We look forward to meeting you soon!
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- Gervais Fowler
- 5 years ago
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1 Welcome to Carolina Glaucoma, We look forward to having you as a patient and assisting you in every way we can with your glaucoma needs. Here are some things to remember to make your first visit a successful one 1. You have received a New Patient Packet either through the mail or provided by your Primary Eye Care Doctor. Please make sure this is completed in its entirety prior to your arrival. If your packet is not completed you may be asked to reschedule your appointment. 2. We offer a 15 minute grace period on all appointment times. Please contact the office at if you feel you are going to be late or need help with directions. Please be advised that arriving later than 15 minutes past your appointment time may result in rescheduling of your appointment. 3. If you are being referred for a surgery or laser evaluation please know that your procedure will not be performed at your first visit. This will be a consult only. 4. You may be dilated for any new patient appointment as deemed appropriate by Dr. Price. If you feel uncomfortable driving while dilated you may wish to bring a driver. 5. Please note that this is the first time we will be meeting you and therefore your appointment may take some time. Please plan to be here for 1-2 hours on your first visit. We look forward to meeting you soon!
2 PATIENT INFORMATION Mary Elizabeth Price, M.D., F.A.C.S SOUTH 17 TH STREET, SUITE 3 WILMINGTON, NC (TEL) (FAX) Last: First: MI: Birth Date: Age: Sex: / / M F Street Address: City: State: Zip: Home Phone (Do not leave messages ) Work Phone (Do not leave messages ) Cell Phone (Do not leave messages ) Social Security Number: Address: - - Marital Status: Do you drive? Preferred Contact Method: S M W D Y N Phone Letter Patient Portal Race (check one): White African American Employer: Asian Native American Other Ethnicity (check one): Hispanic/Latino Non-Hispanic/Latino Primary Doctor Preferred Language (if not English): Spanish Other: Name of Spouse (if applicable) Phone Number: Emergency Contact Name: Phone Number: Who referred you to this office? Preferred Pharmacy and Location? *PRIMARY INSURANCE SUBSCRIBER (check if same as individual responsible for payment ) Last: First: MI: Birth Date: Age: Sex: / / M F Street Address: City: State: Zip: Home Phone (Do not leave messages ) Work Phone (Do not leave messages ) Cell Phone (Do not leave messages ) Social Security Number: - - Address: Insurance Company Group Number Subscriber Number/ID *We need this information in order to file this claim with your insurance company.
3 Patient Name Date of Birth MEDICAL HISTORY Y/N Y/ N Anxiety Hepatitis (A, B or C) Arthritis High Blood Pressure / Hypertension Asthma HIV/AIDS Atrial Fibrillation Hypercholesterolemia Bone Marrow Transplant Hyperthyroidism/Hypothyroidism Breast Cancer Leukemia Colon Cancer Lung Cancer COPD Lymphoma Coronary Artery Disease Prostate Cancer Depression Radiation Diabetes Seizures End Stage Renal Disease Stroke GERD Other Please describe any issues listed above: SURGICAL HISTORY Y/N Y/N Appendix Ovaries Bladder Pancreas Breast Prostate Colon Rectum Gallbladder Skin Heart Spleen Joints Testicles Kidney Uterus Liver Others Please describe any issues listed above:
4 OCULAR HISTORY Y/ N Y/N Macular Degeneration Narrow Angles Blepharitis (eyelid skin irritation) Ophthalmic Migraines Cataract Retinal tear/detachment Contact Lenses PVD/Floaters Corneal Dystrophy Diabetic Retinopathy Dry-eye Glasses Glaucoma Other Please describe any issues listed above: OCULAR SURGERY Y/ N Y/N Intravitreal Injections Strabismus (Muscle)Surgery LASIK Retinal Laser LPI (Glaucoma laser treatment) Retinal Surgery Glaucoma Surgery Cataract Surgery PRK YAG Capsulotomy Laser Ptosis Repair/Droopy Eyelid(s) Other Punctal Plugs Please describe any issues listed above:
5 PLEASE LIST ALL ALLERGIES AND/OR ALLERGIC REACTIONS YOU HAVE TO ANY MEDICATIONS (INCLUDE ALLERGIES SUCH AS LATEX AND ADHESIVES) MEDICATIONS AND/OR SUBSTANCE REACTION SOCIAL HISTORY (Check all that apply and provide details below) Y/ N Y/N Current Smoker Daytime driving Former Smoker Nighttime driving Alcohol use Do you work? Occupation: Please describe any issues listed above: Cancer Diabetes Glaucoma Heart Disease FAMILY HISTORY (Mother, Father, Brother, Sister, Grandparent, )
6 PLEASE LIST ALL MEDICATIONS YOU CURRENTLY TAKE This is very important so that we do not prescribe you any medications that will cause harmful reactions from the medications that other doctors have prescribed to you. MEDICATIONS TAKEN MILLIGRAM HOW OFTEN
