550 Pharr Rd NE, Suite 605 Atlanta, GA Office Fax
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1 550 Pharr Rd NE, Suite 605 Atlanta, GA Office Fax C HILD / A DOLESCENT PATIENT REGISTRATION INFORMATION AND GUARANTOR AGREEMENT Which Provider are you seeing today? Smitha Bhandari, MD Elana Zimand, PhD Karla Viera-Negron, MD Jeremy Salzman, PsyD PATIENT INFORMATION Patient Full Name Nickname (First) (MI) (Last) Age Date of Birth Gender: Male Female Street Address City/State/Zip Cell Phone (parent/guardian) Home/Work Phone (please circle one) Referred by Pediatrician Phone Number Pharmacy Name and Phone Number Parent s Name and Contact Information: Print name phone Parent s Name and Contact Information: Print name phone Page 1 of 3 Revised June 2017
2 Patient Name Date School Name School Address School Phone PATIENT MEDICATION HISTORY Medication Allergies Current Medications (name/dosage/frequency) GUARDIAN/FINANCIAL GUARANTOR INFORMATION Print Name (First) (MI) (Last) Relationship to Patient Street Address (Leave Blank If Same As Patient) City/State/Zip Cell Phone Home/Work Phone (please circle one) Page 2 of 3 Revised June 2017
3 Patient Name Date CUSTODY AGREEMENT If the parents of the minor patient are divorced and custody is Joint Legal, both parents need to sign the Consent for Treatment. However, if parents are divorced and only one parent signs the Consent for Treatment, a copy of the custody agreement must be provided to PATH Group of Atlanta, LLC at the initial appointment. This agreement must reflect which parent obtains authority over medical decision-making. If divorced, second signature required, Parent/Guardian/Guarantor Signature Date CONSENT FOR TREATMENT I hereby agree to have my child be treated by physicians or mental health providers associated with PATH Group of Atlanta, LLC. I authorize PATH Group of Atlanta, LLC to provide information to any physician or therapist who referred me to PATH Group of Atlanta, LLC. I, the undersigned, agree that I am financially responsible for all services provided by PATH Group of Atlanta, LLC. I am aware that office policy requires payments be made at time of service. I understand that unpaid balances over 30 days may incur a 3% late fee per month of the outstanding balance. I have read the policies and understand and agree to them. Parent/Guardian/Financial Guarantor Signature Print Name Date Page 3 of 3 Revised June 2017
4 550 Pharr Rd NE, Suite 605 Atlanta, GA Office Fax OFFICE POLICIES OFFICE HOURS AND EMERGENCY INFORMATION Office hours are Monday through Friday, 9 am to 5 pm. If you have a medical emergency, please call 911 or go to your local emergency room. If you have an urgent question after normal business hours, please call Dr. Bhandari at or Dr. Karla Viera at Otherwise, all routine calls will be answered by the following business day. PAYMENT POLICY All patients are required to pay the session fee in full at the time services are rendered. We accept checks, cash and credit cards. We kindly request that you provide your credit card at each visit. APPOINTMENT CHANGES/CANCELLATIONS Your appointment times are reserved and if you cancel an appointment with less than 24 hours notice, you will be charged the full fee. After hours, you may leave notice of cancellation on our voic service. If for any reason the doctor must cancel an appointment with you, all efforts will be made to notify you as soon as possible. OFFICE PHONE POLICY Please be aware that our doctors are meeting with patients throughout the day and may not be able to return your phone call until a later time. When leaving a message for your doctor, please leave both daytime and evening telephone numbers. Please note that this is for brief phone calls only and you must schedule a phone appointment for extensive calls. EXTENSIVE PHONE CALL POLICY For longer phone calls, you may call the office and schedule a phone appointment with your doctor. There will be a routine charge for phone appointments based on the length of call. Please note that there may be an additional charge for after hour calls, except for life threatening emergencies. Page 1 of 3 Rev 04/16
5 Fees for Extensive Phone Calls (charges may vary with each doctor) minutes $50 MEDICAL INSURANCE POLICY Our providers do not contract with any insurance companies. However, if your insurance company provides out of network benefits, you may file your own claims for reimbursement. We must inform Medicare, Tri-Care and Medicaid patients that we have opted out of these plans. Therefore, patients with the insurance coverages stated above are not permitted to submit claims from our practice to these insurance providers for reimbursement. MEDICATION REFILL POLICY We make every effort during your appointment to provide enough medication to reach your next appointment. However, we are aware that emergencies may arise and appointments may have to be rescheduled for a later date. Medications refills may be requested during regular office hours by calling the office. We will complete medication requests within hours from the time of the request. If requesting a stimulant (controlled medication), please call the office for more information. Stimulant medications require a prescription in hand which may be picked up at the office or mailed to your address. There may be a charge of $10 - $25 for all refill request when patients are due for an appointment. Prescriptions may only be called in for current patients who maintain their regularly scheduled appointments. We encourage patients to pay close attention to your medication supply to ensure that we have enough time to complete each medication request. REQUEST FOR FORMS OR LETTERS POLICY Any requests for forms to be completed or letters to be written on your behalf are subject to a $25 to $50 preparation fee. TERMINATION OF TREATMENT You are under no obligation to continue services and may opt to terminate treatment. Should you decide to discontinue treatment, we strongly urge you to notify the doctor of your decision so that it may be discussed openly. FINANCIAL GUARANTOR AGREEMENT This agreement will remain in effect until written notice of alternate payment arrangements are provided to PATH Group of Atlanta, LLC. The current Guarantor is responsible for any and all charges incurred prior to receipt of notification of other arrangements. If you wish to change Guarantors, please have the newly appointed Guarantor complete a separate Guarantor Agreement with PATH Group of Atlanta, LLC. PLEASE RETAIN THIS PAGE FOR YOUR RECORDS AND RETURN THE SIGNATURE PAGE TO THE OFFICE. Page 2 of 3 Rev 04/16
6 PATIENT NAME NOTICE OF PRIVACY POLICIES I acknowledge that I have read and agreed to, and was offered a copy of the Notice of Privacy Practices for the PATH Group of Atlanta, LLC. If you would like to take home a copy of our Notice of Privacy Practices, please check here: I hereby acknowledge that I have read and agree to the office policies of PATH Group of Atlanta, LLC. Patient Signature (Parent if patient is a minor) Date Print Name Financial Guarantor Signature Date Financial Guarantor Name (please print) PLEASE RETURN THIS PAGE TO THE OFFICE AND RETAIN THE OFFICE POLICIES PAGE FOR YOUR RECORDS. Page 3 of 3 Rev 04/16
550 Pharr Rd NE, Suite 605 Atlanta, GA Office Fax pathgroupatl.com
550 Pharr Rd NE, Suite 605 Atlanta, GA 30305 Office 404.235.5982 Fax 678.705.2756 pathgroupatl.com ADULT PATIENT REGISTRATION INFORMATION AND GUARANTOR AGREEMENT Which Provider are you seeing today? Smitha
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No Show/Short Notice Cancellation Acknowledgement We at Atlanta ENT strive to provide our patients with the best care and quickest appointment times possible. Unfortunately there are patients who make
WIMBERLEY MEDICAL CLINIC
WIMBERLEY MEDICAL CLINIC PATIENT INFORMATION Patient Information Name: Date of Birth: SSN: Mailing Address: City, State, Zip: Home Phone: Work Phone: Cell Phone: Sex: M F Race: Caucasian Black or African
PATIENT INFORMATION FORM
PATIENT INFORMATION FORM NAME: Age: DATE OF BIRTH: SSN: Sex: MARITAL STATUS: PRIMARY CARE PHYS: DRIVER S LICENSE # STATE IF CHILD, GUARDIAN S NAME: ADDRESS: City State Zip Code PHONE: Home Phone Cell Phone
My Doctor at WIM is: Dr. Azam Dr. Cohen Dr. Huynh Dr. Jacobellis Dr. McCarthy Dr. Taylor (CIRCLE ONE)
In order to serve you promptly, we need the following information. Fill out each item or put N/A (not applicable). Please Print Clearly. WESTFORD INTERNAL MEDICINE, P.C. My Doctor at WIM is: Dr. Azam Dr.
ATTENTION: NEW PATIENTS Please allow 4 to 6 weeks to receive your FIRST fill on your prescriptions.
ATTENTION: NEW PATIENTS Please allow 4 to 6 weeks to receive your FIRST fill on your prescriptions. Regional Healthcare does not control shipments of medication. The pharmaceutical company which supplies
Minor Registration Forms Please Print Legibly. Demographics. *Patient Last Name: *First Name: Middle Initial:
*Indicates Required Fields Minor Registration Forms Please Print Legibly Demographics *Patient Last Name: *First Name: Middle Initial: *Date of Birth: / / *Gender: Male Female *Prefix: Mr. Miss Ms. Mrs.
Family & Psychological Services Inc. Greentree Commons 951 Route 73 North, Suite B Marlton, NJ 08053
Date: Patient Name: DOB / / Last First M.I. Soc. Sec. # - - Marital Status: Single Married Separated Divorced Widow(er) Mailing Address: Email Address: Patient Phone # s Ok to Call? Spouse/Parent Phone
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
Family Physicians of Johnson City 303 Med Tech Parkway, Suite 100 Johnson City, TN 37604
Family Physicians of Johnson City 303 Med Tech Parkway, Suite 100 Johnson City, TN 37604 Patient Registration Form Last Name First Name Middle Initial Sex: M F of Birth Address City State Zip Code Social
Jeffrey L. Brooks, M.D. (707)
(707) 252-4955 Welcome to our practice! First, let us thank you for choosing Napa Vascular & Vein Center as your healthcare provider. We are dedicated to providing premier vascular assessment and treatment
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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
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
PEDIATRIC REGISTRATION FORM
PEDIATRIC REGISTRATION FORM **Today s Date: PATIENT INFORMATION: (Please use full legal name, no nicknames) *Last Name: *First Name: Middle Initial: *Address: City: State: Zip: *Sex: *Date of Birth: Age: