Patient Information Form
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- Clarissa Benson
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1 Patient Information Form Welcome to Memphis Surgery Associates The following information will allow us to accurately handle your billing and insurance. Date Referring Physician Primary Care Physician Please present Insurance Card and Photo ID Patient First Name MI Last Birth Date / / Age Marital Status: Married Widowed Single Divorced Mailing Address City State Zip Home Phone Work Phone Cell Phone Male/Female SSN Information required by Federal government Preferred Language Race: Caucasian/White African American/ Black American Indian Asian Other Ethnic Background: Hispanic Non Hispanic Employment status: Full-time/Part Time/Unemployed Employer Work Phone May we have access to your prescription records? Yes or No How may we contact you regarding appointments and medical information? Home Work Cell Where may we leave a message? (check all that apply) Home Work Cell Primary Insurance Policy # Group # Policy Holder s Name Policy Holder Date of Birth / / Policy Holder s SSN Relationship to patient Policy Holder s address if other than patient City State Zip Policy Holder s place of employment Does this insurance plan require a referral? Yes or No What Hospital Facility is in network with your insurance plan: Secondary Insurance Policy # Group # Policy Holder s Name Policy Holder Date of Birth / / Policy Holder s SSN Relationship to patient Policy Holder s address if other than patient City State Zip Policy Holder s place of employment Does this insurance plan require a referral? Yes or No Spouse/(Next of Kin) Relationship Phone Emergency Contact Relationship Phone Pharmacy Location Phone Patient Signature (or guardian) Date Relationship if not patient
2 Memphis Surgery Associates Medica'on*Log* Pa'ent*Name:* *Date*of*Birth: *Date: * It#is#important#to#have#a#complete#record#of#your#current#medica5ons.#Please#list#all#prescribed# and#over#the#counter#medica5ons.#include#the#dosage,#how#it#is#taken(scheduled)#and#the# doctor#that#prescribed#this#to#you.# Medica5on Dosage Schedule# (How#taken) Doctor#who# prescribed Pa5ent#Signature:# #Date:
3 Memphis Surgery Associates Pa#ent'Name: 'Date'of'Birth: ''''Date: ' Pre$evalua)on,Pa)ent,Ques)onnaire' **all,responses,are,kept,strictly,confiden)al**' Reason'for'visit: ' How'long'has'this'been'a'problem?' ' Have'you'been'treated'by'another'physician'for'this'problem'in'the'past?'If'so,'who'treated'you'and'what'was' done:' ' Physician'who'referred'you'here:' ' Primary'Care'Physician: ' Please,note,any,other,condi)ons,for,which,you,see,a,doctor:, (')Hypertension' (')Diabetes' ' (')High'Cholesterol' ' (')Dialysis, (')Stroke' ' (')COPD' ' (')Kidney'Disease' ' (')Blood'Clot/DVT' (')Liver'Disease''' (')Thyroid(hyper/hypo)' ' ' ' (')Seizures' (')Asthma' ' (')Conges#ve'Heart'Failure' ' ' ' (')Hepa##s' ' (')GERD' ' (')Coronary'Artery'Blockages' ' ' ' (')HIV/AIDS' (')Ulcera#ve'Coli#s' (')Diseases'Artery'Blockages' ' ' ' (')Heart'Rhythm'Abnormali#es' (')Crohn s'disease' (')'Valvular'Heart'Disease'or'Heart'Murmur'' (')History'of'cancer?'If'yes,'where'and'when?:' ' ' (')History'of'sexually'transmiWed'diseases?' ' (')History'of'mental'illness?' ' Please'list'any'other'condi#ons:' ' Have'you'ever'had'a'colonoscopy?'If'yes'when'and'by'whom?' ' Have'you'ever'had'a'mammogram?'If'yes'when'and'by'whom?' ' Height:' 'Weight:' ' List'all'prior'surgical'procedures'and'hospitaliza#ons'with'approximate'dates:'' ' Pa#ent'Name: 'Date'of'Birth: ''''Date: '
4 Memphis Surgery Associates Do,you,take,blood,thinners?'(Aspirin,'Plavix,'or'Coumadin/Warfarin)'Yes'or'No''' Do,you,have,any,allergies?'Yes'or'No' ' Please'list'any'allergies'and'reac#ons:' ' Social,History:' Are'you'currently'employed?'If'so,'what'is'your'occupa#on?' ' If'disabled,'please'list'the'nature'of'your'disability: ' Do'you'have'a'history'of'drug'or'alcohol'abuse?'Yes'or'No ' Do'you'drink'regularly?'Yes'or'No'If'yes,'please'list'amount' ' Do'you'use'tobacco'products?'Yes'or'No'If'yes'how'much'per'day 'year'started' ' ' ' If'former'smoker'the'year'you'quit ' Are'you'single/'married?' ' Gynecologic,History:' Number'of'pregnancies' 'Method'of'delivery ' ' Date'of'last'menstrual'period'or'age'of'menopause' ' ' Any'history'of'abnormal'Pap'smear?'Yes'or'No' Family,History:, Please'list'any'major'illnesses'and/or'causes'of'death'with'family'members.'(ex.'Heart'disease,'cancer,'etc.)' Mother: 'Living/'Deceased ' Father: 'Living/'Deceased ' Maternal'Grandparents: ' Paternal'Grandparents: ' Others:, Review,of,Systems:,Please'circle'any'symptoms'that'you'may'be'currently'experiencing.' GENERAL:,Weight'loss/'amount','anorexia,'fa#gue,'fever,'chills' HEAD/NECK:,headache,'visual'changes,'hearing'problems,'sinus'conges#on' RESPIRATORY:,cough,'shortness'of'breath,'(at'rest'or'exer#on),'wheezing,'sleep'apnea' CARDIOVASCULAR:,chest'pain/pressure,'palpita#ons,'easy'fa#gue,'leg'swelling' ABDOMINAL:,nausea,'vomi#ng,'heartburn,'painful'swallowing,'abdominal'pain,'cons#pa#on,'diarrhea,' incon#nence,'blood'in'stool,'dark/tarry'stool,'jaundice' URINARY/SEXUAL:,painful'urina#on,'frequency,'difficulty'star#ng'or'stopping'your'stream,'blood'in'the'urine,' difficulty'achieving'or'maintain'erec#on,'painful'intercourse,'vaginal'discharge' SKIN:,rash,'easy'bruising'or'bleeding' MUSCULOSKELETAL:'joint'pain'or'swelling,'arthri#s' NEUROLOGIC:,Passing'out,'dizziness,'seizures,'numbness,'or'#ngling' PSYCHIATRIC:,anxiety,'bipolar,'depression,'mania,'suicide' Pa#ent'Signature: 'Date: ' Physician'Signature' 'Date:' ' ' ' ' ' ' ' ''''' '
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8 Memphis Surgery Associates Financial Policy and Authorizations We are happy that you selected Memphis Surgery Associates for your healthcare needs and look forward to working with you. To help you understand your financial responsibilities in relation to your medical care, we would like to briefly outline our financial policies. Patients are expected to provide identification and if insured, a current insurance card(s) at time of service. Patients are financially responsible for all services provided and are expected to pay for services at time of service, including any past due balance from a prior date of service. If the patient is a minor child, the parent or other adult accompanying the child will be financially responsible regardless of legal guardianship. Returned checks will be subject to fees. Medicare: The office will bill the Medicare intermediary. Patients are responsible for the following: Annual Medicare deductible All applicable co-pays of the allowed charge Any non-covered services Any covered service ordered by the physician which does not meet Medicare s medical necessity and for which the beneficiary signed an Advanced Beneficiary Notice (ABN). Medicare Supplemental and Secondary Insurances: The Practice will bill both Medicare and secondary insurances. Medicaid: Patients must provide the Practice with a current Medicaid card at each visit. Medicaid patients are responsible for applicable co-pays and for all non-covered services. Medicaid patients are responsible for securing necessary referrals from their primary care physicians. HMOs and PPOs, Commercial Insurance Plans: Patients are responsible for payment of the co-pay, co-insurance and/or deductible, or non-covered amounts at the time of service as well as for any charges for which the patient failed to secure prior authorization, if authorization is necessary. Insurance is filed as a courtesy and benefits are authorized to be paid directly to the Practice. Patients are responsible for the balance in full if not paid by