THE WOODLANDS FAMILY MEDICINE GHPMA
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1 THE WOODLANDS FAMILY MEDICINE GHPMA PATIENT INFORMATION NAME: SEX: [M] [F] ADDRESS: CITY: STATE: DATE OF BIRTH: ZIP: SS#: HOME PHONE: CELL PHONE: WORK PHONE: MARITAL STATUS: [ ] MARRIED [ ] SINGLE ADDRESS: EMERGENCY CONTACT (PLEASE LIST RELATION) PREFERRED PHARMACY: NAME: NAME: NAME: PHONE: PHONE: PHONE: RESPONSIBLE PARTY (COMPLETE IF RESPONSIBLE PARTY IS OTHER THAN THE INSURED OR PATIENT) NAME: DATE OF BIRTH: ADDRESS: CITY/STATE/ZIP: SS#: PRIMARY INSURANCE NAME OF INSURED: INSURANCE COMPANY: INSURANCE PHONE: INSURED DATE OF BIRTH: RELATION TO PATIENT: ID: GROUP: SS#: SECONDARY INSURANCE (IF APPLICABLE) NAME OF INSURED: INSURANCE COMPANY: INSURANCE PHONE: INSURED DATE OF BIRTH: RELATION TO PATIENT: ID: GROUP: I UNDERSTAND THAT THIS FORM MUST BE COMPLETED IN ITS ENTIRETY. I UNDERSTAND THAT IF ALL OF THE ABOVE INFORMATION IS NOT COMPLETED, A CLAIM MAY NOT BE ABLE TO BE FILED TO MY INSURANCE COMPANY; THEREFORE, MAKING ME FULLY RESPONSIBLE FOR ANY CHARGES INCURRED. PATIENT/RESPONSIBLE PARTY SIGNATURE: DATE:
2 Patient History Form Patient name: Date: Medications Please list all medications that you're currently taking, prescription and nonprescription, and their dosage: Medication Dose Allergies Are you allergic to any medications? YES NO If yes, please list the name of the medication the type of reaction: Are you allergic to any foods? YES NO If yes, please list: Past Medical History Please indicate if you have ever experienced any of the following conditions: Alcohol dependence Headache Allergies Heart attack Anemia High blood pressure Angina High cholesterol Anxiety Irregular heartbeat Arthritis Insomnia Asthma Irritable bowel syndrome Blood clots Hepatitis Broken bones Kidney stones Cancer Liver disease Type: Low blood pressure Chronic blood thinner use Migraines Chronic bronchitis Osteoporosis Chronic sinusitis Palpitations Congestive heart failure Seizure/epilepsy COPD/emphysema Sleep apnea Depression Stomach ulcer Diabetes type I Stroke or TIA Diabetes type II Thyroid disease Esophageal reflux Tinnitus Gallbladder stones Tuberculosis Gout Other:
3 Surgical History Please check all that apply and the date of the procedure: Date Date Angioplasty / / Gastric bypass / / Angioplasty with stent / / Hernia repair / / Appendectomy / / Hip replacement / / Back surgery / / Knee replacement / / Carpal tunnel release / / Liver biopsy / / Cataract extraction / / Pacemaker / / Colon surgery / / Thyroidectomy / / Coronary artery bypass graft / / Tonsillectomy / / Gallbladder / / Other: / / Female Surgical History Male Surgical History Please check all that apply: Please check all that apply: Date Date Breast implants / / Prostate biopsy / / Bilateral tubal ligation / / TURP (transurethral / / Breast biopsy / / resection of the prostate) Cesarean section / / Vasectomy / / D&C / / Other: / / Breast reduction / / TAH/BSO (total abdominal hysterectomy) Vaginal hysterectomy / / / / Other: / / Family History Please check if any family member has had any of the following conditions and indicate the name of the affected member, the age of onset and/or if it was the cause of death. Adopted Alcoholism Alzheimer's Heart disease Cancer Type: Depression Diabetes High blood pressure High cholesterol Kidney disease Osteoporosis Stroke Seizures Mother Father Sibling(s) Children Grandparents Cause of death
4 Social History Type of employment Previous work, if retired Marital Status Married Single Divorced Widowed Do you currently use tobacco? Yes No If yes, how many packs per day? Have you previously smoked? Yes No If yes, how many packs per day? Other tobacco units per day (dip, cigars, etc.)? Units per day? Years used? Year quit? Do you drink caffeine? Yes No Type? Amount Daily? Do you drink alcohol? Yes No Daily Weekly Monthly Amount: Religious preference (optional) Immunizations Are your immunizations current? Yes No Do you have copies of your immunization records? Yes No Pharmacy Information Do you have a preferred pharmacy? Yes No Pharmacy: Phone Number: Address: Health Maintenance Last mammogram: Last Well Woman Exam: Colonoscopy: Last lab drawn: Flu shot: Pneumonia shot: Tetanus shot: Results: Results: Results: Results: Additional Information: Are you interested in any cosmetic products or procedures to decrease aging of the skin (wrinkles, fine lines, age spots, melasma, acne etc.)? Yes No
