Physician Disclosure



Similar documents
Wayne Physical Medicine & Rehabilitation Associates 401 Hamburg Turnpike, Suite 105 Wayne, NJ 07470

FAMILY PRACTICE PATIENT REGISTRATION FORM

RETINA CONSULTANTS OF HOUSTON. Date of Birth: Age: Sex: M F Martial Status: S M W D. Name of Spouse: Emergency Contact Name: Number:

REGISTRATION FORM (Please print)

Faculty Group Practice Patient Demographic Form

OFFICE POLICIES. Please note that NO controlled substance requests can be filled via phone as per DEA regulations. (initial)

PATIENT INFORMATION. Patient: S.S.# Address: D.O.B. Home Phone: Bus Phone: Male Female. Emergency contact: Relation to Patient: PH#

You are scheduled to see Dr. Kennard: at. On the day of your visit, he will be located at: (Directions are enclosed)

Patient Financial Policies

If physical therapy is being sought due to an accident, please indicate the and of the accident

Who to call for an emergency: Name: Relationship: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) -

Intake for Services. Birth date: Age: Gender: Name of Spouse: Years Married: Spouse's Age:

Stonebridge Adult Medicine, P.A. Registration Form (Please Print)

Sincerely yours, Rev

PATIENT REGISTRATION Date:

CENTENNIAL MEDICAL GROUP & CENTENNIAL SURGERY CENTER New Patient Paperwork

PATIENT REGISTRATION FORM

Patient Information. Claims Address: Please also provide Health Insurance information in addition to Work Comp /Auto

Patient Registration Form (ecw) (First) (MI) Previous Name. Address

PATIENT REGISTRATION Date:

Welcome and thank you for choosing eriver Neurology of New York, LLC Phone: (845) Fax: (845) Office Policies

Atlanta Diabetes Associates Patient Registration Form. Patient Name: First Middle Last. Address: City: State: Zip Code:

Office Policies Dear Patient: We would like to take the opportunity to explain the policies of our office. Please take notice of the following:

9525 Katy Freeway, Suite 312 Houston, Texas Phone (713) Fax (713) Welcome Friend!

Welcome Information. Registration: All patients must complete a patient information form before seeing their provider.

IRVING & ASSOCIATES IN BEHAVIORAL HEALTH, P.C Mochel Drive, Suite 307 Downers Grove, IL 60515

Patient Information Form Trinity Wellness Center. Insurance Information

Last Name First Name MI. Sex (circle): Male Female Date of Birth SS# Marital Status (circle): Married Single Divorced Widowed Separated

Pediatric Ophthalmology Date: PLEASE PRINT: PATIENT NAME: Male: Female: AGE: First Middle Last BIRTH DATE: / / HOME PHONE: (

SOUTH COUNTY PHYSICAL THERAPY AND REHABILITATION CENTER, INC.

Is your injury work related? Yes No Is your injury auto accident related? Yes No If so, when was the Date Of Injury:

Patient Registration Form

LAST NAME FIRST NAME MI BIRTHDATE ADDRESS CITY STATE ZIP HOME PHONE# CELL# S.S. # ADDRESS

All routine calls will be be returned within hours, in in the order in in which they were received.

I have received a copy of the Notice of Privacy Practices True Health.

P.S. Please remember to bring your completed forms to your office visit!

Welcome to Tri-State Rehab Services

LAS VEGAS PAIN INSTITUTE & MEDICAL CENTER, L.L.C.

489 Union Avenue Bridgewater, NJ Tel (732) Fax (732)

Facts About Dentists and Insurance

Policy Holder Name Relationship to Patient SSN DOB

Filutowski Cataract & LASIK Institute PATIENT REGISTRATION 3.11

Advanced Solutions Pain Management

When you arrive for your first appointment, please bring the following with you:

David A. Wang, MD Primary Care Sports Medicine Physician PRINT NAME: ADDRESS: DOB: AGE: SEX: SS# HOME: MOBILE PHONE: WORK: FAX:

Street Address Apt. or Post Office Box. City State Zip. Telephone Primary: ( ) Home Work Cell. Date of Birth / / Social Security # - -

Patient Information. Mailing Address Street City State Zip. Contact Number Home Mother Mobile Father Mobile

Patient s Last Name First MI. Social Security # Date of Birth. Age Sex M F Family Referring Doctor Doctor. Home Address Apt # City State Zip

! 1220 Howell Street Ste. 110, Seattle, WA (206)

11120 New Hampshire Ave., Suite 411 Silver Spring MD Office (301) Fax (301)

California Pain Consultants - PATIENT REGISTRATION FORM

Psychiatric Associates of Atlanta, LLC Twelve Piedmont Center, Suite Piedmont Road, NE Atlanta, GA (fax)

PLEASE BRING THE FOLLOWING WITH YOU TO YOUR APPOINTMENT:

Dr. H. Lokesh M.D Dr. R. Desai M.D Tarah Savino MMS, P.A. C 4804 Rowan Road New Port Richey, FL (727) (727) Fax

Patient Registration Please Print Patient Name Last First Middle

WELCOME TO PCCMA. We look forward to being of service to you and helping you to be healthier in the future.

2015 Annual Patient Paperwork Update for Existing Patients

Enroll in Interconnect

Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,,

Conroe Physician Associates. Patient Consent Form. I fully understand that this is given in advance of any specific diagnosis or treatment.

LAWRENCE J. FINKEL, M.D., P.C. 360 CHURCH STREET WARRENTON, VA (540) PHONE (540) FAX

ADULT MEDICAL SERVICES PC 6645 Main St. Suite A, Williamsville, NY (716) (Office) (716) (Fax)

Saratoga Cardiology Associates, PC 6 Care Lane Saratoga Springs, NY Phone: (518) Fax: (518)

Updated as of 05/15/13-1 -

Client Initial Interview Form. Address: City: State: Zip: Phone: (h) (C) May I leave messages at these phone numbers? yes no

Copayment Is Due At Time Of Visit. Self-pay (payment due at time of service)

Nephrology Associates New Patient Registration Forms

HI *Home Phone: Alternate Phone: Driver License No.: Address: INSURANCE COVERAGE & SUBSCRIBER INFORMATION (person that has the insurance policy)

The McGregor Clinic Inc. Patient Registration/Demographic Form. Patient Enrollment PLEASE USE LEGAL NAME

THE WORLD OF PEDIATRICS. Medical Records/Health Information Release (Please fill out and fax or send to your current practice or pediatrician)

BORIS RUBASHKIN, MD DONNA EDWARDS, RN, MSN, PMH- NP BERNADATTE WILLIAMS, PMH-NP

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.

Grapevine Behavioral Healthcare Associates 2311 Mustang Dr #300, Grapevine, TX Office (817) Fax (817)

Physical Occupational and Speech Therapy Patient Information Sheet

Nova Medical & Urgent Care Center, Inc Financial Policy

Faculty Group Practice Patient Demographic Form

Warner Family Counseling

New Patient Intake Package

Transcription:

Physician Disclosure As required by Section 102.006 of the Texas Occupations Code, a physician must disclose to a patient those arrangements permitted under applicable Texas law whereby such physician accepts remuneration to secure or solicit a patient or patronage for a person licensed, certified or registered by a Texas health care regulatory agency. The purpose of this Disclosure is to notify you, the patient, that Dr. Michael Ellman may receive remuneration in connection with p] referring you to Rx Unlimited Compounding Pharmacy for certain compounded pharmacy products, and pi) assisting such pharmacy in developing, implementing, and monitoring evidence-based best practice standards and pain management protocols with respect to the safe and effective use of compounded pharmacy products. I acknowledge that my attending physician(s).have disclosed to me, at the time of initial contact and at the time of referral p}his affiliation, if any, facilities or entities for whom, I, the patient am being referred, and (ii) that he will receive, directly or indirectly, remuneration for the referral to facility entity. I understand that I, the patient, have the right to choose the providers of my health care services. You have the right to choose the provider of your healthcare services. Therefore, you have the option to use a healthcare facility, laboratory, or pharmacy other than those listed. You will not be treated differently if you choose to obtain healthcare services by any other facility than those listed. In addition, I understand that Dr. Michael Ellman has ownership interest in the following facilities: Presbyterian Hospital of Rockwall, Legacy Laboratory Services LLC, Preferred Imaging on Piano Parkway, Bent Tree Pain Procedure Center LLC, APSP-North Central LLC If you have any questions or concerns regarding this notice, feel free to ask Dr. Ellman or any representative of the listed facilities. We welcome you as a valued patient and value our relationship with you. By signing this Disclosure of Physician Ownership, you acknowledge that you have read and understand the foregoing notice and understand that your physician has an ownership interest in above mentioned facilities. Signature of Patient Date Print Name of Patient

Pain Management Non-operative Spine Care EMG/NCS. Sports Medicine Male: Female First Middle Last Street City State Zip HomePh: C ell Ph: Email SSN: - - Birth Marital Status: Y N Spouse: Drivers Lie: Ht: Wt: Refferinq Dr/Attorney: Phone #: Street City State Zip Emergency Contacts Name: Ph: Relationship:. Insurance Information: Please present card and drivers license to receptionist Primary lnsurance:_ Group #:_ Secondary Insurance: Group#:_ ID#: policy Holder^ ID#: _Policy Holder:_ 2692 N. Galloway Suite 402 Mesquite, Texas 75150 Phone 972-682-3909. Fax 972-682-9289

Pain Management Non-operative Spine Care EMG/NCS Sports Medicine Patient Consent Form I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected health information. I understand that this information can and willbe used to: # Conduct, plan and direct my treatment and follow-up among the multiple Healthcare Providers who may be involved in the treatment directly and indirectly. *> Obtain payment from third party payers. * Conduct normal healthcare operations such as quality assessments and physician certifications. I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent. Print _ Signature: 2692 N. Galloway Suite 402 - Mesquite, Texas 75150 - Phone 972-682-3909 Fax 972-682-9289

AM lehab ASSOCIATES Pain Management Non-operative Spine Care EMG/NCS Sports Medicine Financial Policy First Middle Last Please initial each line * ; *Our office is not responsible for determining if we are on your insurance plan. It is your responsibility to contact your insurance plan for this information. _*lnsurance companies require that copayments are due at the time of service. * f you do not have insurance or if you have a deductible that has not been met, payment in full is expected at the time services are rendered. *You must present your insurance card and driver's license at the time of each visit. If you are unable to produce proof of eligibility, payment in full will be expected at the tim.e services are rendered. * f our office is not notified of insurance changes within SOdays of the date of service, the account holder will be expected to pay in full for all charges for that date of service. *Claims for any services not covered or considered not a benefit by insurance companies will be billed to the responsible party. : *We accept cash, personal checks, Visa & Mastercard., *We reserve the right to charge $25 for missed appointments. Insurance companies do not pay this fee. It is your responsibility to pay this charge. Please call the office at ieast 24 hours in advance if you need to cancel or reschedule your appointment, so that we can offer the appointment to another patient. *We charge $50 if we forward your account to a collection company. j*you agree, in order for us to service out account or to collect any amounts you may owe, we may contact you by telephone at the telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact by sending text messages or emails, using any email address you provide to us. Methods of contact may include using pre-recorded/artificial voice messages and /or use of an automatic dialing services, as applicable. I/We have read this disclosure and agree that the creditor may contact rne/us as described above. ; _ * have read and agree to the financial polices of Ellman Rehab Associates/Regenerative Ortho Spine of Texas. I assign insurance benefits to be paid directly to Ellman Rehab Associates/and or Regenerative Ortho Spine of Texas. I authorize the release of medical information on my behalf to insurance companies for the purpose of filing insurance claims. ' Signature of Patient: j _ 2692 N. Galloway - Suite 402 Mesquite, Texas 75150 Phone 972-682-3909 - Fax 972-682-9289

XJiJ Pain Management. Non-operative Spi.ne Care - EMG/NCS Sports Medicine Request For Release of Medical Records First Middle Last Patient Date of Birth: I hereby request and authorize the following provider to release medical records for the following patient. Provider Name: City, State & Zip:. Office Ph: Fax: Please release all medical records from (date) to Please Forward Records To: Ellman Rehab Associates 2692 N. Galloway Suite 402 Mesquite, TX 75150 Ph: 972-682-3909 Fax: 972-682-9289 2692 N. Galloway. Suite 402 Mesquite, Texas 75150 Phone 972-682-3909 - Fax 972-682-9289

2026 © DocPlayer.net Privacy Policy | Terms of Service | Feedback  | Do Not Sell My Personal Information