the insurance within 30 days. If the patient is not prepared to pay the co-pay or deductible, a member of the clinical staff will determine if it is medically necessary for the patient to see the physician. If the patient s condition allows, the appointment will be rescheduled. Self-Pay: Patients are responsible for payment in full at the time of services for all services rendered. Personal Injury/Motor Vehicle Accidents and Other Third Party Liability: The patient is responsible for the balance in full at the time of service. Any settlement you receive from your insurance company or other third party will be handled by you, your insurance company, and/or your attorney. Out of State Insurance: If the patient presents with an out of state HMO/PPO insurance card, we will need to verify the patient s benefits for out-ofstate or out-of-network benefits. The patient may be required to make payment in full or pay any co-pay, co-insurance or deductible. Authorizations and Consent ASSIGNMENT AND RELEASE: I hereby assign my insurance or other third party carrier benefits to be paid directly to the Physician Practice, realizing I am responsible for any resulting balance. I also authorize the Physician to release any information required to process this claim to my insurance carrier and/or to my employer or prospective employer (for employer sponsored/paid for claims). I acknowledge that I am financially responsible for services rendered, and failure to pay any outstanding balances may result in collection procedures being taken. Further, I agree that if this account results in a credit balance, the credit amount will be applied to any outstanding accounts of mine, or to a family member whose account I am guarantor for. ELECTRONIC CHECK CONVERSION: When you provide a check as payment, you authorize us either to use information from your check to make a onetime electronic fund transfer from your account or to process the payment as a check transaction. When we use information from your check to make an electronic fund transfer, funds may be withdrawn from your account the same day. CONSENT FOR TREATMENT: I hereby authorize the physicians, midlevel providers, nurses, medical assistants, and other Practice staff to conduct such examinations, and to administer treatment and medications as they deem necessary and advisable. NO SHOW POLICY: I understand if I fail to come for a scheduled appointment or cancel at least 24 hours prior to the appointment, I will be considered a no show and may be subject to a no show charge per occurrence. Ongoing occurrences of no shows may result in dismissal from the Practice. I understand the Financial and No Show Policies, Authorizations and Consent for Treatment, and hereby agree to them:
9 I understand the Financial and No Show Policies, Authorizations and Consent for Treatment, and hereby agree to them: Patient or Parent/Guardian if Minor Date ; Rev ; Rev
Patient Information. Last Name: First Name: Middle Initial: Marital Status: Home Phone: Work Phone: Street Address: City: State: Zip:
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Patient Financial Responsibility To all of our Patients: We will, as a courtesy, file your insurance claims for you. Please be advised that it is solely your responsibility to know and to understand your
New Patient Registration Form
New Patient Registration Form Patient Information Name: (First) (Middle) (Last) SSN: of Birth / / Sex: Male Female Street Address (or PO Box): City: State: Zip: Marital Status: Single Married Divorced
Street Address City State Zip Patient Information. Cell Phone ( ) Preferred
Name (Last, First, MI) Email address Street Address City State Zip Patient Information Emergency Contact Home Phone Cell Phone Work Phone SSN Date of Birth Gender Male Female Employer Retired Disabled
Patient Welcome Form!
Arthritis and Rheumatology Clinical Center of Northern Virginia, PLLC 8130 Boone Blvd suite 340 Vienna VA 22182 Mahsa Tehrani MD 703-734-2222 Mahnaz Momeni MD Patient Welcome Form Dear new patient, Welcome
PATIENT INFORMATION Patient First Name Middle Name Last Name Age Birth Date. Mailing Address City State Zip. Street Address City State Zip
PATIENT INFORMATION Patient First Name Middle Name Last Name Age Birth Date Mailing Address City State Zip Street Address City State Zip Home Phone Cell Phone Employer Name (for work comp only) Employer
PATIENT INFORMATION FORM RICHARD L. MALINICK, M.D. ORTHOPAEDIC SURGERY 1125 Via Verde, San Dimas, CA
Email Address Last Name First Name Previous Name Address City State Zip Country Social Security - - Home Phone - - Cell Phone - - Work Phone - - Ext Drivers License State Responsible Party SELF (use info
CENTRAL FLORIDA NEUROSURGERY INSTITUTE Hunaldo J. Villalobos, M.D., FAANS, FACS
CENTRAL FLORIDA NEUROSURGERY INSTITUTE Hunaldo J. Villalobos, M.D., FAANS, FACS Board certified by the American Board of Neurosurgical Surgery PHONE: 407-288-8638 FAX# 407-288-8639 Dear Sir or Madam: On
NAME (LAST, FIRST, MIDDLE) SSN# BIRTHDATE SEX NAME (LAST, FIRST, MIDDLE) SSN# BIRTHDATE SEX
PATIENT INFORMATION NAME (LAST, FIRST, MIDDLE) SSN# BIRTH SEX ADDRESS CITY, STATE & ZIP CODE EMAIL: MAILING ADDRESS (IF DIFFERENT FROM ADDRESS) CITY, STATE & ZIP CODE HOME PHONE CELL PHONE OTHER PHONE
PATIENT INFORMATION DEMOGRAPHICS. First Name Middle Initial Last Name Gender. Mailing address: Apt # City: State: ZIP Code: Home Phone Cell Phone
PATIENT INFORMATION Gary S. Fields, DPM, FACFAS Kenneth M. Danis, DPM, FACFAS DEMOGRAPHICS First Name Middle Initial Last Name Gender SSN Birthdate Age Email M F Mailing address: Apt # City: State: ZIP
Full Name: / / / (Legal Last Name) (Legal First Name) (Middle Initial) (Preferred First Name)
Patient Name Full Name: / / / (Legal Last Name) (Legal First Name) (Middle Initial) (Preferred First Name) Date of Birth: / / Age: Sex/Gender: Address: / / / (Street/PO Box) (City) (State) (Zip Code) Phone
PATIENT INFORMATION. Last Name: First Name: Middle Initial: Sex: M F Preferred Name: Date of Birth (MM/DD/YYYY): Height: Weight: Mailing Address:
PERSONAL INFORMATION PATIENT INFORMATION Last Name: _ First Name: _ Middle : Sex: M F Preferred Name: Date of Birth (MM/DD/YYYY): Height: _ Weight: Mailing Address: City: State: Zip: Social Security #:
Morris Medical Center, P.A.
Thank you for choosing our practice to assist in your healthcare needs. We appreciate the confidence you and your personal physician have placed in us. Please read the following instructions and information
C.A.I. A Cardiovascular & Arrhythmia Institute
Acknowledgement of Receipt of Notice of Privacy Practices By signing below I acknowledge that I have received the Notice of Privacy Practices of Cardiac Arrhythmia Institute, LLC, which explains its legal
Welcome to our Practice
Welcome to our Practice First, let us thank you for putting your trust in Georgia Eye Partners and our team. Our goal in providing this packet of information is to make the process as easy as possible
Patient Name: DOB: Sex: Male/Female. Primary Address: Home Phone: Mobile Phone: Address: Emergency Contact Name and Phone Number:
Patient Registration Patient Name: DOB: Sex: Male/Female Primary Address: Home Phone: Mobile Phone: Email Address: Emergency Contact Name and Phone Number: Primary Language: Race(s): (Circle all that applies)
FOOT AND ANKLE WELLNESS CENTER DR. LEONARD E. VEKKOS
FOOT AND ANKLE WELLNESS CENTER DR. LEONARD E. VEKKOS NAME: LAST FIRST MIDDLE ADDRESS: STREET APT# CITY STATE ZIP HOME # ( ) WORK# ( ) CELL# ( ) E-MAIL: PREFERENCE: HOME: AGE: DATE OF BIRTH: SS NO.: MALE
Patient Information. Employer's Name. Health Insurance Information HMO. Co-pay Amount. Cross Streets
Registration/Update Form Today's : Patient Information Patient's Name: Last First MI Male Female Age Race: American Indian Black or African American Native Hawaiian White Other Ethnicity: Hispanic or Latino
WOODLAKE PODIATRY, LLC
WOODLAKE PODIATRY, LLC Acct. # (Please fill out completely or mark areas n/a if they do not apply) LAST NAME FIRST NAME MIDDLE INIT. STREET CITY STATE ZIP SSN DOB / / MALE / FEMALE HOME PHONE WORK PHONE
Orthopedic Intake. Patient Name: Date of Birth: Age: Sex: Male or Female. What are we seeing you for? Pneumonia vaccine?
Orthopedic Intake Date: Patient Name: Date of Birth: Age: Sex: Male or Female What are we seeing you for? Have you had Flu vaccine? q Yes q No Date Pneumonia vaccine? q Yes q No Date List of Past Surgeries:
PATIENT INFORMATION SHEET
PATIENT INFORMATION SHEET Patient Name: DOB: Address: ADDRESS CITY, STATE, ZIP SSN: Mailing Address: ADDRESS CITY, STATE, ZIP Same as above Home phone: Cell phone: Work phone: Marital Status: Single /
Patient Name: Date of Birth: Today s Date: First Middle Initial Last PACIFIC UROLOGY
PACIFIC UROLOGY 100 N. WIGET LANE, SUITE 290, WALNUT CREEK, CA 94598 - (925) 937-7740, FAX (925) 933-9868 2222 EAST STREET, SUITE 250, CONCORD, CA 94520 - (925) 609-7220, FAX (925) 689-3298 5201 NORRIS
PATIENT INFORMATION RECORD Title: (please circle) Mr. Mrs. Ms. Dr. other: Suffix: I II III IV Jr. Sr.
Providence Medical Park / 3841 Piper Street, Suite T300 / Anchorage, AK 99508 Alaska Regional Campus / 2925 DeBarr Road, Suite 250 / Anchorage, AK 99508 Ph: (907)-563-3103 F: (907)-561-1862 Mat-Su Regional
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
5149 N. 9th Ave Suite G32 Pensacola, FL phone fax
Dear Patient: Enclosed you will find the following items: 1. Patient Data Sheet 2. Medical Records Release 3. Program Fee Information 4. Manual Registration 5. Photo and Interview Authorization Please
THE HOUSE OF THE GOOD SHEPHERD 798 Willow Grove Street Hackettstown NJ (908) APPLICATION FOR ADMISSION TO LONG TERM CARE
THE HOUSE OF THE GOOD SHEPHERD 798 Willow Grove Street Hackettstown NJ 07840 (908)684-5900 APPLICATION FOR ADMISSION TO LONG TERM CARE Applicant Name Gender M F Home Address () Code Residence Type House
(Please Print using Black or Blue Ink) SEX: GENDER IDENTITY: MARITAL STATUS: SINGLE MARRIED OTHER
PATIENT INFORMATION (Please Print using Black or Blue Ink) LAST NAME: FIRST NAME: MIDDLE INITIAL: ADDRESS: CITY: STATE: ZIP: SEX: GENDER IDENTITY: MARITAL STATUS: SINGLE MARRIED OTHER RACE (OPTIONAL):
NOTICE TO OUR PATIENTS
NOTICE TO OUR PATIENTS Although we participate with most insurance plans, you as the patient and/or insured party are responsible for co-pays, deductibles and any non-covered services, which are outlined,
Quick Patient Registration Form Patient Information:
Quick Patient Registration Form Patient Information: Legal First Name: MI: Legal Last Name: Sex: M F Date of Birth: Primary Language: Marital Status: Married Single Partner Divorced Widowed Race: Ethnicity:
Saline Heart Group, PA
www.salineheartgroup.com Patient Account # Date: Patient Information In order for us to provide you with the best possible care, please fill out these forms as completely and accurately as possible. Last
Sabates Eye Centers P.O. Box Kansas City, MO (913)
Sabates Eye Centers P.O. Box 26425 Kansas City, MO 64196-6425 (913) 261-2020 Type of Visit: u Routine u Medical Contact Lens Wearer? u Yes u No PATIENT INFORMATION Name (Last, First, Middle Initial) Date
Center for Dermatology & Cosmetic Laser Surgery
Center for Dermatology & Cosmetic Laser Surgery Bryan A. Selkin MD Michael Wells MD Gilbert Selkin MD, DMD Angel Puryear MD Mara Dacso MD, MS Ami Bhattacharya PA-C Hope Thibodeaux PA-C Lauren Hughes PA-C
Patient Registration Form
Patient Registration Form Patient Information: Patient/Child First Name: MI: Last Name: Age: Date of Birth: Occupation: Ethnicity: Hispanic Not Hispanic Language: English Spanish Other Race: White Black