my lab results? Your provider will call you or you will receive written results in the mail. Please, contact your provider if you have not received your results in seven days. 10. What does PA stand for? PA stands for Physician Assistant. PA s are licensed, board certified clinicians providing healthcare under a physician s supervision. Page (2)
3 11. What does NP or APRN-C stand for? NP stands for Nurse Practitioner and APRN-C Advanced Practice Registered Nurse Certified. These are both common acronyms for the same position. APRN-C s are licensed, board certified clinicians providing healthcare under a physician s supervision. 12. How do I get in contact with someone in case of an emergency? If you have an emergency that requires immediate medical attention, call 911 or contact St. Francis Hospital at (217) Do you bill my insurance? We accept all major insurances, including Medicare and Illinois Medicaid. At the time of your scheduled appointment, please bring your current insurance card and we will scan the card into our system. We urge you to call your insurance company to verify coverage. Knowing your insurance coverage is the best way not to receive unexpected bills. Please, be advised you are responsible for all balances after billing your insurance. If you do not have insurance coverage, payment for services are expect at the time of your visit unless other arrangements are made in advance. For more information, please call and ask for our Insurance Department for assistance. 14. Can I pay my bill in the office? Yes! You will be directed to the proper area by our front staff. We accept: Cash, Check, Debit & Credit cards (Visa, Master Card, and Discover). We will also accept you payments over the phone when you pay by credit or debit card. We can better assist you if you have all your information available when you call. 15. Whom do I call with questions about my bill? Call our Insurance Department at (217) Our staff will assist you with your billing and insurance questions. Please, have you account information ready when you call. Page (3)
4 16. When do I have to pay my co-pay? Our practice is committed to providing the best treatment to our patients and we appreciate co-pays being made at the time of service. Co-pays and deductibles are part of your contract with your insurance company. Contact your insurance company with any questions you may have regarding your coverage. 17. Why do you make a copy of my insurance card at each visit? We need current information to bill your insurance for your visit. Making a copy of your current insurance card when billing your insurance can save you time and trouble later. 18. Do I need to bring my old records with me when I come for my first visit? You can have your records forwarded to our office before your first visit or after. You must complete a form giving permission for your records to send to your new provider. Your nurse or our Medical Records staff can assist you in transferring your records. 19. Can I walk in and get copies of my medical records? You and your doctor must complete a release form first. We do charge a fee to cover the copy cost. If you request, you will be given an estimate on the charges prior to the work being done. If you have more questions, call our Medical Records at (217) Do you have female providers? Yes, we have both female and male providers to help you with your medical needs. 21. How can I be sure of total patient confidentiality? Even though federal HIPAA laws protect you, it is our duty to keep all visits and communications private. Litchfield Family Practice Center has extensive internal policies to protect your privacy. Page (4)
5 22. What if I cannot make my appointment? Do I have to call and cancel? We understand that problems do occur and you might not be able to make your scheduled appointment. If this is the case, please contact us as soon as possible to cancel your appointment. We would appreciate at least 24 hours notice. This allows us to use your appointment time for someone else that needs to be seen. 23. Do you charge for missed appointments? It is not our policy to charge for missed appointments, but if someone repeatedly misses appointments without calling, they will be charged for missed appointments and/or possibly be terminated as a patient. Please, help us serve you better by keeping your scheduled appointment. Page (5)
Office Policy & Procedures
Office Policy & Procedures Office hours are: Monday Thursday from 8am to 8pm, Friday from 8am to 6pm and Saturday/Sunday/Holidays open for sick visits only. Appointments are not scheduled ahead of time
More informationPatient Registration Form
900 Carillon Parkway Suite 404 St. Petersburg, FL 33716 727-572-1333 727-572-1331 fax www.spencerdermatology.com Patient Registration Form Today s : Name: Suffix First Middle Last of Birth: / / Age: Sex:
More informationPhysician s Practice Organization D/b/a Doctors Park Family Medicine Patient Information Brochure. To Our Patients
Physician s Practice Organization D/b/a Doctors Park Family Medicine Patient Information Brochure To Our Patients Thank you for choosing Doctors Park Family Medicine as the healthcare provider for you
More informationOFFICE 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 informationPsychiatric 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 informationAUBURN MEMORIAL MEDICAL SERVICES, P.C.
AUBURN MEMORIAL MEDICAL SERVICES, P.C. Office Policies We would like to thank you for choosing as your medical provider. We have written this policy to keep you informed of our current office policies.
More informationWelcome to Crozer-Keystone Health Network Primary Care
Welcome to Crozer-Keystone Health Network Primary Care A Guide to Your CKHN Patient-Centered Medical Home: What you can expect from us... What we will need from you......so you can gain the full benefits
More informationOffice Policies Dear Patient: We would like to take the opportunity to explain the policies of our office. Please take notice of the following:
Office Policies Dear Patient: We would like to take the opportunity to explain the policies of our office. Please take notice of the following: Please contact our answering service after hours for EMERGENCY
More informationPutnam North Family Medical Center An Affiliate of Advance Pain Management of Oklahoma
PATIENT INFORMATION AND PRACTICE POLICIES The Putnam North Family Medical Center's commitment to maintaining a broad knowledge and skill base enables your family to benefit from comprehensive and convenient
More informationAll routine calls will be be returned within 24 24 hours, in in the order in in which they were received.
Office Policies We would like to to take the opportunity to to explain the policies of of our office. Please take notice of of include fever, changes with r surgical incision or or increased pain, NO medication
More informationEmergency Room Services Satisfaction Survey
Emergency Room Services Satisfaction Survey Date: «NameF» «NameL» «AddressLine1» «AddressLine2» «City», «StateCode» «Zip» Dear Member: TML MultiState Intergovernmental Employee Benefits Pool (IEBP) appreciates
More informationWelcome 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 informationWelcome! A few things you need to know about being our patient.
Welcome! A few things you need to know about being our patient. Our Programs and Locations Our Medical and Behavioral Health Programs: In Jefferson County: We see children in our pediatric office, school-aged
More informationSingle 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 informationDerry Medical Center Patient Portal Information Page
Derry Medical Center Patient Portal Information Page Your Derry Medical Center/Londonderry Family Practice Patient Portal is a secure and comprehensive online communication tool which helps you and your
More informationUpdated 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 informationOFFICE POLICIES, EFFECTIVE October 19, 2009
Thank you for choosing our office for your medical care. We have written these policies to keep you informed of our current office policies. Please refer to our website for policy updates. OFFICE POLICIES,
More informationPatient 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 informationPatient 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 informationOFFICE POLICIES AND PROCEDURES
David Fivenson, MD, Dermatology, PLLC 3001 Miller Road, Ann Arbor, MI 48103 Phone: 734-222-9630 Fax: 734-222-9631 email: fivensondermatology@comcast.net OFFICE POLICIES AND PROCEDURES Thank you for choosing
More informationTransportation for health care appointments just got easier with
Transportation for health care appointments just got easier with Molina Medicare! With Molina Medicare Options Plus HMO SNP Plan, we offer the added benefit of non-emergency transportation to get you to
More informationPATIENT FINANCIAL POLICIES Effective Date: June 1, 2015
Cardiovascular Specialists of Central Maryland A Community Specialty Practice of Johns Hopkins Medicine 10710 Charter Drive, Suite 400 Columbia MD 21044 PATIENT FINANCIAL POLICIES Effective Date: June
More informationBrain & Spine Center of Texas, L.L.P. Dallas Minimally Invasive Spine
Please print clearly so that we can process your information quickly and efficiently. Thank you! Name (First, M.I., Last) Date of Birth Social Security # Male / Female Race Ethnicity (Latino / Non Latino)
More informationPLEASE 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 informationStonebridge Adult Medicine, P.A. Registration Form (Please Print)
Stonebridge Adult Medicine, P.A. Registration Form (Please Print) PATIENT INFORMATION Last Name: First Name: Is this your legal name? Yes No If not what is your legal name: Date of Birth: Sex: male female
More informationInformed Consent and Clinical Policies
THRIVE Center for ADHD and Comprehensive Mental Health Informed Consent and Clinical Policies Welcome to THRIVE. This document contains important information about our professional services and business
