K. Dean Reeves M.D El Monte St Roeland Park, KS Phone- (913) Fax- (913) PATIENT INFORMATION
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1 K. Dean Reeves M.D El Monte St Roeland Park, KS Phone- (913) Fax- (913) PATIENT INFORMATION : Legal Name: Dr/Mr/Mrs/Ms/Miss First Middle Last Suffix Nickname: of Birth: Age: Sex: M or F (please circle) Street Address City State Zip Home Phone Cell Phone Work Phone Address Employer Occupation/Job Emergency Contact Relationship Emergency Phone Primary Care Physician Who may we thank for referring you to our practice?
2 BILLING INFORMATION Health Insurance Company: _ ID # Group # Secondary Insurance: ID # Group # Other If Applicable (circle type): Work Comp Auto Accident Please fill out all applicable information below: Insurance Company: Phone Number: Address: of accident: Claim Number: Adjuster s Name: Adjuster s Phone Number: I have been informed of the Privacy Practices and Patient Bill of Rights and have received a copy from Dr. Reeves website or in Dr. Reeves office. Health Insurance Portability and Accountability Act Waiver (HIPAA) Because Dr. Reeves office is bound by the rules of the Health Insurance Portability and Accountability Act (HIPAA), we are unable to provide any information to any person other than you without your consent. This includes information about your account, appointment times, prescriptions, or any information contained in your records with us. Please list any persons (and relationship) or agencies that we have your permission to release your information to. This information can be amended by you as needed.
3 Messages: I give my consent to Dr. Reeves and staff at Dr. Reeves office to leave messages or discuss scheduling, treatment, or other information regarding my care as follows: On my answering machine or voice mail at home On my answering machine or voice mail at work On my cell phone On my (for direct communication with Dr. Reeves) I do not consent to messages being left at home, work, , or with any other person.
4 K. Dean Reeves M.D El Monte St Roeland Park, KS Phone- (913) Fax- (913) AUTHORIZATIONS and FINANCIAL POLICY Thank you for choosing the office of K. Dean Reeves, MD. We strive to provide the very best care and in order to do so we would like to take this opportunity to acquaint you with our office policies. Please take a few moments to read over the following information. In addition, we suggest you review your health insurance policy and familiarize yourself with the coverage it provides. Insurance and Driver s License due at time of service I understand that in order for K. Dean Reeves, MD to file insurance claims on my behalf, I must present proper proof of insurance at the time of my appointment. K. Dean Reeves MD accepts several insurance plans and every plan is different. It is up to the insured to know the exact requirements of their own insurance plan. INSURANCE WILL NOT BE FILED WITHOUT A COPY OF THE INSURANCE CARD. Assignment of Insurance Benefits I hereby authorize and assign, my insurance carrier(s), to make payment directly to K. Dean Reeves, MD of insurance benefits for services herein specified and otherwise payable to the insured. K. Dean Reeves, MD files both primary and secondary insurance as a courtesy to patients. I understand and agree that I am financially responsible to K. Dean Reeves, MD for all charges incurred regardless of potential insurance benefits. I understand K. Dean Reeves, MD will not become involved in disputes between the patient and the insurance company. I understand it is my responsibility to verify with my insurance company that K. Dean Reeves, MD, the physician treating me is covered under my insurance and to get referrals and /or authorization for services. Costs & Payment at the time of Service I understand that I am financially responsible for all charges arising from my own or my dependents evaluation, follow up visit or any other billable procedure. Prolotherapy, Perineural Injection and PRP are not covered in all contracts. I am responsible to pay for these procedures at the time of service. I understand that if I am delinquent and default on the terms of this agreement then my account will be closed and I will no longer be able to schedule any other appointments until my bill is paid in full. Reinstatement I understand that if my account is closed with K. Dean Reeves, MD, it will be at management s discretion to accept me back into the practice. If accepted back I know I am responsible to have my balance paid in full before having any future treatments with K. Dean Reeves, MD. I also understand that there will be a minimum of a $25.00 charge for reinstatement fee applied to my account. The reinstatement fee and the full amount of the next visit are due at that time of service. Referral Forms I understand that if I have an HMO or PPO insurance requiring a referral; a completed referral form or referral number from my primary care physician (PCP) must be provided at the time of my appointment. I understand that failure to provide referral information at the time of my visit
5 will necessitate either rescheduling my appointment, or payment in full at the time of the service. Appointments This office only sees an average of 4 patients a day and allows 2 hours or more for initial evaluations. Unexpected cancellations will idle our staff for a major portion of the day and we will be unable to see others who might be requesting a sooner appointment. This makes communication by the patient for changes in scheduling very important for our office. If a cancellation has occurred with less than 24 hours notice, any rescheduling will be at the discretion of Dr. K. Dean Reeves, MD. I understand that if I arrive late for an appointment I may be asked to reschedule my appointment. Minor Patients (Patients under age 18) Any patient under the age of 18 must be accompanied by a parent/guardian to each visit, unless otherwise specified by K. Dean Reeves, MD. I understand by signing KDRMD s financial policy, I am solely responsible for any incurred charges for the below named patient. Patients under the age of 18 may not cancel or change an appointment in this office. Returned Check Fee I understand that if K. Dean Reeves, MD receives a returned check I will be charged an additional $25 above the amount on the check and will be on a cash only basis thereafter. Patient Name (Printed) Guardian/Responsible Party Office Witness
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KILGORE EYE CARE CENTER
KILGORE EYE CARE CENTER Dr. J.T. Roberts O.D. Dr. Jadie Roberts O.D. Dr. Shiloh Roberts O.D. 1100 Stone Rd Suite 2020 Kilgore, Texas 75662 (903) 983-2020 work (903) 983-4000 fax Dear Patient: Welcome to
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PATIENT INFORMATION. Name: Date of Birth: Age: Address: Social Security #: City: Sex: Marital Status: State: Zip: Language: GUARANTOR INFORMATION
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Welcome! 7000 W. Plano Parkway Plano, TX Please remember to bring: New Patient Paperwork. Current Insurance Card
7000 W. Plano Parkway Plano, TX 75093 SW corner of Plano Pkwy & Marsh Welcome! Thank you for choosing Dr. Christine Stiles to care for your child s plastic surgery needs. This is a satellite office of
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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
PSYCHOLOGICAL SERVICES AGREEMENT
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Total Wellness Medical Care. Patient Medical History
Today s date: PCP: Patient's last name: Mr. Mrs. Marital Status: (circle one) Patient s first name: Ms. Miss Single/Married/Divorced/Separated/ Widowed Is this your legal name? Yes or No If not, what is
TEXAS ASSOCIATION OF PEDIATRIC NEUROLOGY, P.A. Jerry J. Tomasovic, M.D.
Jerry J. Tomasovic, M.D. PATIENT NAME D.O.B. Who referred you today? What are the concerns that brought you here today? What specific questions do you have today? Please list present medication and dosage:
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:
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Welcome! Thank you for choosing Dr. Christine Stiles to care for your child s plastic surgery needs. This is a satellite office of our Frisco practice that focuses on Pediatric Plastic Surgery. All appointments
DIRECTIONS TO THE FORT WORTH OFFICE 1001 Washington Avenue
Thank you for making an appointment. Dr. Blue graduated from Wake Forest University School of Medicine. She completed her internship and residency in neurology and her fellowship in cerebrovascular disease