PATIENT REGISTRATION Date:



Similar documents
PATIENT REGISTRATION Date:

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

Faculty Group Practice Patient Demographic Form

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

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.

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

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

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

Patient Registration Please Print Patient Name Last First Middle

Patient Demographic Form

FAMILY PRACTICE PATIENT REGISTRATION FORM

Please fill out the new patient paperwork and bring it with you, along with a photo ID and health insurance or Medicare card.

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

* Do you wish to receive our monthly newsletter? Yes No Marital Status: Single Married Legally Separated Divorced Other Employer Name: (If applicable)

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

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

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

REGISTRATION FORM. How would you like to receive health information? Electronic Paper In Person. Daytime Phone Preferred.

Welcome to North Texas Orthopaedic & Spine 955 Garden Park Dr. Ste. 200 Allen Texas Today s Date: How did you hear of our practice?

PLEASE BRING THE FOLLOWING WITH YOU TO YOUR APPOINTMENT:

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

CONSENT FOR MEDICAL TREATMENT

Virginia South Psychiatric & Family Services

New Patient Intake Package

Patient Information Form Trinity Wellness Center. Insurance Information

California Pain Consultants - PATIENT REGISTRATION FORM

Cell Phone / Best Number To Reach You: Your address: Race: C AA Asian Other. Copay: Copay:

Faculty Group Practice Patient Demographic Form

Cardiology Consultants of Atlanta, P.C N. Decatur Rd. Suite 395, Decatur GA, (404) phone (678) fax

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

PATIENT REGISTRATION FORM

The Healthy Mind PSYCHIATRIC SERVICES

Keweenaw Holistic Family Medicine Patient Registration Form

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

How To Get A Medical Checkup

Medical History Questionnaire

Nephrology Associates New Patient Registration Forms

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

CENTENNIAL MEDICAL GROUP & CENTENNIAL SURGERY CENTER New Patient Paperwork

Policy Holder Name Relationship to Patient SSN DOB

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

155 McDonald Drive SW Shirley E. Charette, MS, PA-C

Advanced Solutions Pain Management

WELCOME TO MY PRACTICE Thank you for choosing me as your therapist. I am looking forward to our work together and providing you with assistance.

PENNSYLVANIA PLASTIC SURGERY ASSOCIATES, P.C. Howard S. Caplan, M.D. Francine A. Cedrone, M.D. Account #

MIGUEL GONZALEZ, MD, FCCP, FACP 303 S. Moorpark Rd. Thousand Oaks, Ca Phone Fax PATIENT INFORMATION

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

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

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

How do you prefer to be reminded of your dental appointments?

Patient Registration Form

Dr. Ronnie Pollard, DPM 1563 Gilpin Street Denver, CO

THE EYE INSTITUTE. Dear Patient:

Patient Financial Policies

BOWLING GREEN INTERNAL MEDICINE AND PEDIATRICS ASSOCIATES TREATMENT AUTHORIZATIONS AND FINANCIAL POLICIES

Name: Location: Phone:

Horizon Eye Care, P.A. Patient Information Sheet. For your convenience, please print and complete the pre-registration forms before your visit.

Thank you for your cooperation.

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

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

pain management AT GARDEN STATE MEDICAL CENTER

New Perspective Counseling Services Child/Teen Intake Form

Single Married Divorced Widowed Student Minor African American Asian Caucasian Hispanic Other:

Advanced Women's HealthCare, SC Registration Form

PATIENT INFORMATION - Please complete and/or verify all information and make changes as necessary.

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

Physical Occupational and Speech Therapy Patient Information Sheet

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

James A. Purvis, Ph.D. Psychotherapy Services Agreement

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

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

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

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

PATIENT INFORMATION FORM. Name: Address: City: State: Zip: Social Security Number: Telephone Numbers Home: Age: Sex: M / F Work: Cell:

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

OUTPATIENT REHABILITATION CENTER

PATIENT INFORMATION EMERGENCY CONTACT LAST FIRST RELATIONSHIP REFERRAL SOURCE DOCTOR / REFERRING CLINICIAN: FAMILY MEMBER/FRIEND: INSURANCE:

NEW PATIENT APPLICATION. Welcome to Corrective Chiropractic! Please answer all questions to the best of your ability. Thank you.

