Ra m sd ell P ed iatrics, I nc.
|
|
|
- Domenic Jefferson
- 5 years ago
- Views:
Transcription
1 Please Print Patient Information: Last Name First MI Address City State Zip - Home Phone Alt. Phone SSN Sex DOB / / Policyholder Information: Policyholder s Name Policyholder s Address Policyholder s DOB / / SSN Employer Business Phone Relationship to patient Insurance Information: Insurance Company Group Number Policy Number Co-Pay $
2 Responsible Party: (Please only fill out this part if the responsible party is different from the policy holder) Name Address Primary Phone Alt. Phone Relationship to patient Signature of authorized party Date As a courtesy to our patients, we will file your insurance claims. Please help us by providing us with accurate information.
3 NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT I understand that under the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), I have certain rights to privacy regarding my protected health information (PHI). I understand that this information can and will be used to Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in the treatment directly and indirectly. Obtain payment from third-party payers. Conduct normal healthcare operation such as quality assessments and physician certifications. I received, read, and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my PHI. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this information at any time to obtain a current copy of the Notice of Privacy Practices. Parent or Legal Guardian (please print) Name (Patient may sign if he or she is at least 18 years of age.) Signature Practice Use Only I attempted to obtain the parent s, legal guardian s, or patient s signature in acknowledgement of the Notice of Privacy Practices Acknowledgement, but was unable to do so as documented below. Date / / Initials Reason
4 CONDUCT AGREEMENT The responsibility of the staff at Ramsdell Pediatrics is to provide a safe environment for you and your children. We will treat families with the courtesy, respect, and care that we would use to treat our own families. In return, we ask that you extend the same courtesy to everyone at Ramsdell Pediatrics, staff and patients alike. Violent behavior, language, cursing, and threats are treated very seriously here. Should you or members of your family behave in a way that is thought to be violent, threatening, or abusive, Ramsdell Pediatrics will not provide your pediatric care. Should you as a patient or family member witness violent or threatening behavior by staff or patient, please bring it to the attention of a doctor or manager immediately. Patient Name Parent/Guardian Date / /
5 AUTHORIZATION FOR RELEASE OF INFORMATION Name of Patient Date of Birth / / is authorized to release protected health information about the above named patient to the entities named below. The purpose is to inform the patient or others in keeping with the patient s instructions. Entity to receive information Check each person/entity that you approve to receive information. o Voice Mail o Spouse o Parent (provide name) o Other (provide name) Description of information to be released Check each that can be given to the person/entity on the left in the same section. o Results of lab tests/x-rays o Other o Financial o Medical, as follows o Financial o Medical, as follows o Financial o Medical, as follows Patient Information I understand that I have the right to revoke this authorization at any time and that I have the right to inspect or copy the protected health information to be disclosed as described in this document. I understand that a revocation is not effective in cases where the information has already been disclosed but will be effective going forward. I understand that information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law. I understand that I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing. This authorization shall be in effect until revoked by the patient. Signature of Patient or Personal Representative Date / / Description of Personal Representative s Authority (attach necessary documentation)
6
7
Accessible, Affordable, Quality Patient Centered Medical Home
PATIENT REGISTRATION Child :Last Name: First Name: MI: D.O.B.: / / Sex: Primary Language: Ethnicity: Hispanic / Non-Hispanic / Unknown Race: Asian / Black / Hawaiian / White Primary Policy: Policy Holder
Authorization to Release Health Information
Authorization to Release Health Information Patient Information: Name of Patient Date of Birth Address City, State, Zip Phone At my request, may release the following information: (Name of the entity)
425 North Wendover Road Charlotte, NC Birthdate: Social Security #: Male Female
425 North Wendover Road Charlotte, NC 28211 PATIENT INFORMATION: Patient s Legal Name: Nickname: Birthdate: Social Security #: Male Female Status: Minor (under 18) Single Married Separated Divorced Widowed
Long Pond Pediatrics & Osteopathy Dr. Sabine M. Schmitt, DO, FAAP, C.S.P.O.M.M. Dr. Shoshana Katz, MD, FAAP Dr. Kimberly Ingalls, MD, FAAP, M.P.
Today s Date Long Pond Pediatrics & Osteopathy Dr. Sabine M. Schmitt, DO, FAAP, C.S.P.O.M.M. Dr. Shoshana Katz, MD, FAAP Dr. Kimberly Ingalls, MD, FAAP, M.P.H NAME OF PATIENT (CHILD) DOB SSN of child SEX
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
HIPAA Privacy Release Form
HIPAA Privacy Release Form The request for release of information is being made for the TDP enrollee identified below. Effective Date Sponsor SSN or DBN Number Full Name of Individual Authorized to Release
Patient Registration. All Inclusive Primary Care. PATIENT INFORMATION Name: (Last, First, MI) Address: City: State/Province: Zip: Country:
Patient Registration PATIENT INFORMATION Name: (Last, First, MI) Address: City: State/Province: Zip: Country: Mailing Address (if different from above): Home Phone: Work: Mobile: Email: SSN: Birth Date:
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
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:
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
PATIENT INFORMATION PATIENT INFORMATION. Middle Initial: Nickname: Date of Birth: Marital Status: Address: City: State: Zip Code:
PATIENT INFORMATION PATIENT INFORMATION First Name: Last Name: Middle Initial: Nickname: Date of Birth: Sex: Marital Status: Address: City: State: Zip Code: Home Phone: Cell Phone: Email: How did you hear
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)
Billing Address for responsible party (if different from home): Subscriber: DOB: Employer:
Today s D Today s Date: Parent/Guardian Name: DOB: Cell: Home: Work: Email: Preferred Method of Contact: Parent/Guardian Name: DOB: Cell: Home: Work: Email: Preferred Method of Contact: Patients Home Address:
70 Hatfield Lane Goshen, New York SSN: First Name: MI: Last Name: Employment: Employed Unemployed Retired Employer: Employer Address:
70 Hatfield Lane Goshen, New York 10924 SSN: First Name: MI: Last Name: Prefix (Ms., Mr.,) Sex: M F DOB: Marital Status: Single Married Divorced Widowed Spouse Name: Employment: Employed Unemployed Retired
AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION
AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION Policy: Rationale: The University of Connecticut will disclose protected health information (PHI) in accordance with the consent, authorization, or
Green Valley Ranch Medical Clinic & Urgent Care. Patient Information Form
Green Valley Ranch Medical Clinic & Urgent Care Patient Information Form Patient Name (Last) (First) (M.I) of Birth// Age Sex_ Marital Status Social Security Number Employment Status (Full Time) (Part
Acquaintance Form & Health History
Acquaintance Form & Health History Date Patient s Name Marital Status Nickname, if preferred Spouse s Name (if married) Date of Birth Residence Street address City Zip Home Phone Cell # Employer Position
If it is not, call your insurance company and have them change the Children s Medical Center to one of Children s Medical Center physicians.
**This form is for your personal use only and is a tool to help you understand your personal health benefits** Call your insurance company (phone number on the back of your insurance card) and ask them
California Cardiovascular and Thoracic Surgeons
California Cardiovascular and Thoracic Surgeons 168 North Brent Street, Suite 508 Ventura, CA 93003 Telephone (805) 643-2375 Fax (805) 643-3511 Your assistance in completing the following information thoroughly
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.
PATIENT REGISTRATION
TIME 10:15 AM PATIENT REGISTRATION DATE 6/15/2016 ID: Chart ID: First Name: Last Name: Middle Initial: Patient Is: Policy Holder Responsible Party Preferred Name: Responsible Party ( if someone other than
Allergy & Asthma Center 2625 Box Canyon Drive Las Vegas, NV Patient Information Patient Name (Last) (First) (M.I.) DOB: SSN:
Allergy & Asthma Center 2625 Box Canyon Drive Las Vegas, NV 89128 Patient Information Patient Name (Last) (First) (M.I.) DOB: SSN: Home # Cell # Work # Marital Status S M D W Sex: M F Age: Address: Appt
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
New Patient Information - Dr. Marc Edelstein
Marc A. Edelstein M.D., FACP, FACG Internal Medicine and Gastroenterology Gastroenterology, Hepatology, and Nutrition Susan P. Edelstein M.D., FAAP Pediatrics and Pediatric Gastroenterology Pediatric Gastroenterology,
Acknowledgement of Privacy Practices
Rev 08/16 Acknowledgement of Privacy Practices My signature confirms that I have been informed of my rights to privacy regarding my protected health information under the Health Insurance Portability &
INSURANCE INFORMATION
PATIENT INFORMATION Last Name First Name M.I. Marital Status: Married Single Divorced Widowed Social Security No.: - - Birth Date: / / Sex: M F Place of Birth: Driver s License Number: Preferred Language:
**** 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 Rx Help Centers!
Welcome to Rx Help Centers! Congratulations! We are thrilled that you have chosen Rx Help Centers as your personal prescription advocate! Rx Help Centers is proud to work on your behalf to save you money
Last Name: First Name: MI: Date of Birth: / / Sex: Home#: Cell#: Address: City: Zip:
PATIENT REGISTRATION FORM DATE: PATIENT INFORMATION Last Name: First Name: MI: Date of Birth: / / Sex: Home#: Cell#: Address: City: Zip: Emergency Contact: Phone: Alt: Email: Primary Care PHYSICIAN Name:
Please print and complete all the enclosed forms and bring them to your first appointment.
Dear Valued Patient, Thank you for requesting an appointment in our office. Please print and complete all the enclosed forms and bring them to your first appointment. When you arrive at our office for
Bozart Family Dentistry
Bozart Family Dentistry Gentle Compassionate Understanding Albert T. Bozart, D.D.S. Date Appointment Date Time PATIENT INFORMATION: Name Birthdate SS# Sex M F Married Widowed Single Minor Separated Divorced
Phoenix Orthopaedic Surgeons Joseph S. Gimbel, M. D. PATIENT REGISTRATION
Phoenix Orthopaedic Surgeons Joseph S. Gimbel, M. D. PATIENT REGISTRATION DATE Chart # PATIENT NAME AGE DATE OF BIRTH MALE FEMALE PREFFERED LANGUAGE RACE/ETHNICITY SINGLE, MARRIED, DIVORCED, SEPARATED,WIDOWED
No Show/Short Notice Cancellation Acknowledgement
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
Consent for Purposes of Treatment, Payment and Healthcare Operations
Consent for Purposes of Treatment, Payment and Healthcare Operations I consent to the use or disclosure of my protected health information by Neuropsych Associates for the purpose of diagnosing or providing
BILL L. JOU, M.D., INC.
BILL L. JOU, M.D., INC. AUTHORIZATION TO TREAT I (and/or the undersigned on behalf of the patient) voluntarily consent to allow Dr. Bill L. Jou and staff to provide such evaluation and/or care and treatments
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
Florida Orthopaedic Associates, P.A.
Florida Orthopaedic Associates, P.A. PATIENT REGISTRATION Date Patient Name SSN Home Address City, St., Zip Date of Birth Age Male/Female Married/Single Phone Home/Work/Cell Phone Home/Work/Cell Employer
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
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
New Wave Internal Medicine Clinic
Amber D. Colville, M.D. *Lydia Latour, M.D., * Ashleigh Teates NP-C Dear Patient, Thank you for your interest in becoming a new patient at New Wave Internal Medicine. Please fill out the enclosed paperwork
Who referred you to us? Who shall we contact in case of emergency? Phone:
Client Information Sheet (Leslie Jensby -Wichita Counseling and Coaching Center) Client: Last Name: First Name: MI Street: City: State: Zip Home Phone: Cell Phone SSN# - - Birth Date: Age: Sex: M / F Work
Name: Social Security# Address: City: State: Zip: Date of Birth: Phone: Cell: *Employer: Phone:
Gallatin Family Practice Center Subir Guha, M.D. * Noridia Mauras, D.O * 608 Commons Drive Suite A * Gallatin, TN 37066 Telephone (615)452-5901 Fax (615)451-2006 Name: Social Security# Address: City: State:
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
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
Legal first and last name of person being assessed today: Marital Status: Social Security #: State: Zip: Employer:
Admissions Staff Place Patient ID Sticker Here Patient Registration Please read and complete both sides of this form Date: Time: Legal first and last name of person being assessed today: Date of Birth:
Patient's Name: Date of Birth:
AUTHORIZATION TO USE AND/OR DISCLOSE HEALTH INFORMATION Magnolia Pediatrics 2497 Herndon Ave., suite #101, Clovis, CA 93611 Phone: (559) 538-3070 Fax: (559) 538-3071 Patient's Name: Date of Birth: Completion
First Name: Middle Name: Last Name: Preferred Name: Address: City: State: Zip: Mother s First & Last Name: Mother s Home Phone: Mother s Work Phone:
Patient Information First Name: Middle Name: Last Name: Date of Birth: Gender: M F Preferred Name: Address: City: State: Zip: Contact Information Mother s First & Last Name: Mother s Address (If different
Past Medical History
Past Medical History Patient Name Age: Sex: M or F Allergies:_ of Birth Current Medicines: If Newborn: Was baby born in a Hospital: Y N If Yes what Hospital: Medical History BIRTH HISTORY (Please list
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
Please print and complete all the enclosed forms and bring them to your first appointment.
Dear Valued Patient, Thank you for requesting an appointment in our office. Please print and complete all the enclosed forms and bring them to your first appointment. When you arrive at our office for
Patient's Name: Date of Birth:
AUTHORIZATION TO USE AND/OR DISCLOSE HEALTH INFORMATION Fresno Children s Pediatrics 7720 N Fresno Street, Ste #104, Fresno, CA 93720 Phone: (559) 438-2300 Fax: (559) 438-1531 Patient's Name: Date of Birth:
Welcome To. Concord Pediatric Dentistry. First Middle Last. Street City State Zip. Dental Insurance Information
Welcome To Concord Pediatric Dentistry Patient Information Patient s Name: First Middle Last Name child goes by: Sex: Mailing Address Street City State Zip Date of Birth: Age: Weight: Child Lives with:
PATIENT REGISTRATION INFORMATION FOR MINORS
Today s Date: / / 620 Dr. Calvin Jones Highway, Suite 212 Please fill out and sign all registration paperwork attached. This will help us better serve you during your time at our clinic. PATIENT REGISTRATION
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,
PATIENT INFORMATION INSURANCE INFORMATION
PATIENT INFORMATION RECORD (Please Print or Write Legibly) DATE ACCT # PATIENT INFORMATION NAME First Middle Init. Last MAILING ADDRESS CITY STATE ZIP SEX RACE Ethnicity: q hispanic/latino q Not Hispanic/Latino
New Patient Information Form
PATIENT INFORMATION New Patient Information Form Patient s Patient s Preferred Name Middle Initial Date of Birth SSN# Primary Language YES NO Email Address Race/Ethnicity Is patient of Hispanic Origin?
Patient Registration Forms
Patient Registration Forms PATIENT INFORMATION First Name: Middle: Last: DOB: / / Sex: M/F Primary Language: Address: City: ST ZIP Ethnicity: Hispanic / Non-Hispanic / Unknown Race: Asian / White / African
MACRI DENTAL LLC 4380 S. Syracuse St. Suite 502 Denver, CO Patient Registration Form
Personal Information Patient Registration Form Responsible Party First Name Initial Last Name Patient First Name Initial Last Name Address City State Zip Home Phone Work Cell Birthday Social Security Email
Kalpana Thakur, M.D. PA Registration Form
Registration Form (Please Print): : Patient Information Last Name: First: Middle: of Birth: Age: Sex: M F Marital Status: Single Married Other S.S. Number Home phone: Mobile: Street Address: City: State:
Acknowledgement of Privacy Practices
To view our Notice of Privacy Practices from the link below. 31TUhttp://www.worldpediatricdental.com/wp-content/uploads/2014/11/WPD-Notice-of-Privacy-Practices.pdfU31T Acknowledgement of Privacy Practices
Workers Compensation Modifier Controllers, Inc.
Thomas Allen, Inc. Supervisor Checklists In order to establish accurate and timely procedures for reporting of workers compensation claims please follow the following list. 1. Immediately fill out the
New Patient Registration. Employer Info Occupation Employer Work Phone #
New Patient Registration Name (last, first, middle initial) DOB Address City State Zip Code Social Security # Sex (M/F) Marital Status Last Tetanus Email Address Home Phone # Cell Phone # Employer Info
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
MasterCare Physical Therapy, Inc.
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
Notice to Patients 4. COMMUNITY FIRST PATIENTS MUST PRESENT CURRENT MONTHLY SHEET AND ID CARD TO BE VERIFIED BEFORE SERVICE CAN BE PERFORMED.
Notice to Patients 1. PLEASE SIGN IN UPON ARRIVAL. PARENT OR LEGAL GUARDIAN MUST BE PRESENT. ANYONE OTHER THAN THE PARENT MUST PROVIDE DOCUMENTATION AUTHORIZING CARE OF THE PATIENT. 2. PAYMENT IS DUE AT
creating beautiful smiles
creating beautiful smiles Patient Information Serving Sanford and Central North Carolina Phone: 919-774-4744 Fax: 919-776-3531 1800 Doctors Drive Sanford, NC 27330 sanfordbraces.com We will file your insurance
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
Washington State Enrollment Form for Medical and/or Prescription Insurance for Individuals and Families
Washington State Enrollment Form for Medical and/or Prescription Insurance for Individuals and Families PLEASE PRINT IN BLACK INK AGENT/AGENCY INFORMATION Agent Name: Agent Number: Key Agency Contact:
PAYMENT AGREEMENT BROKEN APPOINTMENT INFORMATION
PAYMENT AGREEMENT BROKEN APPOINTMENT INFORMATION Thank you for choosing Purcellville Pediatric Dentistry for your dental treatment. Dr. Monajemy is committed to healthy oral hygiene. Purcellville Pediatric
Singh Family Dental Dr. P. Singh, PLLC
Singh Family Dental Dr. P. Singh, PLLC 25 Country Club Road, #301 Gilford, NH 03249 (603)524-7455 251 Mayhew Turnpike Plymouth, NH 03264 (603)536-7600 260 Route 16B Center Ossipee, NH 03814 (603)539-4995
MILLE LACS BAND OF OJIBWE
Name: Suffix: SS#: - - Last Name First Name Middle Initial DOB: Sex: M F Marital Status: Address: Single Married Divorced Never Married Separated Unknown Widow/Widower Street City State Zip County Home
Kinsler Psychology Help when life hurts
1 ADULT INTAKE HISTORY Patient Name Date Age Birthdate Birthplace Gender Male/Female Address City State Zip Social Security# Home Phone Cell Phone Work Phone Occupation: Employer: Name and number of emergency
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
MICHIGAN HEALTHCARE PROFESSIONALS, P.C.
MICHIGAN HEALTHCARE PROFESSIONALS, P.C. PATIENT NOTICE OF PRIVACY PRACTICES As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability and Accountability Act of 1996-(HIPAA),
Any recent Laboratory (blood work) results related to your visit with us. A list of your current medications with dosage and frequency taken
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.
Please be aware that this office does not do pain management and will not prescribe narcotics to new patients, nor on an ongoing basis.
Patient Information Sheet Last Name: First Name: Middle Initial: Patient Is: Policy Holder Responsible Party RESPONSIBLE PARTY Last Name: First Name: Middle Initial: Address: City, State, Zip: Home Phone:
Baldwin Counseling Payment Agreement
Baldwin Counseling Payment Agreement Baldwin Counseling believes that a clear understanding of our financial policies is important for both client and therapist. We are fully committed to helping you accomplish
Our portals are encrypted and password-protected, too, so health data remains secure.
Patient Portal Education Sheet We know you re busy. That s why Palmetto Health-USC Medical Group s physician practices are offering a way for you to manage your health care online. We offer convenient
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES 2013 Murphy Dental 608 East Harmony Road, Suite 301 Fort Collins, CO 80525
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES 2013 Notice to Patient: We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose
Background Information
Scarlet Cramer, LMFT Revised 05/06/2015 Today s Date Background Information I. Primary Client Name (If couple, family, or group, the one person who will be the identified client): First Name MI Last Name
Carolina Dental Alliance
Patient Registration First Name: Last Name: Date of Birth: SSN: Mailing Address: City State Zip Home Phone: Cell Phone: Responsible Party (ONLY COMPLETE IF SOMEONE OTHER THAN PATIENT) First Name: Last
Ellie s Army Foundation Grant Application
Assisting Children and young Adults with Critical Illnesses Ellie s Army Foundation Grant Application Please read the following carefully: Please provide all requested information and complete the application
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
FAMILY HISTORY CHILD/CHILDREN S NAME:
FAMILY HISTORY CHILD/CHILDREN S NAME: FAMILY HISTORY (THINK IN TERMS OF THE CHILD S SIBLINGS, PARENTS, GRANDPARENTS, AUNTS, UNCLES AND FIRST COUSINS): ANY ALLERGIES, HAY FEVER, ASTHMA OR ECZEMA? WHO? ANY
CREEKSIDE DENTAL REGISTRATION FORM. Please Print PATIENT INFORMATION. Patient s Last Name: First: Middle:
Today s date CREEKSIDE DENTAL REGISTRATION FORM Please Print PATIENT INFORMATION Patient s Last Name: First: Middle: Home Phone #: Work #: Cell #: Email Address: Street Address: City: State: Zip Code:
What to bring to first appointment. You must have with you any related allergy testing, lab results, CT Scan or X-ray results, biopsy
Jayanti J. Rao, M.D. Shaili N. Shah, M.D. What to bring to first appointment You must have with you any related allergy testing, lab results, CT Scan or X-ray results, biopsy results, list of current medications,
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.
Sinha Clinic Foxfield Road, Suite 240, St. Charles, IL Office: (630) Fax: (630)
2560 Foxfield Road, Suite 240, St. Charles, IL 60174 Office: (630) 762-9606 Fax: (630) 762-9605 www.sinhaclinic.com info@sinhaclinic.com Patient Name: Date: Home Phone: ( )- Cell Phone: ( )- Preferred
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
Ellie s Army Foundation
Ellie s Army Foundation Grant Application Assisting Children and young Adults with Critical Illness Ellie s Army Foundation Application for Assistance Patient Information: Please complete all of the requested
NOTICE OF PRIVACY PRACTICES
NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR
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)
Richard L. Shindell, M.D. Pediatric Orthopaedics and Scoliosis Board Certified
Richard L. Shindell, M.D. Pediatric Orthopaedics and Scoliosis Board Certified *PLEASE PROVIDE SOCIAL SECURITY NUMBERS IF YOU WOULD LIKE FOR US TO FILE A CLAIM WITH YOUR INSURANCE* PATIENT REGISTRATION
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
PATIENT REGISTRATION (Please Print) Social Security # Address City State Zip. Address
PATIENT REGISTRATION (Please Print) Date Name (Last) (First) (MI) Clinician Social Security # Address City State Zip Email Address Home Phone ( ) Mobile/Alt. Phone ( ) Work Phone ( ) PLEASE IDENTIFY WHICH
Oliver Winston Behavioral Urgent Care, LLC
Presenting Symptoms: What physical or emotional symptoms brought you here today? Current Stressors: Are there significant changes in your life which may have contributed to the symptoms which brought you
6677 W. Thunderbird F N. Hayden Rd. H-100 Glendale, Az Scottsdale, Az
Eye Physicians & Surgeons of Arizona 6677 W. Thunderbird F-101 10603 N. Hayden Rd. H-100 Glendale, Az. 85306 Scottsdale, Az. 85260 George R. Reiss, MD Shamil S. Patel, MD Vinay M. Dewan, MD Christina M.
WOMEN S PREMIER OBGYN REGISTRATION FORM
WOMEN S PREMIER OBGYN REGISTRATION FORM Today s date: PCP: PATIENT INFORMATION Patient s last name: First: Middle: q Miss q Ms. Marital status (circle one) Single / Married / Divorced / Sep / Widow Is
Today s Date: / / Social Security # Date of Birth: / / Home Address. City State Zip County of Residence. Preferred Phone # ( ) Cell Phone # ( )
Patient Registration Palmetto Digestive & Endoscopy Center 2073 Charlie Hall Blvd., Charleston, SC 29414 Phone: (843) 571-0643 Fax: (843) 571-0311 Name Today s Date: / / Social Security # Date of Birth:
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: