Dear. If you have any questions, feel free to call our office. We look forward to seeing you. Sincerely,
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- Elfrieda Barrett
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1 Dear We would like to welcome you to our office and thank you for choosing Heritage Valley Medical Group Internal Medicine Associates. Our hours of operation are Monday through Thursday 8am-5pm, and Fridays 8am-4:30pm. We now offer walk-in hours from 3-5pm Mondays and Wednesdays at our Ambridge location and From 3pm-5pm Tuesdays and Thursdays at our Sewickley location for minor illnesses. Enclosed you will find a patient registration form and a medical history form to complete prior to your appointment. Please bring the completed forms with you to your appointment, which is scheduled for: Heritage Valley Medical Group Internal Medicine Associates 1155 Merchant Street Ambridge, PA Hazel Lane St. 100 Sewickley, PA We ask that you arrive at our office at least 15 minutes before your appointment time so that we may make a copy of your insurance card and review your completed new patient form. Also, if you are taking any medications on a regular basis, please bring a list of these medications. In addition, if you have copies of your previous medical records, please being them with you, or contact your former physician and have them sent prior to your appointment, if possible. If you have any questions, feel free to call our office. We look forward to seeing you. Sincerely, Heritage Valley Medical Group/Internal Medicine Associates
2 Your personal health information is available to you online. Before your appointment become a member of Health Link in order to securely view your health information online. You should receive an from FollowMyHealth. Securely review your health information (allergies, medications, conditions, etc.) View lab results and read summaries from physician office, Convenient Care visits Request prescription renewals Send your physician secure messages To login to Health Link, go to: For help with Health Link, contact: healthlink@hvhs.org or
3 IMPORTANT NOTICE 01/ PLEASE ARRIVE ATLEAST 15 MINUTES PRIOR TO YOUR APPOINTMENT TIME. IF YOU ARE LATE TO YOUR APPOINTMENT YOU MAY BE ASKED TO RESCHEDULE. 2. YOU MUST SHOW YOUR INSURANCE CARD AT EACH VISIT. IF A PCP IS LISTED ON YOUR INSURANCE CARD, IT IS REQUIRED THAT YOU HAVE THE CORRECT PHYSICIAN LISTED, OR YOU MAY BE ASKED TO RESCHEDULE YOUR APPOINTMENT UNTIL THE CORRECT CARD IS RECEIVED. 3. PLEASE LET THE CHECK-IN STAFF KNOW IF THERE HAS BEEN A CHANGE IN YOUR ADDRESS OR PHONE NUMBER. 4. IF YOU HAVE A COPAY, YOUR INSURANCE COMPANY REQUIRES YOU TO PAY AT THE TIME OF YOUR VISIT. 5. IF YOU DO NOT HAVE INSURANCE, YOU WILL BE REQUIRED TO PAY AT THE TIME OF YOUR VISIT. 6. MEDICATIONS: WITH EACH APPOINTMENT BRING A LIST OF ALL THE MEDICATIONS THAT YOU ARE TAKING INCLUDING OVER THE COUNTER MEDICATION. 7. REFERRALS REQUIRE 5 7 DAYS NOTICE. IF YOU CALL THIS OFFICE THE SAME DAY AS YOUR APPOINTMENT TO SEE THE SPECIALIST, WE CANNOT GUARANTEE THAT YOUR INSURANCE WILL COVER YOUR VISIT. 8. DUE TO THE CHANGES IN YOUR INSURANCE, IT IS THE PATIENT RESPONSIBILITY TO KNOW WHERE TO GO FOR BLOOD WORK, X-RAYS AND ALL DIAGNOSTIC TESTS. THIS OFFICE CANNOT BE HELD RESPONSIBLE FOR ANY BILL THAT THE PATIENT RECIEVES FOR HAVING SERVICES AT THE WRONG LOCATION. 9. CONFIRMATION CALLS ARE DONE 24 HRS PRIOR TO YOUR APPOINTMENT. YOU MUST CONFIRM YOUR APPOINTMENT. IF YOU ARE UNABLE TO CONFIRM AT THE TIME THE CALL IS PLACED, YOU MUST CALL US DURING BUSINESS HOURS AT BETWEEN 8AM-4:30PM AT YOU MAY NOT BE SEEN WITHOUT CONFIRMING YOUR APPOINTMENT 10. IF YOU DO NOT SHOW FOR AN APPOINTMENT OR DO NOT CANCEL 24 HOURS PRIOR TO YOUR APPOINTMENT YOU WILL BE CHARGED A $25 FEE.
4 HERITAGE VALLEY MEDICAL GROUP PATIENT INFORMATION Date Referring Dr. Social Security # Patient Name Date of Birth Last First Middle Address City State Zip Home Phone # ( ) Day Phone # ( ) Cell Phone # ( ) F Full Time R - Retired Sex Race Ethnicity Occupation P Part Time N Not Employed S Single D Divorced F Full Time Marital Status M Married W Widowed L Legally Separated Student Status P Part Time N Not A Student Employer Employer Phone # Employer Address City State Zip *HEALTH LINK Please provide us with a current address to securely view your results and health information online Address SPOUSE OR PARENT (please complete even if spouse/parent is uninsured) Name Relationship to Patient Address City State Zip (only if different from Patient) Check here if the address is the same as patient s I authorize payment of insurance benefits to Sewickley Valley Medical Group Sign Here I also authorize release of any medical records As necessary to (Please CIRCLE OPTION AND PRINT name) Sign Here Myself Spouse Other Please provide us with a family contact and phone Number in the event we are unable to reach you DO YOU HAVE A LIVING WILL OR AN ADVANCED DIRECTIVE YES NO
5
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PATIENT UPDATE FORM In an effort to have the most up to date information, we ask that this form be completed annually. DATE: CHART: Social Security Number Date of Birth NAME First, Middle, Last MAILING
Today s date: PATIENT INFORMATION. Address:
Today s date: PATIENT INFORMATION Patient s last name: First: Middle: Please send appointment reminders to: Mobile phone #: Email Address: Mr. Mrs. Registration and Medical History Marital status Single
PALMETTO PULMONARY MEDICINE, P.A.
Peter N Manos, MD FCCP Denise Mercier, PA-C Board Certified: Internal Medicine Pulmonary Disease Critical Care Medicine Sleep Medicine 989 Ribaut Road, Suite 340 Beaufort, SC 29902 (843)-521-8484 Fax (843)
Your appointment with our office is scheduled on
Grand Rapids OB/GYN Dr Stephen C Dalm Nisha McKenzie PA-C Erin Walker PA-C 5060 Cascade Rd SE Ste C Grand Rapids, MI 49546 Phone (616)247-1700 Fax (616)247-3679 www.grandrapidsobgyn.com Welcome to Grand
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
Thank you again for choosing Haymarket Chiropractic. We hope to exceed your expectations.
Dear New Patient, The Staff at Haymarket Chiropractic & Rehabilitation (HCR) and I are delighted that you have chosen our facility for your therapy. Our goal is to provide you with a premium level of care
Please arrive 15 minutes prior to your scheduled appointment time.
Miami Valley Cardiologists 122 Wyoming Street Dayton, Ohio 45409 (937) 223-4461 (937) 449-7603 Fax mvcdayton.com Dear Patient: Please complete the enclosed forms in full prior to your appointment. Bring
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