7 PATIENT ACKNOWLEDGMENT OF RECEIPT OF HIPAA NOTICE (PLEASE INITIAL) I acknowledge that I have received or have been offered a copy of Carolina Glaucoma, PA Notice of Privacy Package, effective August 1, I acknowledge my rights and have been offered the option to request to receive communications of my personal health information by alternative means or at alternative locations. I understand that Carolina Glaucoma, PA may refuse to accommodate my request if it is not reasonable. Please indicate the telephone number you would like our office to use for appointment reminders or other office communications (including but not limited to billing matters and test results) ( ) - Is there a family member or friend that you would allow us to leave messages with or release billing or medical information to? Name: Phone #:( ) -
8 Mary Elizabeth Price, M.D., F.A.C.S SOUTH 17 TH STREET, SUITE 3 WILMINGTON, NC (TEL) (FAX) Patient Name: MEDICAL RELEASE AUTHORIZATION (EXPIRES UPON ONE TIME RELEASE) Date of Birth Street Address City State Zip I authorize the practice below to release my health information: Please forward/release my health information to: 1907 South 17 th Street Ste. 3 Wilmington, NC 28401, Fax: THIS AUTHORIZATION SHALL BE IN EFFECT UNTIL THE INFORMATION HAS BEEN FORWARDED AS REQUESTED Patient Information: I understand that my treatment will not be conditioned upon signing this authorization and that I have the right to refuse to sign this authorization. I understand that information disclosed as a result of this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law. I understand that I have the right to revoke this authorization by sending a written notification to the address below and that a revocation is not effective if the information has already been disclosed but will be effective going forward. I understand that I have the right to inspect or copy the protected health information as described in this document I can do this by written notification to Carolina Glaucoma, P.A. Signature Date Description of Personal Representative s Authority (attach necessary documentation)
9 CONSENT FOR PURPOSES OF TREATMENT, PAYMENT AND HEALTHCARE CONSENT FOR TREATMENT: The undersigned consents to any examination, laboratory procedure, or other medical treatment or service rendered to the patient under the general and special instructions of Mary Elizabeth Price, M.D. The undersigned is aware that the practice of medicine and surgery is not an exact science and acknowledges that no guarantee or assurance has been made or implied to the patient as to the result that may be obtained from examination or treatment. The undersigned has been informed of the patient's rights and responsibilities. RELEASE OF INFORMATION: The undersigned hereby authorizes this medical office to disclose all or any part of the patient's medical record or other medical information to any person or corporation which is or may be liable for all or part of this medical office's charges or having the responsibility for reviewing such charges, including but not limited to this medical office or medical service organizations, health maintenance organizations, insurance companies, workers compensation claims, welfare funds, or peer review organizations. The undersigned agrees to the copying of all medical record(s) which is/are to be sent to a receiving facility in the event that the undersigned must be transferred to another provider/facility. The undersigned acknowledges and consents that medical records, laboratory results, radiology reports, and billing information may be sent electronically or via facsimile to another medical facility or physician office involved in the care of the patient or responsible for any part of the patient's charges. REQUEST FOR PAYMENT, ASSIGNMENT OF BENEFITS, AND RELEASE OF INFORMATION FOR MEDICARE / MEDICAID PATIENTS: The undersigned requests payment of authorized Medicaid/Medicare benefits, if any, for any services furnished to the patient by Carolina Glaucoma, PA, including physician services, and hereby assigns such benefits otherwise payable directly to the patient, to Carolina Glaucoma, PA, or the physician(s) furnishing such services. The undersigned authorizes Carolina Glaucoma, PA or such physicians to submit a claim for such services to Medicare/ Medicaid. The undersigned authorizes any holder of medical or other information about the patient to release to Medicare/Medicaid, or its agent, claims processor, or utilization reviewers, any information needed to determine these benefits or benefits for related services. ASSIGNMENT OF INDIVIDUAL BENEFITS: In the event the undersigned is entitled to medical benefits of any type whatsoever arising out of any policy of insurance insuring patient or any other party liable to patient, the undersigned authorizes Carolina Glaucoma, PA, or physicians to submit a claim for such services, and benefits are hereby assigned to this medical office for application on the patient's bill. It is agreed that Carolina Glaucoma, PA may receive any such payment and such payment shall discharge the paying insurance company of any and all obligations under the policy to the extent of such payment. The undersigned and/or patient are responsible for charges not covered by the insurance. The undersigned certifies that the patient information given by or on behalf of the patient in applying for payment from all third party payors is correct. FINANCIAL AGREEMENT: The undersigned understands and agrees that the patient and guarantor are financially responsible to Carolina Glaucoma, PA for charges for medically necessary services or services requested by or on behalf of the patient if such services are not covered by the patient's insurance plan or Medicare/Medicaid. The undersigned certifies that he/she has read the foregoing and is the patient or guarantor of this bill, or is duly authorized as the patient's general agent to execute the above and accept its terms. I HAVE READ, OR I HAVE HAD EACH OF THE ABOVE SECTIONS READ TO ME, AND ALL OF MY QUESTIONS HAVE BEEN ANSWERED. Signature of Patient or Personal Representative Date
10 PAYMENT POLICY Thank you for choosing Carolina Glaucoma, PA as your provider. We are committed to providing you with quality and affordable health care. Because some of our patients have had questions regarding patient and insurance responsibility for services rendered, we have been advised to develop this payment policy. Please read it, ask us any questions you may have, and sign in the space provided. A copy will be provided to you upon request. Insurance. We participate in most insurance plans, including Medicare. If you are not insured by a plan we do business with, payment in full is expected at each visit. If you are insured by a plan we do business with, but don't have an up-todate insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage. Co-payments and deductibles. All co-payments and deductibles must be paid at the time of service. This arrangement is part of you contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-payment at each visit. There will be an additional charge of $20.00 if we have to bill your co-pay. Non-covered services. Please be aware that some - and perhaps all - of the services you receive may be non-covered or not considered reasonable or necessary by Medicare or other insurers. You must pay these in full at the time of your visit. Proof of insurance. All patients must complete our patient information form before seeing the doctor. We must obtain a copy of your driver's license and current valid insurance to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim. Claims submission. We will submit you claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract. Coverage changes. If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. If your insurance company does not pay your claim in 45 days, the balance will automatically be billed to you. Nonpayment. If your account is over 90 days past due, you will receive a letter stating that you have 20 days to pay your account in full. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we refer your account to a collection agency and you or your immediate family members may be discharged from this practice. If this is to occur, you will be notified by regular and certified mail that you have 30 days to find alternative medical care. During that 30-day period, our physician will only be able to treat you on an emergency basis. Please be aware that should your account be referred to a collection agency, the percentage charged by the collection agency to our practice will be added to the total amount of your bill. Missed appointments. There is a $25 no-show/late cancellation fee. All appointments must be canceled no later than twenty-four (24) hours prior to your appointment (or by 3 PM on Friday for a Monday appointment), to avoid charges for a no-show or late cancellation. Insurance will not cover charges for a no-show/late cancellation fees. We reserve the right to reschedule your appointment if you are more than 15 minutes late. Copies of Medical Records and Insurance/Disability Forms. Our office will gladly make copies of medical records for you. The fee for this service is based on the number of pages copied. If you need our office to complete any disability forms or forms for your insurance company or other parties, we will be glad to do so for a fee of $15.00, payable in advance. I HAVE READ AND UNDERSTAND THE PAYMENT POLICY AND AGREE TO ABIDE BY ITS GUIDELINES: Signature of Patient or Personal Representative Date
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RETINA ASSOCIATES OF SARASOTA
RETINA ASSOCIATES OF SARASOTA John Niffenegger, MD Elizabeth Richter, MD, PhD Keye Wong, MD 3920 Bee Ridge Road, Bldg. D 1370 E. Venice Ave., Suite 201 1509 53rd Ave. West 3280 Tamiami Trail, Suite 41
We look forward to meeting you, and will be available for you at any time. Dr. Douglas Scott, M.D. Dr. Kirk Johnson, M.D.
Welcome to Orthopedic Associates of the Lowcountry. Thank you for your confidence in allowing us to help care for your health. It is a responsibility we respect, and take very seriously. Please take the
Patient Registration
Today s : Patient Registration Name: (First, MI, Last) of Birth: Age: Gender: M F Marital Status: S M D W Address: City: State: ZIP: Home Phone: Work Phone: Cell Phone: Email Address: Preferred Daytime
VASCULAR HEART & LUNG ASSOCIATES
PATIENT INFORMATION Last Name: First Name: M.I: Address: City: State: ZIP: Telephone (Cell): (Home): (Circle preferred contact method). Email: Date of Birth (MM/DD/YEAR): / / Age: Sex: SS# Ethnicity [circle]:
REGISTRATION FORM. Physician (PCP): PATIENT INFORMATION. Last Name: First Name: MI: Billing Address: City: ST Zip Code:
: REGISTRATION FORM Physician (PCP): PATIENT INFORMATION Last Name: First Name: MI: Social Security #: DOB: Sex: M F Billing Address: City: ST Zip Code: Home Phone#:( ) Cell Phone#:( ) Work Phone#:( )
Name: (Last) (First) (M.I.) (Nick Name) Address: City: State: Zip: Address:
Date: / / Welcome and thank you for choosing McCabe Vision Center for your eye care needs. We take pride in providing you with the best vision correction possible. : (Last) (First) (M.I.) (Nick ) Address:
PATI ENT INFORMATION Date=----~--- First Name: Ml: Last Name: ------------ Date of Birth: Sex: [ ] Male [ ] Female Address: City,State, Zip: Home Phone: Cell Phone:, Work Phone: Email Address: Marital
Corederm Dermatology & Cosmetic Center
Please present ALL Insurance cards and Drivers License to the receptionist at every visit. Patient Information: Please Complete All Fields Using Legal Names of the Parties Involved. First name: Last name:
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM PATIENT INFORMATION Name: Date of Birth: Age: Address : Social Security #: City: Sex: Marital Status: State: Zip: Language: Pt Declines Home Phone#: Race: Pt Declines Work Phone#:
Family Foot and Ankle Centers Patient Registration Form (Please present your insurance cards to the receptionist upon arrival)
Family Foot and Ankle Centers Patient Registration Form (Please present your insurance cards to the receptionist upon arrival) Patient s Name First Last M.I. Nickname Address # City State Zip code Phone:
PATIENT REGISTRATION
PATIENT REGISTRATION PLEASE PRINT and be sure to complete the entire form and bring with you to your eye exam. Last Name First Name Middle Name Email Address Date of Birth Age Sex Home Address Street City
PATIENT INFORMATION PRIMARY INSURANCE INFORMATION
1001 Medical Plaza Dr. The Woodlands, TX 77380 www.woodlandsretina.com Tel: 281-367-9700 Fax: 281-367-9701 PATIENT INFORMATION Patient s Legal Name: Date of Today s Visit: Social Security # Date of Birth:
We look forward to serving you and your ophthalmic needs. Please do not hesitate to contact our office if we can be of any further assistance.
Welcome to Biltmore Eye Physicians! Enclosed in our new patient packet are the following items: 1. Patient Registration 2. Credit Policy and Financial Agreement 3. Notice of Privacy Practices 4. Medical
Soderma Dermatology. General, Surgical & Cosmetic
S D General, Surgical & Cosmetic Welcome to Soderma, General, Surgical & Cosmetic Dermatology. We are a comprehensive dermatology practice, providing a full range of medical, surgical and cosmetic dermatologic
Patient Information (Please Print) Appt. Date / /
Patient Information (Please Print) Appt. Date / / Last name: First: MI: DOB: Address: Apt: City: State: Zip: Phone: E-mail address: Cell: SS#: Marital Status: Gender: M or F Responsible Party (If Different
Skin Problems Unexpected weight Loss/Gain None Explain: None Endocrine: Self Family: Musculoskeletal: Self Family: Thyroid
Demographics Last Name: First Name: Initial: : Guarantor: Address: City: State: Zip: Home #: Work #: Cell #: Email: Communication Preferred: email phone mail Pharmacy of Choice: of Birth: Male Female Ethnicity:
Samir Sutaria, MD Samir Rajan, MD NEPHROLOGY & HYPERTENSION
PATIENT REGISTRATION FORM Patient Name: (Last) (First) (Middle) Birth Date: / / Social Security #: / / Age: Gender: (circle) male - female Race: Ethnicity: Language Preference: Marital Status: _ Home Address:
I have read and acknowledge all of the above policies associated with Pioneer Cardiovascular Consultants, PC including: (PLEASE INITIAL)
PH:(480) 345-0034; F:(480)345-4033 Patient s Name (Last) (First) (M.I.) SS# Date of Birth / / Marital Status Sex Race :( optional) Ethnicity: (optional) Preferred language: Referring Physician: _ Phone#:
We look forward to serving you and your ophthalmic needs. Please do not hesitate to contact our office if we can be of any further assistance.
ANN BULLINGTON, M.D. ROBERT H. BULLINGTON, JR., M.D. Cornea and External Diseases AILEEN F. VILLAREAL, M.D. ROBERT E. FINTELMANN, M.D., F.A.C.S. Cornea, Cataract, and Refractive Surgery Welcome to Biltmore
Patient Registration. Patient Information. Guarantor Information (skip if same as patient) Emergency Contact Information. Insurance Information
Patient Registration Patient Information Patient name (Last, First) Patient date of birth Patient gender (M / F) Patient marital status Mailing address (address number & street) Patient Social Security
PATIENT INFORMATION. Caucasian or White Male Female. Unknown IN CASE OF EMERGENCY
Name (Last, First, Middle Initial): PATIENT INFORMATION Salutation: Mr. Social Security # Preferred Language: Race: Ethnicity: American Indian or Alaska Native Hispanic or Latino Asian Not Hispanic or
On the Day Of Your Appointment You Will Need To Bring The Following:
Please complete all patient information forms attached. To better assist you in a timely manner, to guarantee communication with your referring and primary care physicians and to properly care for you,
Minor Patient Information
Minor Patient Information MINOR S INFORMATION: (TO BE FILLED OUT BY CUSTODIAL PARENT OR LEGAL GUARDIAN) Last Name: First Name: MI: Goes By (If Different Than Above): DOB: Sex: M F Ethnicity/Race: Preferred
AUBURN URGENT CARE. Patient Information. Name: Last First Middle. Permanent Address: Apt #: Zip: City: State: Employer: Phone: ( )
AUBURN URGENT CARE Patient Information Name: Last First Middle Date of Birth: / / Social Security: Permanent Address: Apt #: Zip: City: State: Race: Gender: M F Undifferentiated Home Phone: ( ) Cell:(
NOTICE ABOUT REFRACTION
NOTICE ABOUT REFRACTION We have you scheduled for a Complete Eye Exam or surgical consultation today. If you are here for your Eye examination and you are experiencing blurry vision or any visual changes,
Eugene Eye Clinic, LLC
John D. Polansky, M.D. & Jason P. Gross, M.D. 2460 Willamette Street, Eugene, OR 97405 Phone (541) 683-3744 Fax (541) 683-6672 www.eugeneeyedoctors.com Welcome to the Eugene Eye Clinic is scheduled for
NEW PATIENT FORM (please print)
NEW PATIENT FORM (please print) PATIENT INFORMATION Full Name: Nickname: First Middle Last Social Security Number (SSN): Birthdate: Age: Male: Female: Street Address: City: State: ZIP: Home Phone: Work
Commerce Primary Care
Patient Name: DOB: Commerce Primary Care Patient Information Sheet Gender: Male Female Marital Status : Single Divorced Married Race: American Indian/Alaska Native Asian Black/African American White Other
Primary Insurance. Secondary Insurance. Emergency Contact
Street Address: Gender: City, State, Zip: Home Phone #: Marital Status: S M D W *Cell Phone #: *Do you authorize Southeastern Retina Specialists to send you appointment notifications via text messaging?
Patient Registration Form
Patient Registration Form PATIENT INFORMATION Please Print Last Name: First: M.I. Mailing Address: City: State: Zip Code: Date of Birth: Gender: M F Married Single Widowed Divorced Separated Partnered
NOTICE ABOUT REFRACTION
NOTICE ABOUT REFRACTION We have you scheduled for a complete eye exam or surgical consultation today. All surgical consultations require a refraction in order to determine which vision correction procedure
INSURANCE INFORMATION: This information is REQUIRED
4566 Hwy 20 E, Suite 101 301 Medical Drive, Suite B Niceville, FL 32578 Andalusia, AL 36420 (850) 897-7546 (334) 222-7546 PATIENT INFORMATION: Complete with PATIENT Information First Name: Last: M.I.: