550 Pharr Rd NE, Suite 605 Atlanta, GA Office Fax pathgroupatl.com
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1 550 Pharr Rd NE, Suite 605 Atlanta, GA Office Fax pathgroupatl.com ADULT PATIENT REGISTRATION INFORMATION AND GUARANTOR AGREEMENT Which Provider are you seeing today? Smitha Bhandari, MD Elana Zimand, PhD Karla Viera Negron, MD Jeremy Salzman, PsyD PATIENT INFORMATION Patient Name Age (First) (Middle) (Last) Date of Birth Gender: M F Marital Status Street Address City/State/Zip Cell Phone Home/Work Phone (please circle one) Referred by Family Physician Phone number Pharmacy Name and Phone Number Emergency Contact (Name) (Phone) (Relationship) Employer Name Employer Address Employer Phone (Conĕnued on reverse) Revised May 2016
2 Medication History Medication Allergies Current Medications (name/dosage/frequency): FINANCIAL GUARANTOR INFORMATION (IF NOT PATIENT) Guarantor Name (First) (Middle) (Last) Relationship to Patient Street Address (Leave Blank If Same As Patient) City/State/Zip Cell Phone Home/Work Phone (please circle one) CONSENT FOR TREATMENT I hereby agree to be treated by physicians or mental health providers associated with PATH Group of Atlanta, LLC. I authorize PATH Group of Atlanta, LLC to provide information to any physician or therapist who referred me to Path Group of Atlanta, LLC. I, the undersigned, agree that I am financially responsible for all services provided by PATH Group of Atlanta, LLC. I am aware that office policy requires payments be made at time of service. I understand that unpaid balances over 30 days may incur a 3% late fee per month of the outstanding balance. I have read the policies and understand and agree to them. Patient Signature Date Print Patient Name Date Financial Guarantor Signature Date Revised May 2016
3 550 Pharr Rd NE, Suite 605 Atlanta, GA Office Fax OFFICE POLICIES OFFICE HOURS AND EMERGENCY INFORMATION Office hours are Monday through Friday, 9 am to 5 pm. If you have a medical emergency, please call 911 or go to your local emergency room. If you have an urgent question after normal business hours, please call Dr. Bhandari at or Dr. Karla Viera at Otherwise, all routine calls will be answered by the following business day. PAYMENT POLICY All patients are required to pay the session fee in full at the time services are rendered. We accept checks, cash and credit cards. We kindly request that you provide your credit card at each visit. APPOINTMENT CHANGES/CANCELLATIONS Your appointment times are reserved and if you cancel an appointment with less than 24 hours notice, you will be charged the full fee. After hours, you may leave notice of cancellation on our voic service. If for any reason the doctor must cancel an appointment with you, all efforts will be made to notify you as soon as possible. OFFICE PHONE POLICY Please be aware that our doctors are meeting with patients throughout the day and may not be able to return your phone call until a later time. When leaving a message for your doctor, please leave both daytime and evening telephone numbers. Please note that this is for brief phone calls only and you must schedule a phone appointment for extensive calls. EXTENSIVE PHONE CALL POLICY For longer phone calls, you may call the office and schedule a phone appointment with your doctor. There will be a routine charge for phone appointments based on the length of call. Please note that there may be an additional charge for after hour calls, except for life threatening emergencies. Page 1 of 3 Rev 04/16
4 Fees for Extensive Phone Calls (charges may vary with each doctor) minutes $50 MEDICAL INSURANCE POLICY Our providers do not contract with any insurance companies. However, if your insurance company provides out of network benefits, you may file your own claims for reimbursement. We must inform Medicare, Tri Care and Medicaid patients that we have opted out of these plans. Therefore, patients with the insurance coverages stated above are not permitted to submit claims from our practice to these insurance providers for reimbursement. MEDICATION REFILL POLICY We make every effort during your appointment to provide enough medication to reach your next appointment. However, we are aware that emergencies may arise and appointments may have to be rescheduled for a later date. Medications refills may be requested during regular office hours by calling the office. We will complete medication requests within hours from the time of the request. If requesting a stimulant (controlled medication), please call the office for more information. Stimulant medications require a prescription in hand which may be picked up at the office or mailed