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

insurance company policy number issue date (00/00/0000) face amount total policy loan cash surrender value amount paid

WORKERS COMPENSATION INFORMATION. Soc. Sec.# Address Marital Status: Single Married Divorced Widowed Home Phone: Cell Phone: Work Phone:

2015 Annual Patient Paperwork Update for Existing Patients

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

REGISTRATION FORM (Please print)

Garland s Christian Counseling Center

Transcription:

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 SERVICES ARE RENDERED UNLESS WE PARTICIPATE WITH YOUR INSURANCE PATIENT GENERAL INFORMATION: Last Name: First Name: MI EMERGENCY CONTACT INFORMATION: Contact Name: Contact Relation: Sex: M F Date of Birth: Contact Phone: S.S. # Address: Home Phone: Cell Phone: Work Phone: May we call you at work? Yes No Email: No email Preferred Contact # Home Work Cell Email Language: Race: Ethnicity: Decline to Answer Marital Status: Separated Widowed Married Single Divorced Partner If Minor, Guardian Name Last name, First name, MI Primary Care Physician: How did you hear about us? Advertising Physician Referring Physician s Name: Word of Mouth Patient in the Practice Hospital Insurance Company Other: Please specify CONTACT INFORMATION FOR APPOINTMENT REMINDERS: Do you prefer to receive a: Phone Call or Text Phone #: Preferred time to call: Morning Afternoon Evening Contact Cell Phone: NEXT OF KIN: Name: Relation: Phone: EMPLOYER/SCHOOL INFORMATION: Name: Address: Phone: Occupation: GUARANTOR INFORMATION: Patient s Relationship to Guarantor: GUARANTOR (name to whom statements are sent) Last Name: First Name: MI Guarantor Date of Birth: Mailing Address Same as patient s? Address: Optional Guarantor Information: S.S.#: Phone: Email: VMG_7_PatientRegistration_Rev_01_14.docx Page 1

INSURANCE INFORMATION: Policy Holder s Name: Last Name First Name MI Sex: M F Relationship to Patient: Self Mother Father Other: Date of Birth: S.S. # Address: Home Phone: Cell Phone: Work Phone: Email: _ Policy Holder s Employer: Employer s Address: Primary Insurance Company: Policy Holder s ID: Group #: Insurance Company Address: Secondary Insurance Company: Policy Holder s ID: Group #: Insurance Company Address: PHARMACY INFORMATION: Local Pharmacy Name: Phone: Address: Mail Order Pharmacy Name: Phone: Address: PREFERRED LABORATORY: Name: Phone: Address: Fax: WORKER S COMPENSATION INFORMATION (if applicable) W/C Claim Number: W/C Carrier Name: Contact: W/C Carrier Address: Phone: Fax: *Valley Medical Group is the trading as name for Valley Physician Services, Inc., Valley Medical Services, Inc.., and Valley Physician Services, NY, PC VMG_7_PatientRegistration_Rev_01_14.docx Page 2

GENERAL CONSENT FOR TREATMENT Name of Procedure: 1. I hereby consent to treatment, including local anesthesia and diagnostic or therapeutic procedures. 2. The nature and effect of the procedure to be performed, the risks involved, as well as possible alternative methods of treatment, and the prognosis if no treatment is rendered, have been explained to me. I am aware that the practice of medicine is not an exact science, there are risks associated generally and that no guarantees about the outcome of this care have been made to me as a result of examinations and `treatment. 3. I authorize my doctor and staff to take any photographs required for the completion of documentation. 4. I understand and agree that Valley Medical Group (VMG)* may disclose any or all parts of my medical record in order to obtain payment for any service rendered to me. 5. I understand that in order to facilitate the best care and treatment, my doctor may need to access information about me from my other providers and facilities where I have received care and services, such as specialists, diagnostic center, laboratories, and he/she may need to access my prescription history information. 6. I understand and agree that VMG may disclose any or all parts of my medical record to other providers for health care services or goods in order to make arrangements for coordinated health care delivery. 7. I understand and agree that the information, which my doctor may disclose, may include information about and/or reference HIV/AIDS related diagnoses/conditions, drug or alcohol use or abuse, pain management and psychiatric or psychological information, reports, evaluations and diagnoses, as well as history and physical examinations results, consultations and treatment recommendations. 8. I understand and agree that other practitioners may assist with the procedure(s) as necessary, and may perform important tasks related to the surgery. 9. After treatment is received, I will follow the medical advice and instructions given and I will continue treatment and follow-up care with the physician/provider to whom I am referred as indicated on this record. 10. I, the undersigned agree, whether the patient or an authorized agent of the patient, that in consideration of the services to be rendered to the patient, I hereby individually obligate myself to pay the account of the practice in accordance with the regular rates and terms of VMG. I certify that I have read and understand this consent form, and that I have been given the opportunity to have any questions related to this treatment which have been answered by the clinical staff of this facility. Patient or Authorized Representative Signature Name of Person Signing Witness Date Relationship to Patient Date *Valley Medical Group is the trading as name for Valley Physician Services, Inc., Valley Medical Services, Inc., and Valley Physician Services, NY, PC VMG_P_6_ConsentForTreatment_Rev_11_13.doc

ACKNOWLEDGEMENT OF OUR NOTICE OF PRIVACY PRACTICES I hereby acknowledge by signing below that I have received or have been given the opportunity to receive a copy of Valley Medical Group Notice of Privacy Practices. HIPAA Patient Name (please print clearly) Date Patient/Guardian Signature Person Signing on behalf of the patient Relationship to Patient *Valley Medical Group is the trading as name for Valley Physician Services, Inc., Valley Medical Services, Inc., and Valley Physician Services, NY, PC VMG_5a_AcknowledgementOfOurNoticeOfPrivacyPractices_11_13.docx

PATIENT RESPONSIBILITIES AND STATEMENT OF UNDERSTANDING In the current healthcare environment, it is increasingly difficult for medical providers to be paid for their services. Dealing with insurance companies is also becoming more confusing to our patients. As a result, we would like to clarify your responsibilities as a Valley Medical Group patient. Insurance Coverage Your insurance policy is a contract between you and your insurance company, not your provider. Changes to your insurance coverage must be communicated to our office at the time of service upon check-in. Your insurance company may require you to choose a primary care physician in order to receive in network benefits. If you have chosen a Valley Medical Group physician as your PCP and his or her name does not appear on your insurance card, you must verify that your insurance company has the correct information before services are rendered. If your claim is processed incorrectly by your insurer, you give Valley Medical Group permission to appeal the claim on your behalf by your signature below. If your insurance plan requires a PCP and the Valley Medical Group physician is not your PCP, you may be responsible for deductibles, co-insurance, and other non-covered services. If your plan requires referrals from your Valley Medical Group PCP to specialists, it is your responsibility to obtain the referral from our office prior to your appointment with the specialists. Please be aware that non-emergent referrals can take up to two weeks to process. In addition, referrals will NOT be dated retroactively. Financial Obligations 1. Co-payments are due at the time of service. 2. Valley Medical Group will bill participating insurance companies after verifying coverage. If claims are not paid, Valley Medical Group will bill you for services rendered. 3. Payment for non-covered services, deductibles, and co-insurance amounts are due within thirty (30) days of receipt of invoice. 4. If insurance payments are paid to you in error instead of Valley Medical Group, the payment must be forwarded to us. You may issue a personal check to Valley Medical Group. Be sure to include a copy of your insurance company s documentation or explanation of benefits. 5. If you do not have insurance that Valley Medical Group participates with, you are responsible for payment in full for today s services. 6. Processing fees may be imposed for non-payment of out-of-pocket expenses referenced in #1 and #5 above, and for checks returned by the bank for non-payment. 7. Valley Medical Group bills an additional fee for weekend and holiday visits. 8. If requested, you are responsible for providing your insurance company with any other insurance coverage, details of an injury, dependent student information, and other non-medical information. Failure to comply with an insurance company request for information will result in your being responsible for payment. I HAVE READ AND UNDERSTAND THE INFORMATION AND MY RESPONSIBLITIES AS STATED ABOVE: Patient/Guardian: Date: Witness: Date: A copy of this form is available upon request. *Valley Medical Group is the trading as name for Valley Physician Services, Inc., Valley Medical Services, Inc., and Valley Physician Services, NY, PC VMG_3_PtResp&Statement_Rev_11_13.doc

AUTHORIZATION TO DISCUSS HEALTH INFORMATION WITH OTHERS AND/OR LEAVE TELEPHONE MESSAGES The purpose of this document is to inform us if we have your permission to: Relay information to other people regarding your care and treatment. Leave information about your care and treatment on your telephone answering machine. Call you at work, and/or on your cell phone or other telephone number. Patient Name: Date of Birth: E-mail Address: When our physicians or office staff need to speak with you about your healthcare, we generally place a telephone call and ask to speak with you, our patient, first. Some examples of when we may need to call you are: to see how you are feeling after a visit to us; with follow-up instructions after a visit; and/or with laboratory, radiology, or other diagnostic test results, etc. If you are unavailable when we telephone you, May we leave such information on your answering machine? No Yes Comment: May we leave such information with other people in your household? No Yes Comment: If Yes, please note specifically who: May we contact you at work? No Yes Telephone: May we contact you via cell phone? No Yes Cell phone: Is there any other telephone number you would like us to call to reach you or another person you would like us to contact to discuss your health care? PLEASE INDICATE YOUR PREFERRED METHOD FOR OUR FOLLOW-UP COMMUNICATIONS WITH YOU: Home Phone Cell Phone Work Phone Other: (E-mail can only be used to contact you when all other means fail.) Is there someone you have given the authority to schedule, confirm, or cancel appointments for you? No Yes If Yes, please specify: Patient Signature: Date: Valley Medical Group will abide by the guidelines given in this document unless you instruct us differently. *Valley Medical Group is the trading as name for Valley Physician Services, Inc., Valley Medical Services, Inc.,, and Valley Physician Services, NY, PC VMG_1_AuthToDiscuss_Rev_11_13.doc

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