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9 DISCLOSURE OF FINANCIAL INTEREST GHPMA PLLC, WITH WHICH YOUR PHYSICIAN HAS A FINANCIAL RELATIONSHIP, OPERATES DIAGNOSTIC/IMAGING CENTERS IN WHICH YOU CAN RECEIVE THE DIAGNOSTIC/IMAGING SERVICE(S) ORDERED FOR YOU. YOU CAN ALSO RECEIVE DIAGNOSITC SERVICE(S) AT THE FOLLOWING FACILITIES: WOODSTEAD MRI 1733 WOODSTEAD CT SUITE 100 THE WOODLANDS, TX THE WOODLANDS OPEN MRI AND IMAGING 4800 WEST PANTHER CREEK SUITE 150 THE WOODLANDS, TX OPEN MRI AND DIGITAL IMAGING 6225 FM 2920 ROAD SPRING, TX WILSON IMAGING 1011 MEDICAL PLAZA DRIVE SUITE 130 THE WOODLANDS, TX WOODLANDS IMAGING 8850 SIX PINES DRIVE SUITE 190 THE WOODLANDS, TX WE WILL BE SETTING UP THE TEST AT OUR DIAGNOSTIC CENTER HERE IN THE BUILDING. PLEASE NOTIFY US IF YOU WISH TO HAVE IT AT ANOTHER FACILITY. PATIENT/RESPONSIBLE PARTY SIGNATURE DATE
10 Brent Allmon, M.D. Woodlands Family Medicine St. Luke's Way, Suite 190 The Woodlands, Texas Phone: Fax: NEW POLICY REGARDING MISSED APPOINTMENTS Effective Jan. 1, 2014 We are dedicated to helping our patients and appreciate those who value this dedication of time, energy and service. We received many calls from patients who wish to be seen on the same day. Our schedule is often full. Last minute cancellations and no-shows adversely affect other patients. Therefore, effective Jan. 1, 2014: All no-show/missed appointments will result in a fee of $50. The same $50 fee will also apply to patients who do not give us at least a 24-hour cancellation notice. Your understanding and cooperation is appreciated. Dr. Brent Allmon, M.D. Dr. Alice Grogan, M.D. Dr. Joel Kerschenbaum, M.D. Patient signature Date
11 Prescription Refill Policy Effective 9/10/12, revised 3/15/13 Currently, our office receives a large-volume of calls and faxes daily for medication refill requests. Our office can no longer safely manage this volume of phone and fax requests. As of September 10, 2012, we have a new prescription refill policy. We understand that this is a change for both you and us. We hope to work together to ensure safe, efficient and high-quality medical care. Thank you for being our valued patient! It is typically my practice to give prescriptions with refills for 6 months at a time to coincide with six-month followup appointments for monitoring. It is very important to request your prescriptions during your routine office visits. In order to ensure that you do not run out of your medications, please make sure to schedule a followup appointment at the end of each visit. If office visits are scheduled and kept on a regular basis, prescriptions are refilled at these visits, and pharmacies follow instructions on prescriptions given, then requests for refills outside of office visits should rarely occur. As of September 10, 2012, requests made for prescription refills made outside of an office visit may be subject to a fee: 1. $15.00 may be charged for 1-3 prescription refills that or not requested during an office visit 2. $25.00 may be charged for 4+ prescription refills that are not requested during an office visit. To request a refill, please leave a detailed message on our refill request voic . Please allow 2 business days for refill requests to be completed. Ways to reduce unnecessary refill requests and medication errors: 1. We do require office visits on a regular basis for all of our patients taking prescription medication. The interval for followup will vary depending on the type of medication you are prescribed. Please be sure you have enough medication to last until your next scheduled visit. 2. Before you come to your regular appointment, you should look over your medications, diabetic supplies, inhalers etc. to determine if you need to request any new prescriptions at your appointment. 3. Please bring all of your prescription bottles with you to your appointment. This is important to make sure that you're taking the correct medications in the correct dosages. We will to take the time to carefully review your medications and write for refills at your office visit. 4. It is your responsibility to schedule a followup appointment before you run out of your medication. We recommend you schedule your next visit before you leave our office. 5. If you are changing pharmacies, you can usually have your new pharmacy request prescriptions be transferred from your old pharmacy.
12 Auto-Renewal, Auto-Fax, Readyfill etc. Most of the requests for refills that we receive are generated automatically from the pharmacy without the patient's knowledge. "Auto-renewal" or "Auto-Fax" programs with most pharmacies are at fault for most of these requests. As of March 15, 2013, we will no longer respond to refill requests that are faxed from the pharmacy. If you are in need of a refill we expect you to contact us directly and leave a detailed message on our Refill Request Voic . Reasoning: From my research, the main benefit for "auto renewal" is for the pharmacy. This generates a constant stream of cash flow for pharmacies and often does not benefit the patient. It is my experience that when we receive "Auto-renewal" refill requests from the pharmacy, the patient usually still has medication and is not actually in need of refill. In many cases, the pharmacy is requesting a refill on behalf of the patient without their knowledge and may be billing insurance for the medication regardless of whether the prescription was picked up by the patient. Refilling prescriptions without a patient's approval raises the possibility of insurance fraud, state officials say. According to the L.A. Times, one national pharmacy chain is under federal investigation for this very reason. Auto Renewal also increases chance for medication errors. Consider this common example: In the past few weeks we heard from a patient utilizing the automatic refill system who picked up three prescriptions but later called the pharmacy to report he had picked up a blood pressure pill called Norvasc, which his doctor had previously discontinued. Fortunately, he hadn t yet taken any. In another case a patient s Cardizem, a heart medication, was increased from 240 mg to 360 mg. The elderly gentleman purchased the new prescription for diltiazem 360 mg but also received the diltiazem 240 mg prescription that had been filled earlier through the automatic refill program. After receiving a call from the confused patient, the pharmacist contacted the patient s doctor to determine which strength the patient should be receiving. Had the patient accidentally taken both strengths of Cardizem, it could have caused serious heart or blood pressure complications. Acknowledgement of Receipt: Patient Signature Date
13 WOODLANDS FAMILY MEDICINE FINANCIAL POLICY We require all patients to pay at time of service by credit card on file. You will be charged at every visit for any outstanding deductible, co-insurance or copay due, as well as any fees for services not covered by your insurance plan. Your Plan What You Do What We Do Medicare Pay your deductible ($147 for 2014) and coinsurance We will file Medicare for you. (20% of the allowable.) If you request any services that Medicare does not cover, you agree in writing to pay our regular fee for those services. Medicare + Secondary Insurance No payment due at time of service. We will file Medicare and your secondary insurance for you. Commercial Insurance Pay your deductible, co-insurance or co-pay at time We will file your insurance for you. of service. Insurance we are not contracted with Pay the visit in full at time of service. We will provide a receipt for your services for you to file with your insurance for reimbursement. Health Savings Account (HSA) Your HSA credit card may be used We will file your insurance and if the amount due is not paid, you may use your HSA. Additional Charges: No Show/Cancellation < 24hrs: $50 Completion of Forms: $25 to $50, based on time Out of office prescription refills: $15 to $25 Prior Authorization for medication (if required by your insurance): $25
14 FINANCIAL POLICY FOR WOODLANDS FAMILY MEDICINE AGREEMENT TO PAYMENT POLICY I acknowledge that I received a copy of Woodlands Family Medicine financial policy and agree to the terms of payment due. ASSIGNMENT OF BENEFITS I hereby request that payment of authorized Medicare, Medicaid and all other insurance benefits be made on my behalf to Woodlands Family Medicine/GHPMA for any services provided to me and/or my dependents. I authorize any holder of medical information about me and/or my dependents to release to the appropriate entity and its agents any information needed to determine these benefits payable for related services. GUARANTEE OF PAYMENT If my insurance has a contract with Woodlands Family Medicine/GHPMA I am not responsible for amounts that have been agreed to write-off. Otherwise, I agree that I am responsible for services provided that are not paid by my insurance. If my insurance does not have a contract with Woodlands Family Medicine/GHPMA, I agree to be responsible for any services provided. In the event that I default on payment of my account, I understand I am responsible for any and all costs incurred on the collection of my account, including court costs and reasonable attorney s fee. If the debt is assigned to a third party collection agency, I agree to be responsible for collection fees and interest due to amounts in default. Failure to pay any outstanding debt may be considered cause for dismissal from Woodlands Family Medicine/GHPMA. Patient s Name Printed Patient s Signature Responsible Party Signature Patient s Date of Birth Date Relationship to Patient
THE WOODLANDS FAMILY MEDICINE GHPMA
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Total Care Family Practice 1701 N Green Valley Pkwy Bldg 5-C Evan C. Allen, MD Henderson, NV PH: (702) Fax: (702)
Demographics Last : First : What would you like to be called: Marital Status: Single Married Other Gender: Male Female DOB: Social Security: Email: Address: City: State: Zip Code: Home Ph: Cell Ph: Employment
PATIENT INFORMATION & PREFERENCES (Please print or type) YOUR MAJOR HEALTH CONCERNS OR QUESTIONS
Dear Patient: The following questions are designed to collect important information about you and your health. Answering these questions before your office visit will allow more time for a detailed discussion
AUBURN URGENT CARE. Patient Information. Name: Last First Middle. Permanent Address: Apt #: Zip: City: State: Employer: Phone: ( )
AUBURN URGENT CARE Patient Information Name: Last First Middle Date of Birth: / / Social Security: Permanent Address: Apt #: Zip: City: State: Race: Gender: M F Undifferentiated Home Phone: ( ) Cell:(
PATIENT INFORMATION. Caucasian or White Male Female. Unknown IN CASE OF EMERGENCY
Name (Last, First, Middle Initial): PATIENT INFORMATION Salutation: Mr. Social Security # Preferred Language: Race: Ethnicity: American Indian or Alaska Native Hispanic or Latino Asian Not Hispanic or
HUNTSVILLE PEDIATRIC AND ADULT MEDICINE ASSOCIATES PATIENT INFORMATION
HUNTSVILLE PEDIATRIC AND ADULT MEDICINE ASSOCIATES PATIENT INFORMATION Patient s Name Sex Male Female Date of Birth Address City/State Zip Code Home Phone Cell Phone E-mail address Driver License # Marital
Patient Information. Patient Name (Last, First, Middle Initial): Local Address: City: State: Zip: Address: Home Away Address: City: State: Zip:
Patient Information Date: Patient Name (Last, First, Middle Initial): Local Address: City: State: Zip: Male Female Social Security #: Birth Date: / / Age: Local Phone: ( ) Cellular Phone: ( ) Email Address:
Would you like to receive our monthly ed newsletter? Yes! No thanks.
Phone: 540-885-4500 Fax: 540-885-4600 PATIENT DEMOGRAPHIC INFORMATION PLEASE PRINT NAME: AGE: (LAST) (FIRST) (MIDDLE) SEX: M F (CIRCLE) DATE OF BIRTH: PERSON RESPONSIBLE FOR ACCOUNT: MAILING ADDRESS: (CITY)
HOLSTON MEDICAL GROUP Multi-Specialty Physician Practice
HOLSTON MEDICAL GROUP Multi-Specialty Physician Practice 105 West Stone Drive, Suite 4-C Kingsport, TN 37660 Telephone (423) 578-1595 Facsimile (423) 578-1596 Gastroenterology Lawrence Bailey, Jr., MD
Patient Information & Health History Page 1. Date:
Patient Information & Health History Page 1 Patient Information Mr. Mrs. Ms. Dr. First Name M.I. Last Sex: Male Female Birth Date: Age Soc. Sec. # Address City State Zip Home Phone ( ) Cell Phone ( ) Email
Welcome to Bay Area Gastroenterology Associates. We look forward to caring for you. To better serve you, please complete the information below..
1 Welcome to Bay Area Gastroenterology Associates. We look forward to caring for you. To better serve you, please complete the information below.. Patient name: Marital Status: Single Married Divorce Widowed
PATIENT INFORMATION. Patient Name: Last First Middle Nickname. DOB: Sex: SSN: Marital Status: Drivers Lic #:
PATIENT INFORMATION Preferred Provider: Dr. Preferred Pharmacy: Patient Name: Last First Middle Nickname DOB: Sex: SSN: Marital Status: Drivers Lic #: Ethnicity (circle one): African American American
New Patient Information
New Patient Information Patient Title Dr. Mr. Mrs. Ms. Miss Last Name First Name M.I. Address Apt/Ste # City State Zip Date of Birth / / Age Male Female Home Phone Cell Phone Is it ok to leave a detailed
We look forward to meeting you, and will be available for you at any time. Dr. Douglas Scott, M.D. Dr. Kirk Johnson, M.D.
Welcome to Orthopedic Associates of the Lowcountry. Thank you for your confidence in allowing us to help care for your health. It is a responsibility we respect, and take very seriously. Please take the
Reason for visit today: How did you hear about us?
**Please be sure to fill out EVERY section thoroughly. Indicate N/A for sections that do not apply to you Name: Street Address: Date: City / State: Zip Code: Date of Birth: Gender: Marital Status: Occupation/Employer:
Demographic Information
Demographic Information Patient Name: Mailing Address: City: State: Zip Code: Home Phone: OK to Leave Message: Brief Extended Cell Phone: OK to Leave Message: Brief Extended Work Phone: OK to Leave Message:
PATIENT INFORMATION. Preferred Name: Age: Gender: M F TG. Responsible Guardian(s) Relationship. Billing Address if different: City State Zip
PATIENT INFORMATION Name: Last First MI Address: Street Unit# City State Zip Preferred Name: Date of Birth: _ Age: Gender: M F TG Marital Status: S P M D W Responsible Guardian(s) _ Relationship Billing
Patient Update Information
Patient Update Information Patient Name: Last First D.O.B If your info has not changed since your last visit, please sign the bottom of this page and all the consents for our yearly update! If any of the
NOWOBILSKA MEDICAL PRACTICE PATIENT REGISTRATION FORM 4201 West 95 th Street Oak Lawn, IL 60453
NOWOBILSKA MEDICAL PRACTICE PATIENT REGISTRATION FORM 4201 West 95 th Street Oak Lawn, IL 60453 Please Print: Patient Name. First MI Last Address: City: State: Zip: Home Phone: Work Phone: Cell: Email
CROSSROADS HEALTH CLINIC Thank you for choosing us as your Health Care Provider.
PATIENT INFORMATION First Name: Middle Initial: Last Name: Mailing Address: Street Address: City: County: State: Zip: Phone #: Work: Ext: Would you like us to text you? Yes No Cell #: Driver s License
Your appointment is scheduled for at am/pm with
Dear Patient: Enclosed in the letter you will find our new patient paperwork. We ask that you complete the paperwork prior to your appointment and either return it to us in the mail, fax it to us or bring
Referring Physician: Primary Care Physician: Other Physician(s)/Specialty: EMERGENCY CONTACT INFORMATION INSURANCE INFORMATION
PATIENT INFORMATION Name: Date of Birth: Sex: Male Status: Single Married Divorced Widowed Other 502 Elm Street NE Language: Female Race: American Indian or Alaska Native Native Hawaiian or Or Pacific
Office Location and Directions
Office Location and Directions Our office is located at 395 Commercial Court, Suite E, Venice, FL 34292 off Jacaranda near I-75, exit # 193. Turn at traffic light with Hess gas station and McDonald's on
Marital Status: Single Married Divorced Widowed SSN: Husband s SSN: Husband s Employer: Phone: ( ) Emergency Contact: Relationship: Phone: ( )
PARKWEST GYNECOLOGY, P.C. 9330 Parkwest Blvd., Suite 302 Knoxville, TN 37923 (865) 531-5878 PATIENT REGISTRATION FORM Please complete form using your legal name as it appears on your social security card.
You will need to bring all of your insurance cards and a photo ID. If you have seen another doctor in the past, please bring in your records.
Welcome to AMELI DADOURIAN HEART CENTER Enclosed you will find a patient profile packet. Please complete these forms and bring them with you to your appointment. Please do not e-mail your forms to us.
Sammy Lerma III, M.D. P.A. History and Physical Name: DOB: Age:
History and Physical Name: DOB: Age: Reason for Visit : Current Medications: Previous Hospitalizations: Last Physician's Name: Previous Surgeries: Reason for Changing Physicians: Current Specialists: Medication
PATIENT INFORMATION:
ALLISON SHIGEZAWA MD PATIENT REGISTRATION Today s Date: PATIENT INFORMATION: Patient Name: Patient Street Address Apartment City State Zip Code Home Telephone Number: Sex: Female Male Work: Cell Number:
COLLAR CITY PODIATRY
Richard Altwerger, DPM COLLAR CITY PODIATRY PATIENT INFORMATION FORM Timothy Fauler, DPM Name: Email PATIENT INFORMATION Date of Birth: Sex: M F Marital Status: City: State: Zip: Home Phone: Cell Phone:
Female Patient Questionnaire & History
Female Patient Questionnaire & History Name: Today s Date: (Last) (First) (Middle) Date of Birth: Age: Occupation: Home Address: City: State: Zip: E-Mail Address: May we contact you via E-Mail? ( ) YES
Winter Park Colon & Rectal Specialists, LLC JACQUELINE L. KAISER, MD 255 N. Lakemont Ave #100 Winter Park, FL 32792
JACQUELINE L. KAISER, MD 255 N. Lakemont Ave #100 DATE: PLEASE PRINT NAME: Last First MI GENDER: M F DATE OF BIRTH: AGE: SSN: _ MARITAL STATUS: Single Married Widowed Divorced Separated RACE: White Black
PATIENT REGISTRATION. (Please do not leave any field blank; if something does not apply, write N/A. If unknown, write unknown )
PATIENT REGISTRATION (Please do not leave any field blank; if something does not apply, write N/A. If unknown, write unknown ) Patient First Name/Last Name: Date of Birth/Age: MALE / FEMALE (Circle one)
Bellingham Arthritis & Rheumatology Center. 470 Birchwood Avenue, Suite C, Bellingham, WA (P) (F)
Bellingham Arthritis & Rheumatology Center 470 Birchwood Avenue, Suite C, Bellingham, WA 98225 (P) 360-734-5754 (F) 360-734-0586 Patient Name SSN Last First M.I. Date of Birth Age Sex: Male Female Address
REGISTRATION FORM (Please Print)
REGISTRATION FORM (Please Print) Today s date: Primary Care Physician: PATIENT INFORMATION Patient s last name: First: Middle: q Mr. q Mrs. q Miss q Ms. Marital status (circle one) Single / Mar / Div /
NEW PATIENT INFORMATION
NEW PATIENT INFORMATION GENERAL PATIENT INFORMATION (Please Print) Patient Name: of Birth: Sex: Male Female Marital Status: Single Married Divorced Other Street Address: Home Phone: City/State: Zip: Cell
If you have any questions about this payment method, do not hesitate to ask. Visa MasterCard American Express Discover Other:
To Our Patients: As you know if you have ever checked into a hotel or rental car, the first thing you are asked for is a credit card, which is imprinted and later used to pay your bill. This is an advantage
Medicare Patient Registration
Medicare Patient Registration Name: Jr Sr Dr First Middle Last SS#: - - DOB: / / Sex: M F Primary Language: Race: Hispanic Non-Hispanic Decline E-Mail address: Is it okay to email you about upcoming cosmetic
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: