Dear Patient, If you have any questions about your appointment, please do not hesitate to call us at (910) Welcome to our practice!
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- Jemimah Elliott
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1 Dear Patient, Thank you for choosing Wilmington Hearing Specialists for your audiology care! We are excited to welcome you to our practice and provide the high quality services, products, and attention you deserve. To save time in the office, we encourage you to complete the attached paperwork before you appointment. Please provide as much detail as you can, and skip over anything that doesn t apply. During your appointment, we will take some time to review your personal and family medical history and discuss the reason for your visit. If you have any questions about your appointment, please do not hesitate to call us at (910) Welcome to our practice! Sincerely, Wilmington Hearing Specialists Mary Maddock, AuD Bruce Mock, AuD, PhD CONTACT INFORMATION Phone: (910) Fax: (910) Wilmington Office Wrightsville Ave Wilmington, NC Southport Office 412-E N. Howe St Southport, NC 28461
2 Patient Information Last Name: First : MI Mailing Address: City: Zip: Phone: Home: Work: Cell: Address: Written communication from our office may be by or Regular Mail Male Female Single Married Widowed Patient SS#: Birthdate: (We request your SS# to assist with insurance filing. If there is a problem with your insurance we will need your social security number to correct the problem. If we do not have the number on file you will be responsible for the full bill and for filing your own insurance.) Primary Care Physician: May we send a report to your MD: Yes No How were you referred to our office: In Case of Emergency Contact: Name: Relationship Phone Number: Insurance Information We will copy your insurance cards at the time of your visit. If you do not have your insurance cards you will be expected to pay for the visit. Co-Payments on due on the service date Primary Insurance Company: Secondary Insurance Company: Subscriber (if other than patient) Information: Name: DOB: SS#: Assignment and Release: I, the undersigned certify that I (or my dependent) have insurance coverage as listed above and assign directly to Dr. Maddock all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges not paid by my insurance. I hereby authorize Wilmington Hearing Specialists to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions. Signature Date:
3 Office Financial Policy As a courtesy to you we will file your insurance for you and allow you to assign those benefits directly to us. This policy reduces your out of pocket expenses. It is understand and agreed that health insurance policies are an arrangement between the insurance carrier and the patient. This office will prepare any necessary reports and forms to assist in making collections from the insurance company and that any amount authorized to be paid directly to this office will be credited to the patient s account upon receipt. It is clearly understand and agreed that all services rendered to are charged directly to the patient and the patient is personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered to me will be immediately due and payable. Dr. Maddock is a participating providers with: Medicare Medicaid BCBS Cigna MedCost TriCare NCTEDP Easter Seals United Health Care Department of Labor Vocational Rehabilitation Wilmington Hearing Specialists agrees to follow your insurance company s guidelines and accept payment from those insurance companies as directed. All deductibles and copayments are expected at the time of service. What you will receive from you insurance company is an Explanation of Benefits (EOB) and not a bill. As long as your insurance company pays their portion and your co-payment and deductible payment has been made, no further payments will be expected from you. If your insurance company has not paid your claim within ninety days of submission, you agree to take an active part in the recovery of your claim. If your insurance carrier has not paid your claim within one hundred and twenty days of submission, you accept responsibility for payment in full of any outstanding balance. If your insurance company is not one with which Dr. Maddock participates we will assist with the filing of your insurance but payment in full is expected at the time of your visit. Medicare does not cover hearing aids. In the event that you have insurance that has hearing aid coverage our office manager will call your company to verify coverage. Your insurance company s verbal statement that they cover hearing aids is not a guarantee of payment. We will file your insurance and work diligently to recover the amount that the insurance company promised to cover, however the portion of the hearing aid purchase that is not expected to be covered is due at the time of the fitting. Hearing aid coverage does not include follow-up services related to the hearing aid purchase. Signature Date
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LAST NAME FIRST NAME MI BIRTHDATE ADDRESS CITY STATE ZIP HOME PHONE# CELL# S.S. # EMAIL ADDRESS
The more information we know about you and your family, the better medical care we can provide you. None of this information will be released to any person except with your written consent. LAST NAME FIRST
Sincerely yours, Rev. 06.10
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www.cheverlychiropracticcare.com CheverlyChiroCare@yahoo.com Dr. Ella Pantazis 12200 Annapolis Rd #221 GlennDale MD 20769 301 464 5813 Fax: 301 464 5815 Dear Patients and Prospective Patients: Our office
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)
New Perspective Counseling Services Child/Teen Intake Form
Child/Teen Intake Form Welcome to New Perspective Counseling Services. We look forward to providing you with excellent and efficient counseling services. Please take a few minutes to fill out this form.
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
Worker 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
UPDATE 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
Facts About Dentists and Insurance
Welcome TO THE PRACTICE Patient Information Date Name Birthdate SS# Address City/State Zip Code Driver s License # Name of Employer Check appropriate box Minor Single Married Divorced Widowed Contact Numbers
FLATIRON PEDIATRICS. What You Need to Know about Your Health Plan Coverage and Our Financial Policies EFFECTIVE SEPTEMBER 2014
What You Need to Know about Your Health Plan Coverage and Our Financial Policies EFFECTIVE SEPTEMBER 2014 *Please read & return last page* Introduction We are privileged to have you as our patient, and