to your address. There may be a charge of $10 $25 for all refill request when patients are due for an appointment. Prescriptions may only be called in for current patients who maintain their regularly scheduled appointments. We encourage patients to pay close attention to your medication supply to ensure that we have enough time to complete each medication request. REQUEST FOR FORMS OR LETTERS POLICY Any requests for forms to be completed or letters to be written on your behalf are subject to a $25 to $50 preparation fee. TERMINATION OF TREATMENT You are under no obligation to continue services and may opt to terminate treatment. Should you decide to discontinue treatment, we strongly urge you to notify the doctor of your decision so that it may be discussed openly. FINANCIAL GUARANTOR AGREEMENT This agreement will remain in effect until written notice of alternate payment arrangements are provided to PATH Group of Atlanta, LLC. The current Guarantor is responsible for any and all charges incurred prior to receipt of notification of other arrangements. If you wish to change Guarantors, please have the newly appointed Guarantor complete a separate Guarantor Agreement with PATH Group of Atlanta, LLC. PLEASE RETAIN THIS PAGE FOR YOUR RECORDS AND RETURN THE SIGNATURE PAGE TO THE OFFICE. Page 2 of 3 Rev 04/16
5 PATIENT NAME NOTICE OF PRIVACY POLICIES I acknowledge that I have read and agreed to, and was offered a copy of the Notice of Privacy Practices for the PATH Group of Atlanta, LLC. If you would like to take home a copy of our Notice of Privacy Practices, please check here: I hereby acknowledge that I have read and agree to the office policies of PATH Group of Atlanta, LLC. Patient Signature (Parent if patient is a minor) Date Print Name Financial Guarantor Signature Date Financial Guarantor Name (please print) PLEASE RETURN THIS PAGE TO THE OFFICE AND RETAIN THE OFFICE POLICIES PAGE FOR YOUR RECORDS. Page 3 of 3 Rev 04/16
550 Pharr Rd NE, Suite 605 Atlanta, GA Office Fax
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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
Review of Systems (Please check all that apply)
Patient Name Birthdate Review of Systems (Please check all that apply) Constitutional Respiratory Skin Fever/chills Cough Rash Excess weight loss/gain Wheezing Diaper rash Loss of appetite Chest tightness
PATIENT INFORMATION Date Patient last name Patient first name Patient middle name. Primary Address City State Zip. Alternate Address City State Zip
Clinic Name: The Mollen Clinic Physician/Provider being seen today: Arthur Mollen, DO, Martin Mollen, MD, Melvin Bottner, MD, Monika Sajecki, PA, Kaitlin Kramer, PA PATIENT INFORMATION Date Patient last
Allergies None Penicillin Sulfa Drugs Codeine Aspirin Tape Latex Iodine-Shellfish. Other allergies: Medications
Today s Date: Height Weight Shoe size (CIRCLE) Allergies None Penicillin Sulfa Drugs Codeine Aspirin Tape Latex Iodine-Shellfish Other allergies: Medications SOCIAL HISTORY (CIRCLE) Do you smoke? No Yes
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
Catherine A. Casteel, DPM 7501 Lakeview Parkway, Ste. 135 Rowlett, TX Phone Fax
Catherine A. Casteel, DPM Authorization to Leave a Voicemail Please provide number(s) ONLY IF you approve us to leave DETAILED information related to appointments, billing, test results, diagnosis, and
PATIENT INFORMATION FORM
PATIENT INFORMATION FORM Alpharetta Braselton Cumming East Cobb Johns Creek Marietta Sandy Springs Sugar Hill West Paces Woodstock www.napc.md ALL PATIENTS OR RESPONSIBLE PARTIES MUST COMPLETE THIS FORM
New Patient Registration Packet
New Patient Registration Packet This Patient Registration Packet includes the following: 1. Patient Registration Sheet (page 1) This form is for patient demographic and physician referral information.
CINCINNATI PAIN PHYSICIANS, LLC (CPP) ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
CINCINNATI PAIN PHYSICIANS, LLC (CPP) ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES By signing below, I acknowledge that I have received a copy of CPP s Notice of Privacy Practices. The Notice
PSYCHOLOGICAL SERVICES AGREEMENT
PSYCHOLOGICAL SERVICES AGREEMENT Jane Allemang, PhD, Clinical Psychologist CLIENT INFORMATION: TODAY S DATE: Name: Date of birth: Age: Sex: Relationship status: (circle) SINGLE MARRIED COHABITING WIDOWED
NEUROLOGICAL INSTITUTE OF MICHIGAN PATIENT INFORMATION FORM
NEUROLOGICAL INSTITUTE OF MICHIGAN PATIENT INFORMATION FORM PATIENT NAME: HOME ADDRESS: BIRTH : SSN#: CELL: HOME TELEPHONE: EMPLOYER: WORK: EMERGENCY CONTACT: REFERRING DOCTOR: PRIMARY CARE MD: PHONE:
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: