PATIENT REGISTRATION
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- Christopher Jackson
- 5 years ago
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1 PATIENT REGISTRATION NAME: HOME ADDRESS: CITY, STATE, & ZIP CODE: HOME PHONE: CELL: WORK: SOCIAL SECURITY NUMBER: SEX: MALE/FEMALE DATE OF BIRTH: AGE: EMERGENCY CONTACT: RELATIONSHIP: EMERGENCY CONTACT S PHONE NUMBER: ADDRESS: PRIMARY PHYSICIAN: REFERRING PHYSICIAN: PRIMARY INSURANCE: POLICY #: POLICY HOLDER S NAME: SECONDARY INSURANCE: POLICY HOLDER S NAME: OCCUPATION: DOB: POLICY #: DOB: EMPLOYER: EMPLOYER S ADDRESS: EMPLOYER S PHONE #: Is this a work-related injury or claim? YES / NO Did you file an accident report? YES / NO Is this an injury or claim related to an auto accident? YES / NO Who is responsible for payment? Date injury or accident: Do you have a lawyer? YES / NO Name of lawyer: Phone Number: Is someone, other than you, responsible for this account? YES / NO If yes Who: SIGNATURE: DATE:
2 PATIENT MEDICAL HISTORY The purpose of this questionnaire is to help us understand your health status and to ensure you receive a complete and thorough evaluation. This form is considered part of your medical record. Name: DOB: Age: Diagnosis: Date of Onset: Chief Complaint: How did injury or pain occur? Please describe your pain: Circle on the scale below your level of pain TODAY. 0=No Pain 10=Pain would make you go to the ER Circle the word or words below that best describe your pain. Sharp Dull Stabbing Throbbing Spasm Shooting Numbness Pins/Needles What increases the pain? Decreases? Is the pain: Constant or Intermittent (circle one) Do you have pain with sleep? YES/NO What are you not able to do now as a result of this problem? Did you have any limitation in function prior to this problem: YES/NO If yes, explain: Last date worked due to this problem: Date returned to work: List other treatment you have had for this problem: Have you had: X-rays or MRI or Special Tests (circle) Results: Where were tests done? Have you fallen in the last year? Yes / No If yes, how many times have you fallen in the last year? Were you injured in the fall? Yes / No If yes, how were you injured?
3 PATIENT MEDICAL HISTORY CONT. Do you have or have you had any of the following? YES NO YES NO Allergies or Asthma (circle) Bronchitis or COPD (circle) Cancer Chest Pain Depression Diabetes Dizziness/Fainting(circle) Emboli/Blood Clot (circle) Epilepsy/Seizures (circle) Fractures Heart Attack Heart Disease Hepatitis Hernia High Blood Pressure HIV Incontinence Latex Allergy Infectious Disease Kidney Disease Low Back Pain Metal Implants MS Osteoarthritis Osteoporosis Pacemaker Parkinson s Rheumatoid Arthr. Shortness of Breath Sleep Disturbance Stroke Thyroid Problems Weakness Weight Loss Do you smoke? YES/NO Do you consume alcohol? YES/NO Are you pregnant? YES/NO Please list all surgeries: PLEASE COMPLETE SEPARATE MEDICATION/VITAMIN/SUPPLEMENT SHEET HEIGHT: WEIGHT: What are your goals for physical therapy? How did you hear about us? Patient/Guardian Signature: Date:
4 PATIENT MEDICATION RECORD PLEASE COMPLETE THIS MEDICATION RECORD AND BRING WITH YOU TO YOUR 1 ST APPOINTMENT. IT IS REQUIRED BY MEDICARE AND OTHER INSURANCE COMPANIES THAT YOU DOCUMENT ALL MEDICATIONS INCLUDING VITAMINS, AND SUPPLEMENTS AND INCLUDE DOSAGE, FREQUENCY, AND ROUTE (oral, injection, IV, etc.). WE MUST THEN VERIFY THE MEDICATIONS WITH YOU DURING YOUR 1 ST VISIT. IF YOU HAVE PREPARED YOUR OWN LIST, YOU CAN BRING IT IN AS LONG AS IT CONTAINS ALL OF THE REQUIRED INFORMATION. ATTACH ANOTHER SHEET IF NEEDED. THANK YOU. MEDICATION NAME DOSAGE(mg, etc.) FREQUENCY ROUTE(oral, injection, etc.) PATIENT/GUARDIAN SIGNATURE: DATE:
5 FINANCIAL POLICY AGREEMENT Thank you for choosing Sidney Rehabilitation & Wellness Clinic! We are committed to provide you the highest standard of service and care. The nature of health insurance coverage is changing, with higher deductibles and co-payments meaning a greater portion of your services will be your financial responsibility. It is vital to our practice that we collect payments you are responsible for; therefore patients will be required to establish financial arrangements for payment of their account. SRWC will verify your insurance benefits prior to beginning treatment. While we will take all reasonable action to provide accurate benefit information, be aware that verification of benefits is not a guarantee of payment from your insurance carrier. We urge you to familiarize yourself with your Schedule of Benefits available in your insurance policy. It will help you understand the agreement you have with your insurance company. Understanding the nature of your coverage including preauthorization requirements, deductibles, co-payments, co-insurance, visit limitations, and annual limits will help you make informed decisions about your financial responsibilities. Sidney Rehabilitation & Wellness Clinic (SRWC) will bill your insurance as a courtesy to you. SRWC assumes payment of insurance benefits is not forthcoming on charges older than 60 days. Charges outstanding for more than 60 days will be due in full from you regardless of the type of insurance involved. Depending on the type of agreement between SRWC and your insurance, any remaining balance after your co-pay and insurance has paid, including items classified as above usual and customary, is due from you upon receipt of the explanation of benefits from your insurance carrier. Accounts will be charged at a rate of 1.5% per month for unpaid balances. All per visit co-pays are due at every visit. The balance will be due in full at the time of service or upon receipt of the monthly billing statement. In the event you are unable to pay the balance in full, we are willing to make reasonable payment arrangements. However, please be advised SRWC is not a credit grantor, and therefore, failure to maintain the agreed upon the arrangement may result in the placement of your account with a collection agency or attorney for collection. Accounts with no payment activity will be sent to a collection agency or attorney when they are 90 days delinquent. Once your account has been sent to the collection agency, we will not be able to reverse this action. You agree to pay all fees associated with the recovery of any debt including but not limited to collection services, attorney fees, and court costs. For your convenience, we accept cash, checks, and debt/credit cards are accepted. There will be a $30.00 service charge for returned checks. It is your responsibility to inform SRWC of any and all changes in your insurance coverage. Failure to do so may result in denial of coverage from your insurance company. For In-Network patients, SRWC has contracted with your insurance company to accept the Preferred Provider maximum allowable charge as full payment for the services rendered. There will be no balance billing for covered services. You are responsible to pay for any and all services not covered under your policy. For Out-of-Network patients, you are responsible for the difference of billed charges and your insurance company s maximum allowable charge.
6 FINANCIAL POLICY AGREEMENT CONT. Fee-for-service is exclusively a non-insurance financial arrangement. Fee-for-service receipts CANNOT be submitted to insurance for reimbursement. SRWC will discount our standard fee schedule by 25% for feefor-service arrangement. Full payment must be received at the time the services are rendered to be eligible for the discount. The discount is based upon a paperwork reduction discount for not filing your claim to an insurance company. Medicare and Medicaid recipients are not eligible for this arrangement unless the treatment is not normally covered by Medicare or Medicaid. During the course of your treatment, your therapist or other medical provider may recommend specialized equipment or supplies. SRWC will not submit claims to your insurance company for these items, therefore full payment for these items is due at the time of issuance or as arranged between you and SRWC. You may submit receipts for these items to your insurance company on your own. If you are claiming Worker s Compensation, you must provide SRWC with a copy of your personal insurance card and a current authorized claim number along with case manager contact information. SRWC will confirm your authorization. In the event your claim is denied by worker s compensation, the claim will then be filed with your personal insurance company. If your claim is denied by your personal insurance company, then you are responsible for the full payment of your bill. In the case of a LEGAL SUIT, SRWC will accept a legal letter of protection if you meet the following criteria: 1. Are indigent and cannot pay for charges using cash or credit card, and 2. Do not qualify for benefits under any insurance policy (medical or auto), and 3. Are awaiting settlement and subsequent payment of damages from a related legal case, and 4. Return our agreement, signed by both you and your attorney. Prior to your settlement, payment on your account will not be required unless your charges remain outstanding for more than 90 days from the date of the last treatment. Upon settlement of your legal case, your balance is due in full within 30 days. Our overdue and collection policy as noted above, will be in force on accounts over 90 days unless another written agreement is made. Minor patients must be accompanied by a parent or legal guardian to the initial visit. The parent or legal guardian is responsible for full payment as previously outlined in this financial policy. The parent or guardian that accompanies the minor patient to the initial visit shall be fully responsible for payment of services rendered should a dispute arise between the parent and guardian. I HAVE READ CAREFULLY AND AGREE TO THE PAYMENT POLICIES DESCRIBED HEREIN. PATIENT/GUARDIAN SIGNATURE: DATE:
7 Notice of Privacy & Disclosure 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 CAREFULLY. Sidney Rehabilitation & Wellness Clinic (SRWC) is required by law to maintain the privacy of Protected Health Information and to provide notice of its legal duties and privacy practices with respect to Protected Health Information. This notice fulfills the Notice requirements of the Health Information Portability and Accountability Act of 1996 (HIPPA) Final Privacy Rule. SRWC uses your health information primarily for treatment, processing claims and obtaining payment for treatment, conducting internal administrative activities, and assessing the quality of care we provide. We use your health information to consult with any other practitioner involved in your care for the problem you are seeking current treatment for, and in addition, we may disclose your health information without prior authorization for public health purposes, auditing tracking, and research. In any other situation, SRWC will obtain your written authorization before disclosing your personal health information. Your health record is the property of Sidney Rehabilitation & Wellness Clinic, but the content is about you, therefore belongs to you. You have the right to review or obtain a copy of your personal health information. You have the right to request that we correct inaccurate or incomplete information in your records. You also have the right to request a list of instances where we disclosed your personal health information for reasons other than for treatment, payment, or other related administrative purposes. You must make a request in writing to obtain access to your health information. You may be charged a reasonable cost-based fee for expenses such as copies, postage, staff time, and other expenses as applicable. You have the right to request restrictions on the uses and disclosures of your health information, other than those required by law. Your request must be made in writing and must specify our additional restriction. You have the right to request communications of your health information by alternative means or at alternative locations should we need to contact you. This request must be made in writing and must specify the alternative means of communication. You have the right to revoke your authorization to use or disclose health information except to the extent that action has already been taken, or is limited by law. You may request a copy of our Notice of Privacy & Disclosure Practices at any time. If you have questions about this notice or desire to have further information concerning the information practices at SRWC, please call us at If you believe your privacy rights have been violated, you have the right to file a complaint with us and/or with the U.S. Secretary of Health and Human Services with no fear of retaliation by this office. Acknowledgement of receipt of this notice: I have been informed of the Privacy & Disclosure Practices of Sidney Rehabilitation & Wellness Clinic. Patient/Guardian Signature: Date:
8 AUTHORIZATION FOR RELEASE/ASSIGNMENT OF BENEFITS/CONSENT TO TREAT The undersigned hereby authorizes Sidney Rehabilitation & Wellness Clinic (SRWC) to release from my medical record requested information to appropriate health practitioners and any insurance company for the purpose of processing claims and obtaining payment for the account which services are/were provided to the patient. SRWC will accept assignment of benefits which means we will receive direct payment for any services provided and you will be responsible for any deductible, coinsurance, co-payment, and/or any procedure or visit that is not covered by insurance. By signing this authorization, the patient, parent, or legal guardian hereby consents to medical treatment. MEDICARE RELEASE I certify the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I request that payment of authorized Medicare benefits be made to me or on my behalf to Casey Cortney, MPT dba Sidney Rehabilitation & Wellness Clinic (PTAN#: NA1019). For services rendered to me by the provider, I authorize any holder of medical information about me to release to the Social Security Administration or its agents any information required to process the benefits payable for the related services. FINANCIAL AGREEMENT The undersigned hereby agrees that, in consideration of the services to be rendered to the patient, to pay SRWC in accordance with the regular rate and payment policy. The services of SRWC are billable services and are due by the patient. Interest will be charged to all account balances overdue by 30 days and accounts that are 90 days delinquent will be sent to collections. Please see SRWC s Financial Policy Agreement for further conditions and terms. WORKMAN S COMPENSATION Please notify the receptionist if this is a workman s compensation injury. Any patient claiming worker s compensation must bring notice of injury from their employer, or must be received from your worker s compensation carrier, before the claim will be sent to workman s compensation insurance. If a notice is not received, the claim will be submitted to the patient or personal medical insurance. Patient/Guardian Signature: Date:
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IMS Allergy & Immunology New Patient Registration Sheet. Personal Information
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PATIENT INFORMATION FORM
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Atlantis Physical Therapy Associates Date Called/Walk-In: Appointment Date: Time: PT/OT: Diagnosis/ICD9/Body Parts: Frequency & Duration: X Referring Doctor: Dr. Phone#: Fax: NPI: Addresss: Ins Type: (Circle
North Country Holistic Care Center PATIENT REGISTRATION FORM. Patient Information. Name: Address: City: State: Zip: Email
PATIENT REGISTRATION FORM Patient Information Name: Address: City: State: Zip: Telephone #: Home: Cell: Email Date of Birth: Age: Sex: M F Social Security #: - - Referred by: Employment Information Employer:
CARSON 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
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,
ST. LAWRENCE REHABILITATION CENTER OUTPATIENT POLICIES AND REGISTRATION INFORMATION
Outpatient Services 2381 Lawrenceville Road 609-896-9500 voice Patient Name: Account #: ST. LAWRENCE REHABILITATION CENTER OUTPATIENT POLICIES AND REGISTRATION INFORMATION Your first day of outpatient
*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
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 # Last Name First Name Middle Initial Address Apt # City State Zip DOB (mm/dd/yy) Gender Male Female SSN # Home Phone ( ) Mobile
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)
MVA Accident Questionnaire
MVA Accident Questionnaire Name Date Date of Accident Time of Accident Road conditions at time of accident Were you the driver? Were you the passenger? Where were you seated in the vehicle? FRONT BACK
PRO SPORTS THERAPY, INC. (P.S.T.)
Dear Patient, Thank you for choosing Pro Sports Therapy. Enclosed is the paperwork that you will need to complete and bring with you for your physical therapy evaluation. Please arrive at least 15 minutes
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)
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 # Last Name First Name Middle Initial Address Apt # City State Zip DOB (mm/dd/yy) Gender Male Female SSN # Home Phone ( ) Mobile
MIGUEL GONZALEZ, MD, FCCP, FACP 303 S. Moorpark Rd. Thousand Oaks, Ca 91361 805-497-7508 Phone 805-495-6834 Fax PATIENT INFORMATION
MIGUEL GONZALEZ, MD, FCCP, FACP 303 S. Moorpark Rd. Thousand Oaks, Ca 91361 805-497-7508 Phone 805-495-6834 Fax PATIENT INFORMATION DATE: REFERRED BY: NAME: SEX: M / F MARITAL STATUS: BIRTHDATE: DRIVERS
CENTENNIAL MEDICAL GROUP & CENTENNIAL SURGERY CENTER New Patient Paperwork
New Patient Paperwork NAME OF PATIENT ( ) MALE ( ) FEMALE ADDRESS APT CITY STATE ZIP HOME PHONE # CELL PHONE # DATE OF BIRTH AGE SOCIAL SECURITY # MARITAL STATUS E-MAIL ADDERSS OCCUPATION EMPLOYER EMPLOYER
Patient/Guardian Signature Witness Signature
Today s Date Full Name Date of Birth Gender M F Social Security # Email * Home Address City State Zip Home Phone Work Phone Cell Phone Patient Employer Job Title Insurance Subscriber Subscriber Birthdate
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
ACE PHYSICAL THERAPY & SPORTS MEDICINE INSTITUTE PATIENT REGISTRATION
ACE PHYSICAL THERAPY & SPORTS MEDICINE INSTITUTE PATIENT REGISTRATION ALEXANDRIA FAIRFAX FALLS CHURCH LEESBURG HERNDON TYSONS CORNER PATIENT INFORMATION (Please Print Clearly) Name Last First Middle of
If you miss 3 consecutive appointments we may have to notify your physician and will require a new referral in order to continue your treatment.
Welcome to POST Physical Therapy Brookline. We strive to provide our patients with excellent service and quality care. Our commitment to your well-being and health care is something that we at POST Physical
Welcome To Pace Physical Therapy
Welcome To Pace Physical Therapy Please take a few minutes to fill out the following registration forms prior to coming to your appointment. This will allow your physical therapist more time to attend
LOUISIANA PHYSICAL THERAPY CENTERS OF PINEVILLE, LLC 1135 EXPRESSWAY DRIVE, SUITE 100B PINEVILLE, LA 71360 (318) 487-6525 FAX: (318) 487-6527
1135 EXPRESSWAY DRIVE, SUITE 100B PINEVILLE, LA 71360 (318) 487-6525 FAX: (318) 487-6527 Patient Information Name First Middle Last Address City State Zip Phone Other Contact Email Social Security # DOB
Keweenaw Holistic Family Medicine Patient Registration Form
Keweenaw Holistic Family Medicine Patient Registration Form How did you first learn of our Clinic? Circle one: Attended Lecture Internet KHFM website Newspaper Sign in window Yellow Pages Physician Friend
CAMARILLO AQUATICS AND REHABILITATION SERVICES
CAMARILLO AQUATICS AND REHABILITATION SERVICES Last Name First M.I. Address Apt.# City State Zip Code Phone # SS# Date of Birth Sex M F Driver s License # Marital Status: S M D W Spouse s Name How did
4765 Carmel Mountain Rd. Ste 202, San Diego, CA 92130 Phone (848) 847-0055 Fax (858) 847-9944
4765 Carmel Mountain Rd. Ste 202, San Diego, CA 92130 Phone (848) 847-0055 Fax (858) 847-9944 Dear Patient, Your insurance may pay your total bill for services rendered by Pilates People Torrey Hills.
New Patient Registration Information
New Patient Registration Information Form 8026 5/09 3038 PR&C Dear WellSpan Orthopedics Patient: Welcome to WellSpan Orthopedics. Thank you for allowing us the opportunity to assist with your health care
BIRTHDATE - - AGE SEX EMERGENCY CONTACT PHONE( )
PATIENT INFORMATION SOCIAL SECURITY # MARRIED SINGLE WIDOW DIVORCED NAME Last First MI HOME ADDRESS BILLING ADDRESS ACCT# DRIVER S LICENSE# BIRTHDATE - - AGE SEX CITY STATE ZIP CITY STATE ZIP PHONE HOME(
Advanced Solutions Pain Management
Joseph Ho, M.D. Sabrina Shue, M.D. Patient Information Name: M F Age: Last, First, Middle (Circle One) DOB: SSN: Single Married Divorced Separated Widowed Address: City: State: Zip: Home Phone: Cell: Work:
Briefly describe the reason for your visit today (diagnosis, body part, or physical complaint):
Patient Registration Form Today s Date / / Last Name First Middle Date of Birth / / Age: Gender: M F Social Status: Single Married Live with domestic partner Live alone SSN: Contact Information: (please
How To Get A Physical Therapy At West Point Physical Therapy Center
Palmdale (Main) 1115 West Ave. M-14 Palmdale, CA 93551 (661)265-0060 To our workers compensation patients: Cathedral City 68-845 Perez Rd., Ste. H6-H7 Cathedral City, Ca 92234 (760)328-0292 California
PENNSYLVANIA PLASTIC SURGERY ASSOCIATES, P.C. Howard S. Caplan, M.D. Francine A. Cedrone, M.D. Account #
PENNSYLVANIA PLASTIC SURGERY ASSOCIATES, P.C. Howard S. Caplan, M.D. Francine A. Cedrone, M.D. Account # PATIENT INFORMATION QUESTIONNAIRE Patient Name Resp. Party/Spouse Address Address City, State, Zip
Dymond Speech & Rehab., P.A. Patient Registration Information
Dymond Speech & Rehab., P.A. Patient Registration Information Client s Name: First Middle Last Street Address: Mailing Address: City : State: Zip code: Sex: Marital Status: Home Phone: ( ) - Cell: ( )
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
Holbrook Chiropractic, PC 233 Union Ave Suite 102, Holbrook, NY 11741 631-981-2222
Holbrook Chiropractic, PC 233 Union Ave Suite 102, Holbrook, NY 11741 631-981-2222 Name: Home Phone: Work Phone: Ext Cell Phone Email Address Home Address City, State, Zip Social Security # Date of Birth
DEL MAR PHYSICAL THERAPY Patient Information
PLEASE PRINT CLEARLY DEL MAR PHYSICAL THERAPY Patient Information Name Birthdate Last First M.I. MM/DD/YYYY Age Sex M / F Marital Status SS# Address City Zip Phone ( ) Work ( ) Cell ( ) Email **********************************************************************************
PATIENT INFORMATION EMERGENCY CONTACT LAST FIRST RELATIONSHIP REFERRAL SOURCE DOCTOR / REFERRING CLINICIAN: FAMILY MEMBER/FRIEND: INSURANCE:
PATIENT INFORMATION LAST FIRST MI GENDER M F BIRTHDATE MO./ DAY/ YEAR SS# - - ADDRESS CITY ST ZIP PHONE (CELL) PHONE (HOME) EMAIL MARITAL STATUS EMPLOYER ADDRESS OCCUPATION WORK PHONE EXT WHO IS YOUR PRIMARY
Medicare Patient Information. Patient Name: SS#: - - Date of Birth: / / Sex: Female Male. City: State: Zip Code:
Medicare Patient Information Patient Name: SS#: - - Date of Birth: / / Sex: Female Male Address: Street: City: State: Zip Code: Home Phone: ( ) - Work/Mobile Phone: ( ) - Please print your name as it Appears
Cancellation/No Show Policy
Cancellation/No Show Policy If you are unable to keep your scheduled appointment we require a 24 hour advance notice. Failure to provide this notice will result in a $50.00 cancellation/no show fee. You
ATTENTION MEDICARE PATIENTS: Are you currently receiving home health care? Yes No HAVE YOU BEEN SEEN IN ANY OF OUR CLINICS BEFORE?
ACTION POTENTIAL Today's Date: ATTENTION MEDICARE PATIENTS: Are you currently receiving home health care? Yes No HAVE YOU BEEN SEEN IN ANY OF OUR CLINICS BEFORE? NO YES When: How did you hear about us?