Saratoga Cardiology Associates, PC 6 Care Lane Saratoga Springs, NY Phone: (518) Fax: (518)
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1 Patient Name: DOB: Soc Sec#: Thank you for choosing Saratoga Cardiology for your cardiac care. We would like to welcome you to our practice. Please complete the attached form for our records and bring it with you to your appointment. Please arrive 15 minutes early for your appointment. Any insurance that requires a patient co-payment will be collected when you check-in. A surcharge will be instituted if you fail to do so. For your convenience Saratoga Cardiology Associates accepts all major credit cards, cash or personal checks. If you are required by your insurance company to have a referral for a specialist visit please bring that with you to your appointment. Please bring your insurance cards with you for registration. In the event that you cannot keep your scheduled appointment we require a 24 hour cancellation notice or a surcharge will be billed to you personally. All professional services rendered, regardless of participating agreements, are submitted to your insurance company as a courtesy to you. Deductibles and co-insurances are your responsibility. Patients with non-participating insurances will be responsible for their account balances. If your insurance company requires you to pay a copayment, it is due at the time of service. Copayments not received at the time of service are subject to a $10.00 service charge. If there are any questions concerning insurances, please call our billing office at between 8:00 am and 4:00 pm Monday through Friday. We are looking forward to meeting you. Office Hours: 8:00am-5pm Monday thru Friday Testing Hours: 6:30am-5pm Monday thru Friday Telephone Hours: 8:00am-5pm Monday thru Friday Saratoga Cardiology observes the following holidays: New Years Day or preceding/following business day if holiday is on a weekend Memorial Day 4th of July Labor Day Thanksgiving Day and the day after Christmas Day or preceding/following business day if holiday is on a weekend The physicians at Saratoga Cardiology are on call for medical emergencies 24 hours a day, 7 days a week including weekends and all holidays. **Please complete the attached forms and give them to the receptionist at time of check in.
2 Patient Name: DOB: Soc Sec#: PATIENT INFORMATION: Patient's address: Race: Ethnicity: Next of Kin in Case of Emergency: Number(s) where they can be reached from 8am-6pm Primary Care Physician: PRIMARY INSURANCE INFORMATION: (Please bring your Insurance Card) Carrier Name: ID: Group#: Policy Holder Name: DOB: SS#: SECONDARY INSURANCE INFORMATION: (Please bring your Insurance Card) Carrier Name: ID: Group#: Policy Holder Name: DOB: SS#: PERSON RESPONSIBLE FOR PAYMENT, IF NOT THE PATIENT: Name: Date of Birth: Address (if different from patient): City State: Zip: Home Phone: WORKERS COMP/NO FAULT INSURANCE INFORMATION: Carrier Name: Phone#: Address of Carrier: Date of Injury/Accident: Name of Adjustor/Case Manager Case#: I consent for Saratoga Cardiology Associates to leave a message about my test results and appointment reminders. I authorize Saratoga Cardiology Associates to furnish information to insurance carriers concerning my illness and treatment and I assign to the physician all payments for medical services rendered to myself or my dependents. Signature: Date:
3 Patient Name: DOB: Soc Sec#: LIST OF CURRENT MEDICATIONS WITH DOSE: Please bring a list of current medications to each visit PREVIOUS SURGERIES WITH DATES: Please list below in the space provided or use the backside if necessary. LIST OF SPECIALIST SEEN WITH DATES: Please list below in the space provided. Please call your specialist and obtain records to bring with you for your appointment or request they be faxed to before your appointment date. (use backside if necessary) LIST OF Allegies and Reactions: Please list below in the space provided.
4 Request For Release of Medical Information I hereby request that my medical records be forwarded to: Saratoga Cardiology Assoicates, PC Attn: Medical Records Department Saratoga, NY Please include the following: History and Physical, Progress Notes Lab and Radiology Reports Pertinent Correspondence Other: I was your patient from to. Patient Name: Patient DOB: Address: Phone: Patient Signature: Date: Requesting Information From: Date Requested: Witness Initials:
5 HIPAA RELEASE FORM HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) was enacted in This act provides for, among other things improved portability and continuity of health insurance coverage in the group and individual markets, and group health plan coverage provided in connection with employment. HIPAA was designed to standardize several different aspects of the health administration field. Some of these standardized fields will include security, privacy, billing and fraud and abuse control. Saratoga Cardiology administers these practices on a daily basis already, and will continue to implement necessary changes to ensure the highest quality of care possible for our patients. In order to do this we are requesting you sign below shared information release form. By filling out the below information, Saratoga Cardiology will be able to discuss your personal information (medical) with the indicated party listed below. Without an identified member on your account, NO medical information will be discussed with anyone except the patient. Feel free to direct any questions regarding this to the HIPAA Officer Pat Ramsey. Shared information release form/release of medical records form I give permission to Saratoga Cardiology Associates to discuss any information regarding my medical care concerning myself, to the individual listed below. I take full responsibility in notifying Saratoga Cardiology in the event that my personal circumstances may change, altering my contact person. Changes to the contact form can be made at any time in person or via a written document. You may not change or add contacts over the telephone. I may revoke this consent in regards to the release of my medical records at any time, understanding that records may have been sent in the interim. This signature will also allow Saratoga Cardiology to release my necessary medical information to my primary care physician and any providers whom are partaking in my medical care, as well as insurance companies, and authorizes direct payment of medical benefits to the physicians within the group for services rendered and acknowledges that I am responsible for all unpaid balances. You may release my information to: 1ST Contact Name: DOB: Relationship: 2nd Contact Name: DOB: Relationship: Patient Name: Patient DOB: Patient Signature: Date: Witness: The above signature also acknowledges the receipt of Saratoga Cardiology Associates Notice of Privacy Practice. If you would like a copy of our policy please request one from our receptionist.
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INTEGRITY WELLNESS CENTER NOTICE OF PRIVACY PRACTICES
INTEGRITY WELLNESS CENTER NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YU CAN GET ACCESS TO THIS INFORMATION- PLEASE REVIEW IT CAREFULLY
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
Community Health Programs Patient Registration. Last Name: First Name: Preferred Name: Zip Code: City: State:
Community Health Programs Patient Registration Last Name: First Name: Preferred Name: Middle Initial: Suffix: Former Last Name: Gender: Male Female Date of Birth: / / Social Security Number: Mailing Address:
Healthy Living Clinic, LLC Phone:(321) 549-2273/ FAX:(321) 549-2066
IDENTIFYING INFORMATION Patient Enrollment Form PATIENT NAME: SEX: MALE FEMALE DOB: / / SS# -- -- MO DAY YEAR CONTACT HOME PHONE: EMAIL: WORK PHONE: Preferred method of communication Email Mail Home Phone
THE EYE INSTITUTE. Dear Patient:
THE EYE INSTITUTE Eye Associates of Wayne P.A. 968 Hamburg Turnpike Wayne, NJ 07470 p. 973-696-0300 f. 973-696-0464 Eye Institute North, LLC 5677 Berkshire Valley Rd. Oak Ridge, NJ 07438 p. 973-208-0600
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
Sincerely yours, Rev. 06.10
Welcome to RehabXperience. Thank you so much for choosing us. We recognize that you have a choice of physical therapy centers and greatly appreciate you for choosing us as your outpatient physical therapy
105 W. Stone Drive, Suite 2B Kingsport, TN 37660 Telephone 423.247.7500 Facsimile 423.247.7556
105 W. Stone Drive, Suite 2B Kingsport, TN 37660 Telephone 423.247.7500 Facsimile 423.247.7556 Scott Fowler, MD, FACOOG Chad Jarjoura, MD, FACOG Renda Knapp, MD, FACOG Christopher Mitchell, MD, FACOG Daphne
The Center for ADHD, Inc.
Consent to Evaluate and Treat Date: Patient: Age: Date of Birth Female Male Black Hispanic White Other Address: City, State, Zip Code: Home Phone: Work/Cell: Person(s) Responsible for Payment: Address
ADULT REGISTRATION FORM. Last Name First Name Middle Initial. Date of Birth Age Identified Gender. Street Address. City State Zip Code
ADULT REGISTRATION FORM Last Name First Name Middle Initial Date of Birth Age Identified Gender Street Address City State Zip Code Home Phone Cell Phone FINANCIALLY RESPONSIBLE PARTY (If different from
Please fill out the new patient paperwork and bring it with you, along with a photo ID and health insurance or Medicare card.
Dear Patient, Thank you for choosing San Antonio Center for Physical Therapy for your rehabilitation needs. We want your time with us to be a positive experience, one that leads you down a road of successful