More informationTips To Improve 5-Star Performance Ratings
Tips To Improve 5-Star Performance Ratings Two different patient surveys impact CMS Star ratings: 1. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, typically mailed to plan
More informationUnderstanding Your Medical Bills. Sinai Hospital of Baltimore. Rubin Institute for Advanced Orthopedics
Understanding Your Medical Bills at the Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore Rubin Institute for Advanced Orthopedics Rubin Institute for Advanced Orthopedics At the Rubin
More informationDate 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 informationFrequently Asked Questions About Our Preventative Care Offering
Frequently Asked Questions About Our Preventative Care Offering Q: What is different in the Preventative Care service that I would not get in the Traditional service? Time, access, and focus on healthy
More informationGroup Benefits. Emergency Out of Country Coverage
Group Benefits Emergency Out of Country Coverage Keep this brochure and a copy of your Emergency Medical Travel Assistance card with your passport so that you or anyone you re travelling with can get assistance
More informationMedicare Plan Finder Training Entering Information (9/6/12)
Medicare Plan Finder Training Entering Information (9/6/12) 1. Go to the Medicare website, www.medicare.gov. Click on Compare Drug & Health Plans PICK TYPE OF SEARCH 2. You can do a Personalized Search
More informationOFFICE POLICY. APPOINTMENT POLICY and FEES
Welcome to the office of Dr. Bruce Millman Board Certified Pulmonary Medicine Board Certified Critical Care Medicine OFFICE POLICY Dr.Millman and staff are committed to provide you with the very best care.
More informationPreferred 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 informationSample 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 informationMyPOMCO.com New Online Features for FSA Online Set-Up Instructions
MyPOMCO.com New Online Features for FSA Online Set-Up Instructions It s now even easier to manage your flexible spending account (FSA) with these new online features: Direct deposit of reimbursements into
More informationAtlanta 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 informationMedicare Prescription Drug Coverage
Medicare Prescription Drug Coverage Information for Seniors and People with Disabilities Medicaid and Medicaid Spenddown A Question and Answer Guide Produced by the CHOICES Program * * * * * * * * * *
More informationPediatric 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 informationIndividual Enrollment Request Form
Individual Enrollment Request Form 3800 Kilroy Airport Way, Suite 100 Long Beach, CA 90806 Please contact VillageHealth if you need information in another language or format (Braille). To enroll in VillageHealth,
More informationHIPAA MANUAL. Most health plans and health care providers that are covered by the new Rule must comply with the new requirements by April 14, 2003.
HIPAA MANUAL What is HIPAA? Health Insurance Portability and Accountability Act. The Health Insurance Portability and Accountability Act (HIPAA) provides rights and protections for participants and beneficiaries
More informationHow do I sign up for the Debit Card? You need to make an active selection on your annual enrollment form.
Debit Card FAQs What is the Debit Card? The Debit Card is a special-purpose MasterCard that gives you an easy, automatic way to pay for eligible healthcare expenses. The Card lets you electronically access
More informationHow to Ensure Your Healthcare Gets Paid For West Virginia
Cancer Legal Resource Center 919 Albany Street Los Angeles, CA 90015 Toll Free: 866.THE.CLRC (866.843.2572) Phone: 213.736.1455 TDD: 213.736.8310 Fax: 213.736.1428 Email: CLRC@LLS.edu Web: www.disabilityrightslegalcenter.org
More informationBILLING HEADACHES? STAFF OVERLOAD! DENIALS LOST REVENUE
BILLING HEADACHES? STAFF OVERLOAD! DENIALS LOST REVENUE END BILLING HEADACHES! - NBI WILL INCREASE YOUR REVENUE. - NBI WILL DECREASE BILLING COSTS. - NBI WILL REDUCE DENIALS. - NBI WILL PROVIDE 100%OFFICE
More informationUPDATE FORM 2011. Name: (First) (Last) (Middle Initial) Address: Home Phone: Work/Other Phone. Social Security #: Date of Birth:
COMPREHENSIVE PSYCHIATRIC CARE Psychopharmacology & Psychotherapy Adults, Adolescents, Children & Seniors UPDATE FORM 2011 Please fill out this form completely (front and back) Name: (First) (Last) (Middle
More informationNOTICE OF PRIVACY PRACTICES
NOTICE OF PRIVACY PRACTICES This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. A federal regulation,
More informationWelcome to Our Practice Welcome to Patriot Pediatrics!
Welcome to Our Practice Welcome to Patriot Pediatrics! Thank you for choosing Patriot Pediatrics to care for your child s health. You are your child s most important caregiver, and we look forward to working
More informationTOTAL WOMEN S HEALTHCARE Robert L. Levy, M.D.
TOTAL WOMEN S HEALTHCARE Robert L. Levy, M.D. PATIENT NAME: DOB: FINANCIAL and other OFFICE POLICIES Please be assured that everyone in this practice is dedicated to providing the highest quality medical
More informationBORIS 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
More informationNotice of Privacy Practices Walter L Cohen High School School-based Health Center. Effective as of August 6, 2004
Effective as of August 6, 2004 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. We are required
More informationHarris County - Texas HIPAA Notice of Privacy Practices
Harris County - Texas HIPAA Notice of Privacy Practices Effective Date: September 23, 2013. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS
More informationWorker s Compensation Intake Form
Worker s Compensation Intake Form Patient Information: Name Home Phone Address Work Phone Social Security No. Date of Birth Sex Male Female Height Weight lbs Occupation Marital Status Employer No of Children
More informationCardiology 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 informationHealth Reimbursement Arrangement (HRA).
Retiree benefits 1 Retiree benefits Health Reimbursement Arrangement (HRA). Benefits for Union Pacific s Medicare-eligible retirees and their Medicare- eligible spouses and/or dependents. 2 Union pacific
More informationReferring 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 informationPATIENT REGISTRATION FORM
Phone: 831-708-2919 Fax: 831-708-2937 PATIENT REGISTRATION FORM Who may we thank for referring you to us? Name (First, Mid Int. Last) Address City State Zip Code Home Phone w/ area code Email Cell Phone
More informationReproductive Medicine Associates of New Jersey, LLC
NOTICE OF PRIVACY PRACTICES Effective Date: September 20, 2013 Last Modified: May 12, 2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO
More informationAbout the Program 1. What is the current Osphena (ospemifene) Savings Offer for 30 day prescription?
2015 Osphena Savings Program Frequently Asked Questions Click here for Full Prescribing Information, including Boxed WARNING regarding Endometrial Cancer and Cardiovascular Disorders. Have a question about
More informationMedi-Pak Advantage: Frequently Asked Questions
Medi-Pak Advantage: Frequently Asked Questions General Information: What Medicare Advantage product is Arkansas Blue Cross Blue Shield offering? Arkansas Blue Cross and Blue Shield has been approved by
More informationPatient Information. Last First MI (Preferred Name) Male Female Married Single Child. City State Zip Code Emergency Contact/Relation Phone
LEWIS C. COLE DMD Family and Cosmetic Dentistry 525 ENERGY CENTER BLVD SUITE 1603 NORTHPORT, AL 35473 PHONE 205.344.6900 FAX 205.344.6910 www.lewiscoledentistry.com Patient Name: Patient Information Date:
More informationADVANCED ORTHOPAEDIC INSTITUTE 103 E. Third St Arlington, WA 98223 360-403-0333 360-403-0331FAX (Revised March 11, 2012)
ADVANCED ORTHOPAEDIC INSTITUTE 103 E. Third St Arlington, WA 98223 360-403-0333 360-403-0331FAX (Revised March 11, 2012) PATIENT REGISTRATION FORM & FINANCIAL PAYMENT POLICY Patient Info: Please print
More informationPatient 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
More informationTHE WORLD OF PEDIATRICS. Medical Records/Health Information Release (Please fill out and fax or send to your current practice or pediatrician)
Medical Records/Health Information Release (Please fill out and fax or send to your current practice or pediatrician) Date: To: Fax: Please, release a copy of medical records for the following patient(s):
More informationNOTICE 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 informationLAKE CITY MEDICAL CLINIC. www.neighborcare.org. Mabuhay!
LAKE CITY MEDICAL CLINIC Mabuhay! www.neighborcare.org Mabuhay! Mabuhay! Welcome to Lake City Medical Clinic Medical Services / 206-417-0326 We provide a range of primary care health services for men,
More information* 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 informationwww.attorneygeneral.gov
Required fields are marked with an asterisk* Your information: Are you a veteran? Yes No Are you on active duty? Yes No Age Group: Under 18 18-34 35-59 60-64 65 and older Mr. Mrs. Address* Ms. Dr. Name*
More informationNew 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?
More informationHunter-Hopkins Center, P.A. 7421 Carmel Executive Park, Suite 320, Charlotte, NC 28226 Telephone (704) 543 9692 Facsimile (704) 543 8547
Hunter-Hopkins Center, P.A. 7421 Carmel Executive Park, Suite 320, Charlotte, NC 28226 Telephone (704) 543 9692 Facsimile (704) 543 8547 Dear New Patient: We are happy that you have chosen our office,
More informationPLEASE BRING THE FOLLOWING WITH YOU TO YOUR APPOINTMENT:
To Our New Patient: Our primary concern is providing you with excellent eye care. Your understanding of our policies and your cooperation with our procedures enables us to provide this care. Complete eye
More informationStudent Communication Package
Student Communication Package Print communication for the Student Journey PROGRAM HOME/ Main PAGE INTRODUCTION COPY: Practical Nurses - http://www2.algonquincollege.com/healthandcommunity/program/orientationto-nursing-in-ontario-for-practical-nurses/
More information2015 Lone Star Script Care LLC ALL AGENTS ARE REQUIRED TO READ AND UNDERSTAND ALL OPERATING POLICIES AND PROCEDURES.
2015 Lone Star Script Care LLC ALL AGENTS ARE REQUIRED TO READ AND UNDERSTAND ALL OPERATING POLICIES AND PROCEDURES. The History of Benefit Plans The aim of discount benefit plans at first was to fill
More informationCalifornia 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 informationFaculty Group Practice Patient Demographic Form
Name (Last, First, MI) Faculty Group Practice Patient Demographic Form Today s Date Patient Information Street Address City State Zip Home Phone Work Phone Cell Phone ( ) Preferred ( ) Preferred ( ) Preferred
More informationHere for you. Here for your health.
Here for you. Here for your health. A guide to your plan Contact information This guide to your plan can help you make the most of your health care and Assurant Health s Customer Care Center can do the
More informationFAMILY 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 information2014 Prescription Drug Schedule Humana Medicare Employer Plan
2014 Prescription Drug Schedule Humana Medicare Employer Plan Option 98 City of Newport News Y0040_GHHHEF3HH14 SECTION I - INTRODUCTION TO SUMMARY OF BENEFITS Thank you for your interest in the Humana
More informationSTATEMENT OF PRIVACY PRACTICES
STATEMENT OF PRIVACY PRACTICES We, at Seattle Smile Works, are dedicated to protect the privacy rights of our patients and the confidential information entrusted to us. The commitment of each employee
More informationCARSON PHYSICAL THERAPY, INC.
PATIENTS WITH WORKER'S COMPENSATION INSURANCE We are interested in providing you with the best and most effective care possible. In order to begin your Physical Therapy as soon as possible, we offer you
More informationNOTICE OF PRIVACY PRACTICES
NOTICE OF PRIVACY PRACTICES Effective Date: Immediately This information is made available to all patients THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU
More informationWELCOME 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 informationHow to Ensure Your Healthcare Gets Paid For - Kentucky
Cancer Legal Resource Center 919 Albany Street Los Angeles, CA 90015 Toll Free: 866.THE.CLRC (866.843.2572) Phone: 213.736.1455 TDD: 213.736.8310 Fax: 213.736.1428 Email: CLRC@LLS.edu Web: www.disabilityrightslegalcenter.org
More informationHIPAA Security Manual Administrative Security/Omnibus Rule
Notice of Privacy Policies Form ***This notice describes how medical information about you may be used and disclosed and how you can get access to this information. PLEASE READ IT CAREFULLY!*** The tells
More informationThese are just some of the eligibility requirements meeting these criteria does not guarantee acceptance.
BARACLUDE PATIENT ASSISTANCE PROGRAM The Baraclude Patient Assistance Program is designed to provide free medication to qualifying patients who do not have prescription drug coverage and are having a hard
More informationFrequently Asked Questions. Healthpointe Center
Frequently Asked Questions Healthpointe Center Q: What is the Healthpointe Center? A: The Healthpointe Center is a state-of-the-art onsite medical clinic, located at the Healthpointe Building on the Pleasanton
More informationCo-Authors: Jessie Gruman, PhD Dorothy Jeffress, MBA, MSW, MA Susan Edgman-Levitan, PA
C E N T E R F O R A D V A N C I N G H E A L T H Creating a Patient Guide for a Medical Home Physician Practice Co-Authors: Jessie Gruman, PhD Dorothy Jeffress, MBA, MSW, MA Susan Edgman-Levitan, PA Leigh
More informationWORKERS COMPENSATION INFORMATION. Soc. Sec.# Address Marital Status: Single Married Divorced Widowed Email: Home Phone: Cell Phone: Work Phone:
WORKERS COMPENSATION INFORMATION PATIENT INFORMATION Name: Birthdate: Soc. Sec.# Address Marital Status: Single Married Divorced Widowed Email: Home Phone: Cell Phone: Work Phone: Preferred Pharmacy: Tel
More informationDoctor Visits. How Much to Participate
Family Caregiver Guide Doctor Visits Caregiving involves not only major crises, but also routine experiences like going to the doctor. HIPAA is a federal law that protects patient privacy, while allowing
More informationKaiser Permanente Northwest Region Enrollment Service Area
Kaiser Permanente v Kaiser Permanente Northwest Region Enrollment Service Area Kaiser Permanente Senior Advantage Medicare Plan The Value of Kaiser Permanente Sr. Advantage Medicare Plan and PHIP Partnership
More informationNHA Certified Medical Administrative Assistant 2015
NHA Certified Medical Administrative Assistant 2015 CMAA-2015 This document describes the correlation between curriculum, supplied by Applied Educational Systems, and the NHA Certified Medical Administrative
More informationAdvanced Women's HealthCare, SC Registration Form
Patient Full Name Address Advanced Women's HealthCare, SC Registration Form Street Account # Provider Last First Middle Maiden(0ther) Apt/Suite# City State Zip Code Phone # (Please circle preferred contact
More informationNHA Certified Medical Administrative Assistant (CMAA) Test Plan (Detailed)* 110 scored items, 20 pretest items Exam Time: 2 hours 10 minutes
NHA Certified Medical Administrative Assistant (CMAA) Test Plan (Detailed)* 110 scored items, 20 pretest items Exam Time: 2 hours 10 minutes # scored items 1. Scheduling 19 A. Evaluate different types
More informationPatient Billing & Insurance Information Q&A
Patient Billing Requirements Patient Billing & Insurance Information Q&A At your first visit our office you are required to bring your insurance card and driver s license. Our office will copy this information
More informationUniversity of Nebraska Prescription Drug Program 2014
University of Nebraska Prescription Drug Program 2014 The University of Nebraska s prescription benefit program is administered by CVS Caremark, a leading national provider of prescription drug benefit
More informationPATIENT 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 informationFraud and abuse overview
Fraud and abuse overview The National Insurance Association of America (NIAA) and the National Health Care Anti-Fraud Association (NHCAA) estimate that the financial losses due to health care fraud are
More informationHello. Medicare Advantage plans. Overview 2. Plans 3. Timing 6. Tools 7
Hello Advantage At UnitedHealthcare, we want you to get the most from your Medicare coverage. Our simple, all-in-one Medicare Advantage plans are designed to offer you benefits, services and tools to help
More informationVirginia South Psychiatric & Family Services
All forms must be completed before seeing the Physician Information for Medical Records Patient s Name: Social Security #: Date of Birth: Sex: Male Female Marital Status: Single Married Divorced Widow
More informationYour Special Delivery
BIRTHING SERVICES Your Special Delivery Pre-Admission Information Congratulations, your baby is almost here! Our pre-admission program is designed to ensure that your admission is processed smoothly. To
More informationHow To Get A Medical Checkup
NAFISA TEJPAR, M.D., F.A.C.S. 2501 N. Orange Ave, Ste 513 Orlando, FL 32804 (407) 894-1280 APPOINTMENT TIME: (Please be at the office 30 minutes before) Welcome to NAFISA TEJPAR, M.D. PA. We appreciate
More information