Agnes Kinra, M.D., P.A West 15 th Street Suite 101 Plano, Texas Office: Fax:
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1 Agnes Kinra, M.D., P.A West 15 th Street Suite 101 Plano, Texas Office: Fax: Dear Patient: Thank you for making an appointment with us. Please arrive 15 minutes before your appointment time so that we will have time to create your patient file. The office is located on the south side of 15 th Street between Coit and Plano Parkway, just west of the Plano Transit Center. We are in a white two-story building marked Please complete the new patient registration forms prior to coming in for your appointment. You must present your current insurance card (with mailing address, ID number and group number). If time allows, please mail the completed forms back to the office at least FIVE days prior to your scheduled appointment. If you know that your insurance plan includes Wellness Benefits, YOU must inform the doctor during your visit. You may have to contact your Member Services department to obtain this information. For morning appointments ONLY: You will need to come in fasting for 12 hours. You may have as much water, BLACK coffee, or tea (no sweetener) as you like. If your insurance information is not available, you will be responsible for the entire bill at the time of service. Payment can only be made with a CHECK, CASH, MasterCard or Visa. If you need to cancel or reschedule this appointment, please notify us at least 48 hours in advance. We look forward to meeting you.
2 Patient Registration Name: Age: Birthdate: Address: City, State: Zip: Home Phone: Work Phone: Mobile Phone: SSN: Medicare #: Employer: Occupation: Bus. Address: City, State: Zip: Driver s License #: State: Marital Status: Emergency contact: Emergency contact phone: Referred by: Insurance Information Insured s name: Insured s employer: Birthdate: Insurance carrier: Group #: ID#: PPO? YES NO Insurance company address: City: State: Zip: Secondary Insurance Information If None, Check Here: Insured s name: Insured s employer: Birthdate: Insurance carrier: Group #: ID#: PPO? YES NO Insurance company address: City: State: Zip:
3 PAYMENT POLICY Agnes K. Kinra, M.D., P.A West 15th Street Suite 101 Plano, Texas We hope to provide you with quality and affordable care for your internal medicine needs. We hope that this payment policy will answer your questions regarding patient and insurance responsibilities for services rendered in our office. Please read it carefully, ask any questions you may have, and sign as an agreement in the space provided. Method of Payment. Our practice accepts checks, cash, Master Card, and Visa. Insurance. We participate in most insurance plans and Medicare, Humana Medicare, and Aetna Medicare. We do not accept Medicaid. If our practice is not contracted with your insurance plan, payment in full is expected at each visit. If you are insured by a plan with which we do business, but you do not have an up-to-date insurance card, you MUST have the insurance companies name, group number, type of plan (PPO, POS, HMO), the claims address, and your co-payment amount, otherwise, payment in full for each visit is required until you can update your coverage. KNOWING and PROVIDING YOUR INSURANCE BENEFITS IS YOUR RESPONSIBILITY. Please contact your insurance company with any questions you may have regarding your coverage, including whether or not you have well or preventive coverage. Please allow your insurance carrier 45 days to process your claim. Co-payments and deductibles. All co-payments must be paid at the time of service. This arrangement is part of your contract with your insurance company. Your insurance company considers it fraud if we fail to collect co-payments from its members. Please help us abide by the law in paying your co-payment at each visit. Non-covered services. Please be aware that some, and perhaps all, of the services you receive may be non-covered or not considered necessary by Medicare or other insurance companies. You must pay for these services in full after your insurance company makes their determination. Due to the contract language between physician and insurance company, you must understand that you are financially responsibility for all charges deemed to be noncovered benefits by your insurance even if the insurance s Explanation of Benefits states the procedure is a non-covered benefit and patient is not responsible. Proof of Insurance. All patients must complete our patient information before seeing the doctor. We must obtain a copy of your driver s license and current valid insurance card to provide proof of insurance. The patient information form and copy of valid insurance card may need to be completed again upon change of that information, but no less than every twelve months. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the full payment of a claim.
4 Claims submission. We will submit your primary claim and your secondary claim. Due to increasing administrative costs, we will not submit third and fourth insurance claims. We will assist you in any reasonable way we can to help you get your claims paid, but your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Your insurance benefit is a contract between you and your insurance company; we are not a party to that contract. Please understand that the balance of your claim is your responsibility whether or not your insurance pays your claim. Coverage changes: If your insurance changes, please notify us before or at your next visit, so we can update your insurance information to help you receive your maximum benefits. If your insurance company does not pay your claim within 45 days, the balance will automatically be billed to you for prompt payment. Self-Pay Patients. If you do not have insurance coverage, full payment is expected at the time of service. We offer a 20% discount to those patients who pay IN FULL at the time of service. Nonpayment. If your account is over 90 days past due, you will be expected to pay the past due balance in full within 21 days. Partial payments will not be accepted unless approved by the office manager. Be aware that if a balance remains unpaid, we may refer your account to a collection agency and you may be discharged as a patient from this practice. If this is to occur, you will be notified by regular and/or certified mail that you have 30 days to find another physician. During that 30-day period, our physician will only be able to treat you on an emergency basis. MISSED APPOINTMENTS. Our practice reserves the right to charge $25.00 for missed appointments not cancelled at least 24 hours in advance. These charges will be your responsibility and billed directly to you. Please help us to better serve you by being on time for your scheduled appointments. Thank you for reviewing our payment policy. Please let us know if you have any questions or concerns. Our practice is committed to providing the best treatment for our patients. Our prices are representative of the reasonable and customary charges for our area. Patient/Legal Guardian Signature Date Print Name
5 History Update: Please let us know of any changes in the following areas since last year: (New patients- Please fill out completely) Name Age Preferred Contact: Home Phone, Cell Phone Marital Status: (Circle) Married Divorced Single Widowed Legally Separated Other Pharmacy Name: Intersection or Phone Number: Smoking History: (Circle ONE) Never Smoked Former Smoker, Quit Date Current Daily Smoker Occasional Smoker Family Medical History: CIRCLE any positives and put approximate age of onset Mother: Alive, age Died, age, Hypertension High Cholesterol Diabetes Heart Attack Coronary Disease Stroke Alzheimer s Depression Cancer Type Thyroid Problems Tobacco use: Yes No Other Problems Father: Alive, age Died, age, Hypertension High Cholesterol Diabetes Heart Attack Coronary Disease Stroke Alzheimer s Depression Cancer Type Thyroid Problems Tobacco use: Yes No Other Problems Health Problems In the Family?* *Maternal Grandparents *Paternal Grandparents *Aunt/Uncles *Brothers/Sisters Any Drug allergies? Please list the type of reaction also: Please list names and dosages of all PRESCRIPTION drugs you take: Please list all SUPPLEMENTS and over the counter drugs you take: Have you had any of the following? If so, when? Colonoscopy Eye Exam Tetanus TDap Pneumonia Vaccine Flu Shot Zostavax Hep B Series Hep A Series Gardasil Series Hepatitis C Screening Women Only: Mammogram Pap Smear Bone Density Number of Pregnancies Number of Live Births Menopausal?
6 Since your last yearly check-up have you had any hospitalizations, serious illness, or surgeries? Please circle/ comment if you are experiencing any of the following symptoms recently: Fatigue Weight Loss or Gain Headache Dizziness/Light Headed Vision Changes Depression/Anxiety Insomnia Daytime Sleepiness Substance Abuse Concern Allergy Symptoms Chest Pains/Palpitations Shortness of Breath or Wheeze Cough Heart Burn Gas/Bloating Diarrhea/ Constipation Urinary Symptoms Sexual Problems Back or Neck Ache Joint Ache Edema/ Swelling at ankles Numbness/Burning Any other concerns about your health? Describe your current exercise level and frequency Describe alcohol use: None Rare Socially/Occasionally Daily (Amount/Type) If there a history of prior abuse of alcohol abuse, how many years sober? Any dietary questions/ concerns/ problems you are having? (Office use): BP HR R T Ht Wt
7 New Patients Only Main reason for your visit today Please list all current and past Medical Problems that you have had, how long you have had them, or when they occurred: Please list all Surgeries and the approximate date:
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LEGAL NOTICE/DISCLAIMER The information contained in this document does not establish a standard of care, nor does it constitute legal advice. The information is for general informational purposes only
CROWNVIEW MEDICAL GROUP, INCORPORATED
PATIENT REGISTRATION FORM LAST NAME FIRST NAME MIDDLE INITIAL Mothers name if minor Patient Fathers name if minor patient ADDRESS CITY STATE ZIP DOB SOCIAL SECUIRTY NUMBER - - MARITAL STATUS (S M D W)
Your appointment at Dry Eye Institutes of America is scheduled on, at am/pm at our Grapevine location.
Dear New Patient, Thank you for choosing Dry Eye Institutes of America. We strongly believe in a TEAM approach to patient care and our team is committed to providing a smooth patient experience. Our holistic
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New Patient Mobility Intake Form NAME: DATE OF BIRTH: Address City State Zip Code Phone Gender Male Female Height Weight Social Security Number Email address Primary Insurance Group # -- Secondary Insurance
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3055 SOUTHWESTERN BLVD. 3500 SHERIDAN DR. ORCHARD PARK, NY 14227 AMHERST, NY 14226 (716) 675 2500 (716) 204 4263 PATIENT INFORMATION (Please Print) Today s Date: / / Name Date of Birth / / First M.I. Last
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NORTH TEXAS ARRHYTHMIA ASSOCIATES, PA
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Gentle Family & Cosmetic Care. Raj Zanzi, DMD WELCOME. Insiya Zanzi, DDS
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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)
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One Stop Medical Center Tel:
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Chiropractic Case History/Patient Information
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PATIENT HISTORY FORM. DOB: Age: Male Female Marital Status. Address: Preferred Method of Contact: Home Cell Work Text
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NORTHSIDE PRIMARY CARE
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VASCULAR HEART & LUNG ASSOCIATES
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