APPLICATION FOR ASSISTANCE
|
|
|
- Tracy Willis
- 5 years ago
- Views:
Transcription
1 Beacon Light Fund MGNJA, Inc. P.O. Box 302 Annandale, NJ (201) DATE APPLICATION FOR ASSISTANCE NAME ADDRESS TELEPHONE(s) ADDRESS SOCIAL SECURITY NO. Check List for Items to Include with Submission This Application Completed Photo ID of Applicant (copy) Current Health Status Verification (copy) Original Bill to be Paid Bank Statement or Income statement (copy) Social Security Card (copy) Any Backup Information (if necessary) Have you Applied for Assistance before: YES NO If YES When is the Approx Date of Last Assistance CURRENT ESTIMATED INCOME as of Date: WHAT ASSISTANCE IS REQUIRED By my signature below I hereby release and hold harmless Miss Gay New Jersey Association, Inc., Beacon Light Fund, their agents, servants, and employees from Liability and or responsibility what so ever resulting from, associated with or arising out of my participation in this fund. I hereby allow, Miss Gay New Jersey Association the right to verify my current health status in order to participate in the fund. Without this information verified funds can not be distributed. This by no means will be shared with anyone. Your privacy is the utmost importance to the organization. APPLICANT S PRINTED NAME APPLICANT S SIGNATURE Check each that apply: Wish to be included in future Beacon Light Events Want counselors to check in with you once in awhile ******************************************************************************************************************************* To be filled out by Beacon Light Intake Counselor s Name: Signature: Income Verified Documentation Attached Bill Attached Application Complete Assistance Package Completed / Paid / Sent Date Received *******************************************************************************************************************************
2 HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF PATIENT INFORMATION PURSUANT TO 45 CFR TO: Beacon Light Fund, MGNJA, Inc Name of Healthcare Provider/Physician/Facility/Medicare Contractor PO BOX 302 Annandale, NJ RE: Patient Name: Date of Birth: Social Security Number: I authorize and request the disclosure of all protected information for the purpose of review and evaluation in connection with a legal claim. I expressly request that the designated record custodian of all covered entities under HIPAA identified above disclose full and complete protected medical information including the following: All medical records, meaning every page in my record, including but not limited to: office notes, face sheets, history and physical, consultation notes, inpatient, outpatient and emergency room treatment, all clinical charts, r ports, order sheets, progress notes, nurse's notes, social worker records, clinic records, treatment plans, admission records, discharge summaries, requests for and reports of consultations, documents, correspondence, test results, statements, questionnaires/histories, correspondence, photographs, videotapes, telephone messages, and records received by other medical providers. All physical, occupational and rehab requests, consultations and progress notes. All disability, Medicaid or Medicare records including claim forms and record of denial of benefits. All employment, personnel or wage records. All autopsy, laboratory, histology, cytology, pathology, immunohistochemistry records and specimens; radiology records and films including CT scan, MRI, MRA, EMG, bone scan, myleogram; nerve conduction study, echocardiogram and cardiac catheterization results, videos/cds/films/reels and reports. All pharmacy/prescription records including NDC numbers and drug information handouts/monographs. All billing records including all statements, insurance claim forms, itemized bills, and records of billing to third party payers and payment or denial of benefits for the period to. I understand the information to be released or disclosed may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV), and alcohol and drug abuse. I authorize the release or disclosure of this type of information. This protected health information is disclosed for the following purposes: Financial Assistance This authorization is given in compliance with the federal consent requirements for release of alcohol or substance abuse records of 42 CFR 2.31, the restrictions of which have been specifically considered and expressly waived. 2
3 HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF PATIENT INFORMATION PURSUANT TO 45 CFR Continued You are authorized to release the above records to the following representatives of defendants in the above-entitled matter who have agreed to pay reasonable charges made by you to supply copies of such records: Officers of the Beacon Light Fund, MGNJA, Inc. Name of Representative Records Requestors, Assistance Counselors Representative Capacity (e.g. attorney, records requestor, agent, etc.) I understand the following: See CFR (c)(2)(i-iii) a. I have a right to revoke this authorization in writing at any time, except to the extent information has been released in reliance upon this authorization. b. The information released in response to this authorization may be re-disclosed to other parties. c. My treatment or payment for my treatment cannot be conditioned on the signing of this authorization. Any facsimile, copy or photocopy of the authorization shall authorize you to release the records requested herein. This authorization shall be in force and effect until two years from date of execution at which time this authorization expires. Signature of Patient or Legally Authorized Representative (See 45CFR (c)(1)(vi)) Date Name and Relationship of Legally Authorized Representative to Patient (See 45CFR (c)(1)(iv)) Witness Signature Date 3
4 Additional Assistance Resources Universal Service Fund Program (USF, ) (New Jersey Department of Community Affairs) USF provides low-income customers a payment plan to help lower the monthly cost for electric service. Participants pay a maximum percentage of their total household income for electric and natural gas. USF is a statewide program administered by the New Jersey Department of Human Services. Fresh Start, the debt forgiveness component of USF, provides a one-time opportunity to eliminate pre-program account arrearages. There are household income and other program qualification requirements. New Jersey Statewide Heating Assistance and Referral for Energy Services (New Jersey SHARES, or ) New Jersey SHARES is a non-profit corporation organized to provide assistance to individuals and families living in New Jersey who are in need of temporary help in paying their energy bills. This program is designed to assist customers who would otherwise have no means of assistance. A history of good faith utility payments is considered for eligibility. New Jersey Social Services Dial Life line Across America Contact your local utility provider and reference Lifeline Across America is a federal/state working group that includes the Federal Communications Commission, the National Association of Regulatory Utility Commissioners, and the National Association of State Utility Consumer Advocates. Our mission is to provide information and resources regarding the Lifeline and Link-Up programs, which provide discounts to low-income consumers for telephone installation and monthly bills. Hyacinth AID Foundation Welcome to Hyacinth AIDS Foundation, the first and largest AIDS service organization in New Jersey. Founded in 1985, we are a not-for-profit, tax-exempt agency. We provide client services in six regional offices as well as several statewide services... that include individual client advocacy as well as hotline counseling for prevention, care and treatment, service referrals, professional and community education workshops, legal services and public policy advocacy. Norwescap Dedicated to housing development, energy conservation, child care, Head Start, volunteerism, nutrition, child care referral, outreach, information & referral, food bank, case management, and Utility assistance programs in Hunterdon, Warren, Somerset Counties. Energy Assistance via Norwescap NY Office of Temporary and Disability Assistance - 4
5 NY Rental Assistance Programs - NY Emergency Assistance NYC Affordable Housing Resource Center - NY HRA Temporary Cash Assistance - JOE-4-OIL - Applicants must call JOE-4-OIL ( ) to apply for the program. Applications are not available online. - A customer service representative will take some preliminary information over the phone. The applicant will receive an Income Verification Form by mail. - The applicant must fill in their income, sign and return this form. - For qualified applicants, a voucher for oil will be sent to their home. - The customer is responsible for contacting their approved dealer and scheduling a delivery. - Our Program only approves a one time delivery of 100 gallons per household. PLEASE NOTE - The application process for JOE-4-OIL takes 4-5 weeks for this service as it is not an emergency assistance program. 5
Name: DOB: SS: Mailing Address: City: State: Zip: Home #: Cell phone #: Martital Status: Address:
Patient Information: Name: DOB: SS: Mailing Address: City: State: Zip: Home #: Cell phone #: Martital Status: Email Address: Race: Ethnicity: Gender: Primary Language: Preferred Spoken Language: Would
WELCOME TO OUR OFFICE. Patient s Name: Today s Date: First Middle Last. Home Address: City: State: Zip: Telephone: Home ( ) Cellular: ( ) Work: ( )
WELCOME TO OUR OFFICE Patient s Name: Today s Date: First Middle Last Home Address: City: State: Zip: Telephone: Home ( ) Cellular: ( ) Work: ( ) Email: Personal Work DOB: Age: SSN#: Ethnic Background:
Trinity Family Physicians
Trinity Family Physicians Consent and Authorization for Minors By law, a healthcare provider must attempt to contact a birth / custodial parent or legal guardian prior to rendering treatment to a minor
Pharmaceutical Assistance Program
Thank you for choosing the Shannon Pharmaceutical Assistance Program to provide service for you. Our goal is to provide medications at a minimal cost for qualifying patients with chronic conditions so
PATIENT INFORMATION. PATIENT S NAME: Last name First name Middle. Birth Date: / / Sex: [ ] M [ ] F Social Security #: / /
![PATIENT INFORMATION. PATIENT S NAME: Last name First name Middle. Birth Date: / / Sex: [ ] M [ ] F Social Security #: / /](/thumbs/85/92736920.jpg "PATIENT INFORMATION. PATIENT S NAME: Last name First name Middle. Birth Date: / / Sex: [ ] M [ ] F Social Security #: / /")
Dr. Osehotue Okojie, M.D. Godwin Okojie, P.A. Patient Registration Form (Please Print) PATIENT INFORMATION PATIENT S NAME: Last name First name Middle Birth Date: / / Sex: [ ] M [ ] F Social Security #:
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)
Who to call for an emergency: Name: Address: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Relationship:
Patient Information: Patient Name: Social Security Number: / / Date of Birth: / / Sex: M / F (Circle one) Married/Single/Divorced/Widow Address: Zip Code: Home Phone: ( ) - E-mail Address: Cell Phone:
**** Does the above address, match the address on your State Identification Card? Yes No *****
Kenneth B. Chapman, M.D. Kiran V. Patel, M.D. Keyvan Jahanbakhsh, M.D. Uel J. Alexis, M.D. Cameron Marshall, M.D. Brian Maloney, M.D. Last Name First Name: SS# Birth : / / Age Sex: F M Marital Status:
Welcome To Our Office
Welcome To Our Office Since 1977 The Miami Counseling & Resource Center ( MCRC ) is a large, private Center that has been helping individuals, couples, and families in Miami for over 30 years, and we are
Welcome to our office
Welcome to our office I, the undersigned, realize that I am financially responsible for all services rendered to me by the Haben Practice for Voice & Laryngeal Laser Surgery, PLLC. For those insurances
Utah Transit Authority Personal Injury Protection Information
Utah Transit Authority Personal Injury Protection Information Revised 11/2016 A passenger on a UTA bus or a pedestrian injured by a bus may be entitled to Personal Injury Protection benefits. To claim
CLIENT INFORMATION DATE OF INTERVIEW: INTERVIEWER NAME: ARE YOU PRESENTLY REPRESENTED? REFERRED BY: HOW DID YOU HEAR ABOUT US?
CLIENT INFORMATION DATE OF INTERVIEW: INTERVIEWER NAME: ARE YOU PRESENTLY REPRESENTED? REFERRED BY: HOW DID YOU HEAR ABOUT US? EMAIL ADDRESS: NAME: PHONE: ADDRESS: CITY: STATE: COUNTY: ZIP CODE: DATE OF
PATIENT REGISTRATION FORM
Today s Date / / PATIENT REGISTRATION FORM PATIENT INFORMATION Patient Name Last First Middle Is this your legal name? If not, what is your legal name? Birthdate Age Sex q YES q NO / / q M q F q T Street
Patient Name: Last First Middle Address: Marital Status: (circle one) Single Married Divorced Widowed Other Gender: Female Male
Patient Information Patient Name: Last First Middle Address: City: State: Zip Code: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Email Address: of Birth: / / Social Security #: - - Marital Status:
STATEMENT OF DISABILITY IMPORTANT: Read the instructions first. Fill in appropriate sections. Print in ink or type.
MARYLAND STATE RETIREMENT AGENCY 120 EAST BALTIMORE STREET BALTIMORE, MD 21202-6700 sra.maryland.gov STATEMENT OF DISABILITY IMPORTANT: Read the instructions first. Fill in appropriate sections. Print
In addition there are several aspects of your disability claim that you should be aware of:
Dear Colleague: American Airlines has partnered with Harvey Watt and Company as the Claim Administrator for the Pilot Long Term Disability Plan (the Plan). We have enclosed the Claim Application along
ELA Settlement Services, LLC Data Collection Form
ELA Settlement Services, LLC Data Collection Form Complete the following forms, and mail, fax or email with any relevant documents to: ELA Settlement Services 1435 Morris Ave. P.O. Box 3137 Union, NJ 07083
Patient Registration Form
Patient Registration Form PATIENT INFORMATION Full legal name (First, Middle, Last, suffix) Nickname Sex: Male Female Date of birth Social security number Race Preferred language Ethnicity: Hispanic n-hispanic
Premier Obstetrics and Gynecology
, FL 33607, FL 33635 Patient General Information Name Birth date Age Social Security # Drivers License Home # Cell # Work # Street Address City State Zip Code Email Address Occupation Employer Spouse s
STANDARD TORT CLAIM FORM PLEASE TYPE OR PRINT IN INK
STANDARD TORT CLAIM FORM PLEASE TYPE OR PRINT IN INK General Liability Claim Form Pursuant to Chapter 4.92 RCW, this form is for filing a tort claim against the Public Utility District No. 3 of Mason County.
For faster claim payment* please submit your claim online at
Claims Made Easy For faster claim payment* please submit your claim online at www.combinedinsurance.com/claims FILING A CLAIM BY MAIL 1. Download the claim form 2. Print all six pages of the claim form
ADMINISTRATIVE POLICY & PROCEDURE
HUNTINGTON MEMORIAL HOSPITAL ADMINISTRATIVE POLICY & PROCEDURE SUBJECT: AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI) AUTHORIZED APPROVAL: POLICY NO: 155 PAGE 1 of 5 EFFECTIVE
BRICKSTREET INJURY KIT
West Virginia BRICKSTREET INJURY KIT POLICY # COMPANY NAME CONTACT PERSON AND NUMBER JURISDICTION Your Business. Your People. You re Covered. 866.452.7425 brickstreet.com BRICKSTREET INJURY KIT SUPERVISOR
INFORMATION FORM. Page 1 of 17
INFORMATION FORM Page 1 of 17 Client Information and Acknowledgment of Informed Consent to Treatment Therapist: Neila Senter, LPCC, is a licensed independent counselor engaged in the private practice of
VISITORS TO CANADA Insurance Claim Form
Claims Administration OLD REPUBLIC INSURANCE COMPANY OF CANADA RELIABLE LIFE INSURANCE COMPANY Box 557, 100 King Street West Hamilton, Ontario L8N 3K9 Toll Free: 888.831.2222 Fax: 866.551.1704 VISITORS
DISABILITY RETIREMENT IS A TWO STEP PROCESS
Baltimore, Maryland 21202-6700 410-625-5555 or toll free 1-800-492-5909 DISABILITY RETIREMENT IS A TWO STEP PROCESS First, you must file your initial claim package and supply whatever documentation is
Standard Tort Claim Form Packet
Standard Tort Claim Form Packet Please carefully read all of the information in this packet before completing and submitting your Standard Tort Claim. Please note that no documents will be returned. Presenting
NEW PATIENT DEMOGRAPHICS
NEW PATIENT DEMOGRAPHICS Name PATIENT Date: PARTNER Street Address City, State, Zip Social Security # Date of Birth Home Phone# Cell Phone # Work Phone # Email Address Occupation Employer Primary Insurer
WELCOME TO BRAZOSPORT CARDIOLOGY Office of Dr. Scott Harris and Dr. Nabil Baradhi INSURANCE INFORMATION
WELCOME TO BRAZOSPORT CARDIOLOGY Office of Dr. Scott Harris and Dr. Nabil Baradhi Patient s Name Date of Birth / / Home Phone ( ) - Daytime or Cell Phone( ) - YES NO Brazosport Cardiology May Leave Results
Welcome to Southwest Diagnostic Center!
Patient Information Form PATIENT INFORMATION Welcome to Southwest Diagnostic Center! Name: Last Name First Name MI Address: City: SS # Email: State: Zip: Sex: M F Age: Birth date: Marital Status: Patient
Accident Benefits Claim Instructions
Claim Instructions Your Accident Benefit Claim This packet contains the forms necessary to apply for. Every space on these forms should be filled in to avoid delay in processing your application. If a
TORT CLAIM FORM PACKET
TORT CLAIM FORM PACKET Please carefully read all of the information in this packet before completing and presenting your Tort Claim Form. Documents Contained in the Tort Claim Form Packet Instructions
Conway Regional After Hours Clinic
Conway Regional After Hours Clinic Patient Information Patient Name: Date of Birth Sex (M) (F) SS# Marital Status M S W D Home Phone ( ) - Cell Phone ( ) - Work Phone ( ) - Mailing Address: Street City
Standard Insurance Company. Individual Client Services PO Box 711 Portland OR Policy Change Form and Application Supplement A
Individual Client Services PO Box 711 Portland OR 97207 Policy Change Form and Application Supplement A Disclosure Notice - Information Practices Standard Insurance Company (Standard) is committed to
Today s Date (mm/dd/yyyy):
115 Christopher Columbus Drive, Suite 301 Jersey City, New Jersey 07302 201-706-3808 http://www.drsmedicalassociates.com/ WELCOME TO DRS MEDICAL ASSOCIATES LLC. PLEASE COMPLETE THE FORM LEGIBLY AND ENTER
AUTHORIZATION TO USE, DISCLOSE, & RELEASE PROTECTED HEALTH INFORMATION
AUTHORIZATION TO USE, DISCLOSE, & RELEASE PROTECTED HEALTH INFORMATION I understand the following: I have the right to refuse to sign this form for authorization to disclose or release my protected health
Insurance Claim Filing Instructions
Insurance Claim Filing Instructions PROOF OF LOSS CONSISTS OF THE FOLLOWING: 1. A completed and signed Claim form and Attending Physician s Statement. 2. For Hospital/Intensive Care/Hospital Services Coverage
Patient Information PATIENT NAME: DOB: AGE: ADDRESS: ZIP CODE: EMPLOYER NAME: WORK PHONE: RACE: SEX: Male Female PRIMARY DOCTOR: NAME: TELEPHONE#
Patient Information Welcome to our office. We appreciate the confidence that you have placed with us regarding your healthcare needs. To assist us in serving you, please complete the following forms as
Sammy Lerma III, M.D. P.A. History and Physical Name: DOB: Age:
History and Physical Name: DOB: Age: Reason for Visit : Current Medications: Previous Hospitalizations: Last Physician's Name: Previous Surgeries: Reason for Changing Physicians: Current Specialists: Medication
PATIENT HEALTH QUESTIONNAIRE
PATIENT HEALTH QUESTIONNAIRE PATIENT INFORMATION Name Age of Birth Address CityState Zip Secondary Address CityState Zip Home Phone ( ) SS# Email Address Cell Phone ( ) Work Phone ( ) Marital Status M
Connecticut Asthma & Allergy Center LLC Registration Form
Name: Connecticut Asthma & Allergy Center LLC Registration Form Last First Middle Initial Date of Birth: / / Sex: Race: Ethnicity: Language: SS#: xxx-xx- Address: # Street Apt/PO Box Email: Town State
Summary of Benefits Boone County
Summary of Benefits 2017 Boone County Y0027_16-093_EN CMS Accepted 08/30/2016 Summary of Benefits January 1, 2017 December 31, 2017 This booklet gives you a summary of what we cover and what you pay. It
Disability Insurance Claim Packet Instructions
Claim Packet Instructions Your Disability Benefit Claim This packet contains the forms necessary to apply for disability benefits. It also addresses common questions about Disability claims. Please save
MOSERS Continued Dependent Life Insurance for a Disabled Child Instructions
Continued Dependent Life Insurance Instructions Your application for consists of four forms. Every space should be filled in to avoid delay in processing your application. If a section does not apply,
PULMONARY AND CRITICAL CARE SPECIALISTS 160 Kingsley Lane, Suite 103 Norfolk, VA Phone: Fax:
PATIENT INFORMATION Address: PULMONARY AND CRITICAL CARE SPECIALISTS 160 Kingsley Lane, Suite 103 Norfolk, VA 23505 Phone: 757-889-6677 Fax: 757-889-6652 PLEASE PRINT Today s Date: City: State: Zip: Age:
New Patient Intake Paperwork
New Patient Intake Paperwork NAME: Last First Middle DATE OF BIRTH: SEX: M / F ADDRESS: Street City State Zip PHONE: MOBILE: EMAIL ADDRESS: EMPLOYER NAME: PHONE: EMPLOYER ADDRESS: EMERGENCY CONTACT: PHONE:
Continued on Next Page
Accredited by The Samaritan Institute Therapist: AGREEMENT FOR PAYMENT AND FINANCIAL RESPONSIBILITIES Care and Counseling is a non-profit pastoral counseling center. The standard fee for a 1 st evaluation
VIATICAL SETTLEMENT APPLICATION
VIATICAL SETTLEMENT APPLICATION A. PERSONAL INFORMATION - (PRINT OR TYPE) Name of Insured: Male Female Date of Birth: SSN: Address: City: State: Zip: Telephone Number: Email Address: Marital Status: Single/Never
Welcome to Sibley Primary Care
Welcome to Sibley Primary Care We are pleased to have you join our practice. We understand that starting with a practice can be overwhelming and we ve provided this welcome packet to aid with your first
Bergen County Gynecology, P.C.
PATIENT INFORMATION LAST NAME FIRST NAME MIDDLE MAIDEN NAME (IF ANY) DATE OF BIRTH SS# PLACE OF BIRTH MARITAL STATUS RACE ETHNICITY PREFERRED LANGUAGE OTHER LANGUAGES SPOKEN ADDRESS CITY ST ZIP HOME PHONE
PATIENT REGISTRATION FORMS PLEASE PROVIDE INSURANCE CARD(S) & DRIVERS LICENCE TO RECEPTIONIST FOR COPYING
PATIENT REGISTRATION FORMS PLEASE PROVIDE INSURANCE CARD(S) & DRIVERS LICENCE TO RECEPTIONIST FOR COPYING Registered PATIENT INFORMATION Updated Name: DOB: Age First MI last Home Address City: State: ZIP
County: State: ZIP: Address: Billing Address for Premium Notices (complete only if different from above).
Application Form Complete and sign the application. A-425 P.O. Box 6170, Columbia, SC 29260-6170 Blue Option benefits are provided in network only. No benefits are provided for services received out of
Transamerica Premier Life Insurance Company
Insurance Claim Filing Instructions PROOF OF LOSS CONSISTS OF THE FOLLOWING: 1. A completed and signed Claim form and Attending Physician s Statement. 2. For Hospital/Intensive Care/Hospital Services Coverage
Patient/Guardian Signature: I hereby agree that the information above is true and accurate. Patient Medical History Form PATIENT MEDICAL HISTORY FORM
PATIENT MEDICAL HISTORY FORM Patient Medical History Form DATE: Last Name: First Name: Chart#: Birth Date: Sex: Male / Female Height: Weight: PATIENT HISTORY AND SAFETY QUESTIONS Physician Name: Do you
Client Contract. Client Full Name: Social Security Number: POA/Guardian Name: Phone: Address:
Client Contract Client Full DOB: Social Security Number: POA/Guardian Phone: _ I, or my advocate, have discussed my needs with my POA/Guardian. I agree to have Thrive serve has my representative payee
City: State: Zip: Home ( ) Cell ( ) Work ( ) Who Referred You? Phone ( ) Address: City: State: Zip:
Today s : First Name: M.I. Last Name: Address: City: State: Zip: Apt Home ( ) Cell ( ) Work ( ) Email: of Birth: Marital Status: S M D W Sex: F / M Social Security # - - Who Referred You? Phone ( ) Address:
Hospital Indemnity Insurance
Hospital Indemnity Insurance Instructions for filing a Claim Follow the instructions shown below in completing/providing documentation needed to file a claim for your hospital indemnity benefits. 1. Complete
Application for Reinstatement United Home Life Insurance Company 225 S. East St. P.O. Box 7192 Indianapolis, IN
Application for Reinstatement United Home Life Insurance Company 225 S. East St. P.O. Box 7192 Indianapolis, IN 46207-7192 1-800-428-3001 Policy Number Proposed Insured Spouse (If spouse coverage) Premium
Please note missing information and documentation will delay approval or result in denial.
Thank you for choosing Stella Maris for Long Term Care Please note missing information and documentation will delay approval or result in denial. The Application must be completed entirely: First four
Standard Tort Claim Form Packet
Standard Tort Claim Form Packet Please carefully read all of the information in this packet before completing and presenting your Standard Tort Claim. A New Law that Impacts Presenting a Standard Tort
I am looking forward to meeting you and helping you attain your best health possible!
Dear New Patient, Danielle E. Weiss, MD, FACP Center for Hormonal Health and Well-Being 477 N. El Camino Real, Suite D200, Encinitas CA 92024 760-262-7104 (Office hours) 760-753-3636 (Outside office hours)
To begin the medical second opinion process, please complete the following steps:
The purpose of the Medical Second Opinion (MSO) program of Johns Hopkins Medicine International is to provide information to the patient or the local treating physician so that an informed decision can
It is very important to bring the following to your first visit:
Dear New Patient: Welcome and thank you for choosing Capital Digestive Care! The enclosed packet contains important information for your upcoming appointment as well as our new patient registration forms.
Medical Information Sheet
Medical Information Sheet Name: Date: Age: Sex: M F Height: Weight: Dominant hand: R L Occupation: Presently working: Y N Reason for being seen today: Date of Onset: Involved side: R L Both Describe any
Braeburn Patient Assistance Program Application
The provides Probuphine at no cost to patients that do not have healthcare coverage and/or adequate coverage for Probuphine. All applications are reviewed on a case-by-case basis to support the Braeburn
Memorial Hermann Advantage (PPO)
Memorial Hermann Advantage (PPO) INTRODUCTION TO SUMMARY OF BENEFITS January 1, 2015 December 31, 2015 This booklet gives you a summary of what we cover and what you pay. It doesn t list every service
*Emergency Contact/Relationship: Are you currently under another doctor s care? (Doctor s name) (Doctor s name)
23 Cedar Street New Britain, CT 06052 (860) 229-VEIN (8346) PATIENT INFO: Date of Service: Last Name: First Name: MI: Address: Home Phone: Marital Status: City: Work Phone: S.S. Number: Cell Phone: State:
TILAK PEDIATRICS Patient Information Form For all Patients 18 years of Age and Older
Patient Information Form For all Patients 18 years of Age and Older Patient s Information Name: DOB: / / Male Female RACE African-American American Indian/Alaska Native Asian Caucasian Native Hawaiian/Pacific
New Patient Referral and Insurance Verification Form
New Patient Referral and Insurance Verification Form Today s Date: Prior Patient: Y N How did you hear about our practice? Physician: Dr., Internet:, Family/Friend:, Advertising:, Insurance:, Other:. Patient
LAWRENCE J. FINKEL, M.D., P.C. 360 CHURCH STREET WARRENTON, VA (540) PHONE (540) FAX
LAWRENCE J. FINKEL, M.D., P.C. 360 CHURCH STREET WARRENTON, VA 20186 (540) 347-2020 PHONE (540) 341-7980 FAX www.finkelderm.net Dear Patient: Welcome to our Practice. We have you scheduled for your first
Memorial Hermann Advantage (HMO)
Memorial Hermann Advantage (HMO) INTRODUCTION TO SUMMARY OF BENEFITS January 1, 2015 December 31, 2015 This booklet gives you a summary of what we cover and what you pay. It doesn t list every service
Dear State of Florida Retiree:
P.O. Box 6830 Tallahassee, FL 32314 Tel: 866-663-4735 Fax: 800-422-3128 TTY: 866-221-0268 Dear State of Florida Retiree: Congratulations on your retirement! As a new retiree, you need to be aware of State
1199SEIU National Benefit Fund for Rochester Area Members Summary of Benefits and Coverage: What This Plan Covers and What It Costs
1199SEIU National Benefit Fund for Rochester Area Members Summary of Benefits and Coverage: What This Plan Covers and What It Costs Coverage Period: Beginning 04/01/2014 Coverage for: Rochester Area Employers
Physical Therapy with care and knowledge
Patient Demographic Information Last Name: First Name: Middle Initial: Address: City: State: Zip: Primary Phone: Secondary Phone: D.O.B: Social Security: Driver s License Number: May we leave a message?
CLAIM FORM. DATE OF BIRTH: 3. PATIENT'S NAME & ADDRESS- IF ADDRESS IS NEW, PLEASE CHECK BOX r PHONE: ( )
PRIMERICA LIFE INSURANCE COMPANY as Administered by Senior Health Ins. Co. of Pennsylvania Home Office: Boston, MA P.O. Box 64913 St. Paul, MN 55164 Telephone: 1-877-451-5824 CLAIM FORM The patient or
Milestone Psychiatric & Psychological Services, P.C. (Comprehensive Psychiatric & Psychological Services)
Psychological Services, P.C. (Comprehensive Psychiatric & Psychological Services) PSYCHIATRY Raja Rao, MD PSYCHOLOGY Robert J. Maiden, PhD Laura A. DeMarco, PhD Cynthia Dodge, PsyD Terry Taggart, PsyD
REIMBURSEMENT AGREEMENT FOR HOSPITAL SERVICES between OKLAHOMA HEALTH CARE AUTHORITY and
REIMBURSEMENT AGREEMENT FOR HOSPITAL SERVICES between OKLAHOMA HEALTH CARE AUTHORITY and U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES OKLAHOMA CITY AREA INDIAN HEALTH SERVICE ARTICLE I. PURPOSE The purpose
ADVANTAGE CARE NETWORK, INC.
ADVANTAGE CARE NETWORK, INC. FREE STANDING FACILITY APPLICATION Advantage Care Network, Inc. is committed to the provision of high quality care to our clients and their beneficiaries. Proper provider credentialing
2016 Summary of Benefits. Classic Rx (HMO)
2016 Summary of s Classic Rx (HMO) Summary Of s January 1, 2016 - December 31, 2016 This booklet gives you a summary of what we cover and what you pay. It doesn t list every service that we cover, or list
M.I. RESPONSIBLE PARTY M.I. PHARMACY INFORMATION PRIMARY INSURANCE INFORMATION SECONDARY INSURANCE INFORMATION APPOINTMENT REMINDERS
Patient Information First : M.I. Last : Address: City: State: Zip Code: Phones: (H) (W) (C) DOB: Sex: Male Female SSN: Marital Status: Ethnicity: Race: Language: Emergency ContactPhone: Primary Care Physician:
Thank you for choosing Best Practices Medical Clinic as your medical provider!
Thank you for choosing Best Practices Medical Clinic as your medical provider! Prior to being able to schedule a first visit, we need to request some important information about you. Please print and read
STANDARD TORT CLAIM FORM PACKET
STANDARD TORT CLAIM FORM PACKET Please carefully read all of the information in this packet before completing and presenting your tort claim. DOCUMENTS CONTAINED IN THE STANDARD TORT CLAIM FORM PACKET:
2016 Summary of Benefits. Preferred Rx (PPO)
2016 Summary of s Preferred Rx (PPO) January 1, 2016 - December 31, 2016 This booklet gives you a summary of what we cover and what you pay. It doesn t list every service that we cover, or list every limitation
Patient Registration Form Please present insurance cards and photo ID to the receptionist so copies may be made.
Patient Registration Form Please present insurance cards and photo ID to the receptionist so copies may be made. Name: Jr. Sr. Last First Middle Prefer to be called: Married Single Date of Birth / / Patient
PATIENT INFORMATION Patient Name: Last First Middle Initial. Address. Street or P.O. Box City, State Zip
PATIENT INFORMATION - 2018 Patient Name: Last First Middle Initial Address: Street or P.O. Box City, State Zip of Birth: / / Race: Gender: Male Female Social Security #: Marital Status: Single Married
APPLICATION FOR PERSONAL INJURY PROTECTION BENEFITS THROUGH THE MICHIGAN ASSIGNED CLAIMS PLAN
Michigan Automobile Insurance Placement Facility PO Box 532318 Livonia, MI 48153-2318 Phone: 734-464-8111 Fax: 734 744-8552 www.michacp.org Please note, you referenced throughout this application is defined
Standard Tort Claim Form Packet
Standard Tort Claim Form Packet Please carefully read all of the information in this packet before completing and presenting your Standard Tort Claim. A New Law that Impacts Presenting a Standard Tort
PATIENT INFORMATION & PREFERENCES (Please print or type) YOUR MAJOR HEALTH CONCERNS OR QUESTIONS
Dear Patient: The following questions are designed to collect important information about you and your health. Answering these questions before your office visit will allow more time for a detailed discussion
Family Assistance Program
Family Assistance Program The Children s Cardiomyopathy Foundation (CCF) Family Assistance Program was established in 2011 through the generous donations of CCF family members. The fund was set up to assist
Group Customer #
ENROLLMENT CHANGE FORM ENROLLMENT PERIOD FROM OCTOBER 29, 2018 NOVEMBER 16, 2018 GROUP CUSTOMER INFORMATION (To be Completed by the Recordkeeper) Name of Group Customer/Employer Group Customer # 113484
1199SEIU National Benefit Fund Summary of Benefits and Coverage: What This Plan Covers and What It Costs
1199SEIU National Benefit Fund Summary of Benefits and Coverage: What This Plan Covers and What It Costs Coverage Period: Beginning 04/01/2014 Coverage for: Wage Classes I & II and Early Retirees with
2018 REGISTRATION FORM HIGHLIGHTED AREAS REQUIRED (Please Print Clearly)
PATIENT INFORMATION 2018 REGISTRATION FORM HIGHLIGHTED AREAS REQUIRED (Please Print Clearly) Patient s Full Name (as it appears on insurance card) Name you prefer to be called Email How did you hear about
CERTIFICATION OF COMPLIANCE WITH SUBSTANCE ABUSE PREVENTION AND TREATMENT BLOCK GRANT AND COUNTY CONTRACT July 1, 2015 June 30, 2016
Substance Abuse Prevention and Treatment Block Grant Funds (SAPT BG) are dedicated funds mandated by Congress. Behavioral Health and Recovery Services utilizes the funds through a Negotiated Rate Contract
PAGE INTENTIALLY LEFT BLANK
PAGE INTENTIALLY LEFT BLANK OFFICE DIRECTIONS Jordan Young Institute is located on Cleveland Street off Newtown Road. Cleveland Street from the Pembroke area ends at Clearfield. There is no direct roadway
Christina Agustin, MD Board Certified in Adult Psychiatry 1 Lake Bellevue Drive, Suite 101 Bellevue, WA Phone Fax:
Christina Agustin, MD Board Certified in Adult Psychiatry 1 Lake Bellevue Drive, Suite 101 Bellevue, WA 98005 Phone 425-301-9869 Fax: 866-546-1618 Welcome to my practice. I look forward to meeting with
Summary of BenefitS. Cigna-HealthSpring Preferred (Hmo) H Cigna H0354_15_19948 Accepted
Summary of BenefitS Coverage Cigna-HealthSpring Preferred (Hmo) H0354-001 2014 Cigna H0354_15_19948 Accepted SeCtion i - introduction to Summary of BenefitS you have choices about how to get your medicare
Application Checklist and Forms
Application Checklist and Forms Please check off each item enclosed with your application. All items are required. Incomplete applications will not be accepted. Mail your completed application and all
What is the overall deductible?
Molina Healthcare of California: Molina Silver 70 HMO Coverage Period: 01/01/2014 12/31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan
Patient Registration
Patient Registration Please check Primary Home Work Cell phone Gender SSN E-mail Address Driver s License M F Marital Status Preferred Contact Ethnicity Race Married Single Divorced Separated Widowed Life
Combined Insurance Claim Form
Combined Insurance Claim Form Important Instructions on How to Complete the Attached Claim Form and How We Assess Claims Please read these important instructions on how to complete the attached Claim Form.