PATIENT REGISTRATION (PLEASE PRINT)
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1 4705 Towne Centre Road, Ste. 201 Saginaw, MI Telephone (989) Fax (989) PATIENT REGISTRATION (PLEASE PRINT) Patient Name Todays Date Street Address Apt. Phone ( ) City State Zip Sex: Male Female Birthday / / Age Social Security Race / Ethnicity Patient Pharmacy Circle One: Single Married Separated Divorced Widowed Significant Other With whom do you live with: Patient Employed: Full Time Part Time Retired Student Unemployed Disabled Patient Employer Phone Responsible Party (if minor) If pt is a minor: Mother s DOB Father s DOB Primary Insurance Contract or ID# Group Subscriber Subscriber s DOB Secondary Insurance Contract # Group Subscriber Subscriber s DOB Is this a work or auto claim? Yes No Primary Care Physician Phone: ( ) Referring Physician Phone: ( ) Emergency Contact (not living with you) Phone: ( ) Work/ Cell Phone: ( ) ASSIGNMENT OF RELEASE: I authorize any holder of medical or other information about me to release to all carriers any information needed for this or any other related medical insurance claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits to myself or to the party who accepts assignment. I understand I am financially responsible for all charges whether or not paid by insurance. Signature of Insured/Guardian Date
2 4705 Towne Centre, Ste. 201 Saginaw, MI Telephone (989) Fax (989) STATEMENT OF DISCLOSURE Patient Name: Birthdate: AUTHORIZATION TO DISCLOSE MEDICAL INFORMATION I hereby authorize and staff to provide my medical records, mental health therapy or treatment/counseling records, alcohol treatment records, and/or substance abuse records, make a full oral or written report to: Authorization of any and all family members Do not disclose medical information to anyone but myself Disclose medical information only to the following people: (Please include any physicians that you would like a copy of reports sent to) Name: Relationship: Telephone Number: Name: Relationship: Telephone Number: Name: Relationship: Telephone Number: This authorization will expire: at the end of treatment (Expiration Date or Defined Event) I further request that you permit such records be copied or Photostat or otherwise. A photo static copy of this authorization shall be considered as effective and valid as the original. Patient Signature Date
3 4705 Towne Centre Road, Ste. 201 Saginaw, MI Telephone (989) Fax (989) Name Todays Date Birthdate Age M F Social Security: HISTORY OF PAST ILLNESS (please specify): Parkinson s disease (G20) Seizure (R569) Heart disease (I519) Alzheimer s disease (G309) Stroke (I6340) Multiple Sclerosis (G358 Mental Illness Cancer (R971) Other SURGICAL HISTORY & DATES: ALLERGIES: FAMILY HISTORY: Family Member Father Mother Sibling(s) (M/F) Children (M/F) Grandparents Other Health/ Medical problems Death Cause of Death Primary Care Physician: Pharmacy: SOCIAL HISTORY: Tobacco: Never smoked Quit years ago Cigarettes Cigars Pipe Chews Tobacco Dipping Tobacco Smoked # years Packs per day Alcohol: Beer Wine Hard Liquor Never <1 a week 1-5 a week Drinks heavily Drinks occasionally How many per day: Coffee regular/decaf Tea reg/decaf Carbonated Drinks reg/diet Energy Drinks Chocolate Caffeine pills Highest Education Completed: Grade school Some college High School College graduate Higher level (specify): Recreational Drug Use? No Yes If Yes, What Kinds? How long have you used drugs? If you quit, how long ago? Obstetrics: How many pregnancies? How many childbirth s? Complications (please specify): CONTINUE ON BACK
4 PROBLEM LIST GENERAL: Headache (R51) Migraine (G43119) Lethargy/Weakness (M6281) Night Sweats (R61) Fainting/LOC (R55) Dizziness (R42) Recent Weight Loss (R634) Recent Weight Gain (R635) EYES: Blurred Vision (H5319) Double Vision (H532) Eye Pain (H5713) EAR/NOSE/THROAT: Deafness (H9190) Noise in ears (H833X9) Sinus/Congestion (J329) Nose Bleeds (R040) Sore Throat (J029) Hoarse Voice (R499) HEART: Chest Pain (R079) Heart Murmur (R011) Palpitations (R002) High Blood Pressure (I10) Edema (M7989) Location LUNG: Pneumonia (J129) Shortness of Breath (R0602) STOMACH: Constipation (K5900) Diarrhea (R197) Liver Disease (K769) Irritable Bowel Syndrome (K588) KIDNEY/BLADDER/PROSTATE: Frequent Urination (R350) Urinary Incontinence (N3942) Difficulty starting urine (R3911) Dribbling (N3943) Sex Difficulties (F529) Prostate Disease (N4289) INFECTIONS: Meningitis (A879) (please specify): Viral Bacterial BREAST/MENSTRUAL: Menstrual Irregularity (N926) Endometriosis (N809) SKIN: Rash (R21) Dry Skin (L110) Bruise Easily (T1490) MUSCULOSKELETAL: Back Pain (M545) Neck Pain (M542) Difficulty Walking (R262) Arthritis (M069) Fibromyalgia (M797) Muscle Spasm (M6240) NEUROLOGY: Memory Problems (R4181) Confusion (F4489) Forgetfulness (R413) Numbness/Tingling (R209) Balance Problem (R269) Tremor (G250) PSYCHIATRY: Depressed (F328) Considered Suicide (R45851) Anxiety/Tension (F411) Fatigue (R5382) Panic Attack (F410) ENDOCRINE: Thirsty (T731XXA) Diabetes I (E109) Diabetes II (E119) SLEEP: Snore (R0683) Sleep Apnea (G4733) Restless Sleep (G4709) Insomnia (G4700) Sleep walk/talk (F514) Restless Leg Syndrome (G2581)
5 4705 Towne Centre, Ste. 201 Saginaw, MI Telephone (989) Fax (989) HIPPA NOTICE OF PRIVACY PRACTICES FOR DEBASISH MRIDHA, M.D., P.L.L.C. THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Introduction: This Notice describes the personal information we collect, and how and when we use or disclose that information. It also describes your rights as they relate to your protected health information. This Notice is effective since April 14, Understanding Your Health Record/Information: Your medical information is personal. We are committed to protecting your medical information. Each time you visit DEBASISH MRIDHA, M.D., a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a: Basis for planning your care and treatment: We will use medical information about you to provide you medical treatment and services. We may disclose your medical information to doctors, nurses, technicians and other personnel who are involved in providing you medical treatment. For payment: We may use and disclose your medical information so that the treatment and services you receive at this office may be billed to or payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about your treatment to your insurance company so that your health plan may pay us for treatment you received. Sometimes, we may need to send your health information to prior approval or to determine whether your plan will cover the treatment. For health care operation: We may use and disclose medical information about you for office operations. These disclosures are necessary to run the office and make sure that all of our patients receive quality care. We may disclose your medical information when we contact with you as a reminder that you have an appointment for treatment or medical care at this office. For research: Under certain circumstances, we may use and disclose medical information for research purposes.
6 As required by law: We will use and disclose your medical information when required to do so by Federal, State or Local Law. For example, disclosure may be required by Worker s Compensation statutes and various public health statutes in connection with reporting required reporting of certain disease, child abuse and neglect, domestic violence, adverse drug reaction, etc. For legal issue: We may disclose medical information about you to respond to a court order. Health oversight activities: We may disclose your medical information to Government or other oversight agency or organization for activities by Law. For example, disclosure of your medical information may be needed for audits, investigations, inspections, etc. Notification: We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition. Communication with family: Health professionals, using their best judgment, may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person s involvement in your care or payment related to your care. Funeral directors: We may disclose health information to funeral directors consistent with applicable law to carry out their duties. Understanding what is in your record and how your health information is used helps you to: ensure its accuracy, better understand who, what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosure to others. Your Health Information Rights: Although your health record is the physical property of DEBASISH MRIDHA, M.D. the information belongs to you. You have the right to: Obtain a paper copy of this notice of information practices upon request. Inspect and copy your health record. You must request in written form to DEBASISH MRIDHA, M.D. We may charge a fee for the cost of copying, mailing or other supplies associated with our request. Amend your health record. If you feel that the medical information we have about you is incorrect or incomplete, you may ask us to amend the information in writing and you must prove the reason that supports your request. We may deny it if it is not in writing or does not include the reason. We may also deny it if you ask us to amend information that: was not created by us, is not part of the medical information kept by this office, is not part of the information which you were permitted to inspect and copy or is accurate and complete.
7 Obtain an accounting of disclosures. You have the right to request an accounting of disclosures. This is a list of the disclosures this office has made of your medical information. To request this disclosure, you must submit your request in writing to DEBASISH MRIDHA, M.D. Your request must state a time period, which may not be longer than six years and may not include dates before March 15, Request a restriction on certain uses and disclosures of information as provided by 45 CFR , and you must request this in writing to DEBASISH MRIDHA, M.D. Revoke your authorization to use or disclose health information except to the extent that action has already been taken. Our Responsibilities: DEBASISH MRIDHA, M.D. is required to: Maintain the privacy of your health information, Provide you with this notice as to our legal duties and privacy practices with respect to information we collect and maintain about you, Abide by the terms of this notice; notify you if we are unable to agree to a requested restriction. We will not use or disclose your health information without your authorization, except as described in this notice. We will also discontinue using or disclosing your health information after we have received a written revocation of the authorization according to the procedures included in the authorization. If you have questions or would like additional information, you may contact CHINU MRIDHA at (989) If you believe your privacy rights have been violated, you can file a complaint with the practice s Privacy Officer or with the Office for Civil Rights, U.S. Department of Health and Human Services. All complaints must be submitted in writing. This office will not penalize you in any way for filing a complaint. We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will post in the office. In addition, each time you visit the office you are welcome to ask for the most recent Notice in effect. Revision No. 1
8 4705 Towne Centre, Ste. 201 Saginaw, MI Telephone (989) Fax (989) RECEIPT OF NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGEMENT FORM I understand I have the right to review Dr. Mridha s Notice of Health Information Practices prior to signing this document. A copy of this Notice has been provided to me. The Notice of Health Information Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations at Michigan Advanced Neurology Center. This Notice of Health Information Practices also describes my rights and Dr. Mridha s duties with respect to my protected health information. reserves the right to change the practices that are described in the Notice of Health Information Practices. I may obtain a revised notice by calling the office and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment. The undersigned Patient or Authorized Representative acknowledges that he or she personally received and or was offered a copy of the Notice of Health Information Practices on the date indicated below. Name of Patient (please print) Date Signature of Patient or Authorized Representative Relationship to Patient (if signed by Representative) FOR OFFICE USE ONLY Office Representative Signature Date
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Glenn L. Keiper Jr. MD, Ralph G. Peterson PA-C Jonathan D. Sherman MD, Jason A. Kocian PA-C 1410 Oak Street, Suite 200, Eugene, OR 97401 Phone: 541-485-2357 Fax: 541-485-2358 Date: First, MI, Last Name:
Bellingham Arthritis & Rheumatology Center. 470 Birchwood Avenue, Suite C, Bellingham, WA (P) (F)
Bellingham Arthritis & Rheumatology Center 470 Birchwood Avenue, Suite C, Bellingham, WA 98225 (P) 360-734-5754 (F) 360-734-0586 Patient Name SSN Last First M.I. Date of Birth Age Sex: Male Female Address
Patient Information Please print legibly and complete all information. If a prompt does not apply, please draw a line through the space provided.
Patient Information Please print legibly and complete all information. If a prompt does not apply, please draw a line through the space provided. Last Name: First Name: Primary Care Physician: Referring
Villa Medical Arts New Patient Forms
Villa Medical Arts New Patient Forms New Patients, To expedite your check- in process, please print and complete the following pages. If you have access to a fax machine, please fax them along with a copy
Obstetrics and Gynecology 50 Medical Drive Suite 100 (806) Borger, TX
PATIENT INFORMATION First Name MI Last Name Date of Birth Age: Social Security # Race Ethnicity: Sex: Female / Male Marital Status: S M W D Email Address: Mailing Address City State Zip Physical Address
PATIENT REGISTRATION SOCIAL SECURITY NUMBER:
PATIENT REGISTRATION LAST NAME FIRST NAME MI M/F ADDRESS APT CITY STATE ZIP BIRTHDATE AGE MARITAL STATUS HOME PHONE SOCIAL SECURITY NUMBER: OCCUPATION: EMPLOYER NAME: WORK ADDRESS: WORK PHONE: PLEASE INDICATE
FORMS MUST BE COMPLETED IN FULL
1 Nurse Use Only: Height: Weight: Temp: BP: / Pulse: Flu: Pneumonia Mammogram Patient Health Information Patient Name: DOB: Today s Date: How did you hear about us/referring physician: Reason for Today
RESPONSIBLE PARTY DEMOGRAPHIC INFORMATION
BRYAN LEATHERMAN, M.D. PATIENT DEMOGRAP H I C INFORMATION Last Name First Name Middle Preferred Name Maiden Prefix Suffix DOB Sex SSN Ethnicity Marital Status Driver s License # Primary Language English
Babylon Medical Practice
Today s Date: / / Last Name: Page 1 Babylon Medical Practice 350 West Main Street, Babylon, NY 11702 350 West Main Street Babylon, NY 11702 Tel Telephone: lephone: (631) (631) 661-22 661-2277 277 Fax:
1421 S. Potomac Street, Suite 120 Aurora, CO Please print and complete all parts.
Thomas J. Savage, DPM Jay H. Dworkin, DPM PC 1421 S. Potomac Street, Suite 120 Aurora, CO 80012 303.923.3369 www.metrofoot.org 303.923.3882(fax) Please print and complete all parts. Date PATIENT INFORMATION
Multi-Specialty Musculoskeletal Pain Relief Center
Name Social Security # Age Birthdate Date Home Tel Address City State Zip Work Tel Cell Number Email Address Marital Status: M S W D # Children Spouse s Name Your Occupation Emergency Contact Name and
Last Name: First MI. Birthdate: Age: Sex: SSN: Address: City: State: Zip: Home Phone: Work Phone: Cell Phone:
604 W. Warner Road, Ste. B-6~ Chandler, AZ 85225 5301 S. Superstition Mountain Drive~ Gold Canyon, AZ 85118 Phone: 480-963-3881 Fax: 480-899-8610 Complete Medical & Surgical Eye Care for All Ages Thank
Advanced Diabetes & Endocrine Medical Center, P.A.
PATIENT REGISTRATION FORM Primary Care Physician Referring Physician Patient s Name: (Last) (First) (Middle) Address: Marital Status: S / M / D / W City/State/Zip: Social Security: Male / Female Date of
Referring Physician: Primary Care Physician: Other Physician(s)/Specialty: EMERGENCY CONTACT INFORMATION INSURANCE INFORMATION
PATIENT INFORMATION Name: Date of Birth: Sex: Male Status: Single Married Divorced Widowed Other 502 Elm Street NE Language: Female Race: American Indian or Alaska Native Native Hawaiian or Or Pacific
Secondary Insurance Co. Name & Address: Subscriber s Name: Subscriber Soc. Sec. No. Group number:
M a u r i c i o R o n d e r o s, D D S, M S, M P H I. PATIENT INFORMATION: Last Name: First Name: MI: Mr. Mrs. Ms. Male Female Birth date (M/D/Y): Marital status: Dr. Other: Address: City, State: Zip:
NEW PATIENT INFORMATION Salutation First Name MI Last Name Nickname
NEW PATIENT INFORMATION Salutation First Name MI Last Name Nickname of Birth: Address: SSN: City: State: Zip: Home Phone: Daytime Phone: Mobile Phone: Which number do you prefer we use to contact you?
ERIC ROCKMORE, DPM, FACFAS
Date: Name Date of Birth Address City State Zip Code Email Address Preferred Language Social Security(Medicaid only) Referred by Gender Race Ethnicity Home# ( ) Work # ( ) Cell ( ) Preferred phone # (
Family Medicine Center of the Bitterroot, P.C.
PATIENT REGISTRATION / FINANCIAL AGREEMENT Thank you for taking time to complete this form. This information is necessary for the preparation of your clinic records. You are responsible for all charges
HIPAA Authorization Release Form
HIPAA Authorization Release Form I,, give permission to all my health care and medical services providers and payers to disclose and release my protected health information described below to: Name(s):
Haroon Rehman, MD 3200 Talon Drive. Suite 300 Richardson, TX Phone: Fax: Address: City: ST: ZIP:
Haroon Rehman, MD 3200 Talon Drive. Suite 300 Richardson, TX 75082 972-649-5937 Fax: 972-807-0385 Patients General Information Last Name: First Name: Patient s SSN: of Birth MM/DD/YYYY: / / Age: Sex: M/F
Date: Patient Health Information. Patient Name: First Middle Last Nickname. Date of Birth: Age: Sex: Male Female. Referring Physician:
Date: Patient Health Information Patient Name: First Middle Last Nickname Date of Birth: Age: Sex: Male Female Referring Physician: Family Physician: City: City: What is the main reason for your visit?
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
Social Security No: Home Phone: _. Employer: Work Phone: _. Employer Address: Occupation: _. Spouse/Parent Name: Phone No: _
THE NATIONAL RETINA INSTITUTE LEADERS IN THE TREATMENT OF RETINAL DISEASES Patient Information Form Patient Name: Date of Birth: -,--I _----'--/ Age: Social Security No: Home Phone: _ Street Address: --------------------------------------
Surgical Group of Gainesville, PA
Surgical Group of Gainesville, PA REGISTRATION FORM Peter Sarantos, MD* FACS Bruce W. Brient, MD* FACS Stanley V. DeTurris, MD* FACS Brian E. Pickens, MD* FACS Timothy A. Hipp, MD* FACS Jeffery Jeffrey
MEMORIAL AND KATY SURGICAL SPECIALISTS. Patient Information
Patient Information Patient Name Last First Middle Address City State Zip Birthdate Age Sex M F Social Security# Race (Please circle) American Indian Asian Black Native Hawaiian Pacific Islander White
Consent For Treatment
Consent For Treatment I hereby give my permission for Piedmont Neurology, LLC (the Practice) to provide diagnostic services and medical treatment. I permit the Practice to file for insurance benefits to
Acknowledgement of Receipt of Notice of Privacy Practices
Acknowledgement of Receipt of Notice of Privacy Practices **You May Refuse to Sign This Acknowledgement** I,, have received a copy of this office s Notice of Privacy Practices. Signature For Office Use
PLEASE FILL OUT FORM BELOW AND THEN FAX BACK TO: ADDITIONALLY, PLEASE BRING FORM WITH YOU ON THE DAY OF YOUR SCHEDULED APPOINTMENT.
PLEASE FILL OUT FORM BELOW AND THEN FAX BACK TO: 516-354-8597 ADDITIONALLY, PLEASE BRING FORM WITH YOU ON THE DAY OF YOUR SCHEDULED APPOINTMENT. THANK YOU - 1 - NEW PATIENT MEDICAL INFORMATION Patient
Address: How did you hear about us? Name: Date of Birth: / / Address: City: State: Zip code: Phone Number: HOME - - WORK - - CELL - - EMPLOYER:
Date of Appointment: / / Email Address: How did you hear about us? Have you been seen here before? YES NO If YES, WHEN?: PATIENT INFORMATION Name: Date of Birth: / / AGE: SSN: - - GENDER: Male Female Marital
Name: Date of Birth: Sex: Office: Date:
Patient Information Name: Date of Birth: Sex: Office: Date: Address: City: State: Zip: Social Security Number: Home Phone: Cell Phone: Email: May we leave a message? Email? Martial Status Emergency Contact
NEUROLOGIC ASSOCIATES, PLC
Dear, Welcome to Our Office This letter is to serve as confirmation of your appointment at Neurologic Associates, PLC on at am/ pm. Included in this Welcome Packet is our Promise to Pay and Patient Questionnaire.
ADDRESS CITY / STATE / ZIP CODE RACE/ETHNICITY WORK PHONE # ( ) ADDRESS MAY WE CONTACT YOU BY YES NO
PATIENT REGISTRATION Patient Information (please print) PATIENT NAME (last, first, middle) SOCIAL SECURITY # SEX: M F DATE OF BIRTH AGE ADDRESS CITY / STATE / ZIP CODE RACE/ETHNICITY HOME PHONE # CELL
PATIENT INFORMATION SHEET
Dr. Ricky Bare, F.A.C.S. Dr J.G. Cargill III Dr. James Brien Dr. Michael Burris Dr. H. Brooks Hooper Kimberly Bullock, FNP DATE: PATIENT INFORMATION SHEET PATIENT NAME: FIRST MI LAST SOCIAL SECURITY NUMBER:
HIGHLAND PARK FAMILY PRACTICE, LLC ARTHUR H. MILLER MD, FAAFP 505 RARITAN AVENUE HIGHLAND PARK, NJ TEL:
HIGHLAND PARK FAMILY PRACTICE, LLC ARTHUR H. MILLER MD, FAAFP 505 RARITAN AVENUE HIGHLAND PARK, NJ 08904 TEL: 732-393-1331 www.hpfamilypractice.com PATIENT INFORMATION: Patient s Name (Last) (First) (Middle)
Louis Arno, MD, FACP, FCCP Nehal L. Mehta, MD, FCCP, D,ABSM Prashant B. Patel, MD, MS
Dear Patient, Welcome to Respacare! We are sending you our Patient Information, History, Medication and HIPPA Privacy forms for you to fill out before your office visit. DUE TO HIGH PATIENT VOLUME, YOUR
CASCADE SURGEONS 875 Wesley St. Ste 230 Arlington WA (360)
CASCADE SURGEONS 875 Wesley St. Ste 230 Arlington WA 98223-1668 (360) 435-6097 M.C. WHITMAN III, M.D., FACS PETER WOLFF, M.D., FACS DEAR You have been referred to Cascade Surgeons, the office of Dr. Whitman
Patient s Name: Age: Social Security: Height: Weight: Street Address: City: State: Zip: Mailing Address (if different): City: State: Zip:
PATIENT INFORMATION: Patient s D.O.B: Age: Social Security: Height: Weight: Street Address: City: State: Zip: Mailing Address (if different): City: State: Zip: Home Phone: Cell Phone: Work Phone: Email
University Spine Institute Inc
University Spine Institute Inc TREATMENT ADVISEMENT: The physicians of University Spine Institute are specialists in pain management. The examinations and treatments that you will receive here cannot be
PRIMARY INSURANCE: Policy # Group # Name of Subscriber (if other than patient)
MRN: (Office Use Only) PATIENT INFORMATION Social Security #: - - Last Name: First Name: MI: Address: City: State: Zip: Home #: ( ) - Work #: ( ) - Cell #: ( ) - Sex: Male Female DOB: Email: Referring