PATIENT INFORMATION FORM PLEASE COMPLETE THE FOLLOWING INFORMATION
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- Samuel Atkinson
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1 PATIENT INFORMATION FORM PLEASE COMPLETE THE FOLLOWING INFORMATION DATE Please Print All Information LAST NAME FIRST NAME MI ADDRESS CITY ST ZIP PHONE EMPLOYER WORK PHONE DATE OF BIRTH AGE SEX SOC. SEC. # _ SPOUSE NAME DATE OF BIRTH EMERGENCY CONTACT: NAME: RELATIONSHIP PHONE Pharmacy used: REFERRING PHYSICIAN PHONE ADDRESS SIGN DATE REASON FOR VISIT:
2 Medical Information Release Form Name: of Birth: / / Release of Information I authorize the release of information including the diagnosis, records, examination rendered to me and claim information. This information may be released to: Spouse Children Other Information is not to be release to anyone The release of Information will remain in effect until terminated by me in writing. Messages Please call: my home my work my cell Number: If unable to reach me: You may leave a detailed message Please leave a message asking me to return your call The best time to reach me is between (time) Signed
3 HEALTH QUESTIONAIRE Patient Name 1.) List any allergies (i.e., drug, food, latex) Name- Explain type of reaction (rash, itching, swelling) 2.) List all medications you are presently taking, including over- the- counter medications. 3.) Medical History: Circle all that apply to you. Heart Disease Diabetic Neurological Disorder High Blood Pressure Stroke Arthritis Chest Pain Asthma Psychiatric Disorders Heart Attack Bronchitis Depression Thyroid Disease Heart Murmur Emphysema Glaucoma Congestive Heart Failure TB Bleeding Disorders Brain Damage Mitral Valve Prolapse Phlebitis Sickle Cell Disease Cerebral Palsy Hypoglycemia Hepatitis Gastric Ulcers Cancer Skin Cancer Dialysis HIV/AIDS Lupus Kidney Problems Seizure Disorders MS Melanoma Pacemaker Artificial Limbs or Joints OTHER: 4.) List all previous surgeries: Approximate Year Type of Surgery 5.) Are you on any blood thinners (including aspirin)? Yes No 6.) Do you faint or pass out? Yes No 7.) Have you had any blood transfusions? Yes No 8.) If female and being seen for acne or psoriasis; of last menstrual period: 9.) If female and being seen for acne or psoriasis; Do you plan on becoming pregnant? Yes No
4 Patient Name: Hometown: Color of Eyes: : Color of Hair: How did you receive most of your sun damage? (ex. Farming, oil field, ect.) Is your sun damage, mild, moderate, or extreme? Below is for nurse use only: Actinic Keratosis: Hypertrophic Actinic Keratosis: Atypical Nevus: Basal Cell Carcinoma: Basosquamous Cell Carcinoma: Squamous Cell Carcinoma: Malignant Melanoma: OTHER:
5 RELEASE OF INFORMATION I hereby authorize Robert F. Bloom, M.D. to release to any person(s) any information they deem necessary for the collection of this account. ASSIGNMENT OF INSURANCE BENEFITS In consideration of services rendered, I hereby transfer and assign Robert F. Bloom, M.D. all rights, title and interest in any payment due me for services described herein as provided in the policy or policies of insurance. I agree to pay Robert F. Bloom, M.D., the charges of said facility which exceed the amount paid by the insurance company or companies. A photostatic copy of the authorization shall be considered as effective and valid as the original. Signature THIS FORM ALLOWS ROBERT F. BLOOM, M.D. TO FILE YOUR INSURANCE AND COLLECT FROM YOUR INSURANCE COMPANY NON- NETWORK PROVIDERS I, have been informed that my (Patient s Name or Patient Representative) Insurance company is not in network with Robert (Name of Insurance) F. Bloom, M.D. I understand that I will have to pay for my full charged amount when I leave here today. If the total charges go over $ today, I understand that my insurance will be filed and I will owe 20% today. I agree that I will be responsible for any remaining balance after the insurance pays out of network prices. _ Patient Signature or Patient Representative
6 PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION I hereby give my consent for Robert F. Bloom, M.D. to use and disclose protected health information (PHI) about me to carry out treatment, payment, and healthcare operation (TPO). (Robert F. Bloom, M.D. s Notice of Privacy Practices provides a more complete description of such uses and disclosures.) I have the right to review the Notice of Privacy Practices prior to signing this consent. Robert F. Bloom, M.D. reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Robert F. Bloom, M.D. Privacy Office at 1211 East 6 th Street, Suite 150, Bonham, Texas With this consent, Robert F. Bloom, M.D. may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory results among others. With this consent, Robert F. Bloom, M.D. may e- mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that Robert F. Bloom, M.D. restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. By signing this form, I am consenting to Robert F. Bloom, M.D. s use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Robert F. Bloom, M.D. may decline to provide treatment to me. Signature of Patient or Legal Guardian Print Name of Patient or Legal Guardian
7 RECEIPT NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGEMENT FORM I,, have received a copy of Robert F. Print Patient Name Bloom, M.D. s Notice of Privacy Practices. Signature of Patient or Legal Guardian
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Secondary Insurance Co. Name & Address: Subscriber s Name: Subscriber Soc. Sec. No. Group number:
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Patient Registration Date: First Name Last Name Middle Initial Preferred Name E-mail Patient Information Address City State Zip Home Phone Cell Phone Work Phone Ext Birthdate Age Social Security Drivers
Appt. Date & Time: Patient s Name:
Dermatology Center of Denton Cynthia R. Harrington, MD, PA Kaveh Nezafati, MD 209 N. Bonnie Brae St, Suite 202 Denton, TX 76201 (940) 384-7546 (808) 619-3376 WELCOME Appt. Date & Time: Patient s Name:
Buckland Ear, Nose & Throat, LLC. Medical History
Buckland Ear, Nose & Throat, LLC Medical History Patient Name: Today s Date: Primary Care Provider: Referred by: Pharmacy You Use: Date of Birth: Age: Name City 1. Reason for visit: 2. Past Medical History:
William Salcedo, D.P.M. Diplomat American Board of Podiatric Surgery Board Certified in Foot Surgery Se Habla Español
Active feet are happy feet. William Salcedo, D.P.M. Diplomat American Board of Podiatric Surgery Board Certified in Foot Surgery Se Habla Español New Patient Information Form (Please Print) Date: / / Social
Local Address: City State Zip. Permanent Address: City State Zip. Secondary Insurance Co: Insurance Phone: Policy #:
Patient Intake Form : Patient Name: (Last) (First) (M) Local Address: City State Zip Permanent Address: City State Zip Home Phone: Work Phone: Cell Phone: Birthdate: Age: Sex: M F Marital Status: Ethnicity:
NOTICE OF PATIENT FINANCIAL RESPONSIBILITY
Lakeview Eye Care Eye Medicine and Surgery Christine C. Platt, M.D. Chad Lehtonen, O.D. One Lakeview Park Rochester, New York 14613 NOTICE OF PATIENT FINANCIAL RESPONSIBILITY At Lakeview Eyecare, we are
New Patient Information
New Patient Information Name: : What name would you like to be called?: of Birth: Home Phone: Social Security No: Cell Phone: E-mail: Address: City: State: Zip: Employer: Work Address: City: State: Zip:
We look forward to serving you and your ophthalmic needs. Please do not hesitate to contact our office if we can be of any further assistance.
ANN BULLINGTON, M.D. ROBERT H. BULLINGTON, JR., M.D. Cornea and External Diseases AILEEN F. VILLAREAL, M.D. ROBERT E. FINTELMANN, M.D., F.A.C.S. Cornea, Cataract, and Refractive Surgery Welcome to Biltmore
Joshua A. Greenwald, MD Cosmetic Surgery Associates of Westchester
Joshua A. Greenwald, MD PATIENT INFORMATION Name: First Middle Last Age: DOB: / / Social Security Number: - - Month Day Year Address: Street City State Zip Email: Home Phone: ( ) Work Phone: ( ) Cell Phone:
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Name How do you wish to be addressed of Birth Reason for today s visit Former dentist Reason for leaving of last dental visit Reason for last dental visit How often do you brush? How often do you floss?
MEDICAL FORM (Please Fill in all Information)
MEDICAL FORM (Please Fill in all Information) Last Name First M.I. Spouse/Parent Name Home Phone Business or Cell Phone Home Address City and State Date of Birth Zip Code Sex M F Social Security # E-Mail
Parent/Guardian Name: Social Security #: Male / Female: Date of Birth: / / Home Phone: Mobile Phone: Work Phone: Street Address: City: State: Zip:
PATIENT INFORMATION Today s : / / Patient Name (Last, Middle, First) Social Security #: Male / Female: of Birth: / / Street Address: Email Address: Home Phone: Mobile Phone: Work Phone: IF THE PATIENT
Gary W. White, M.D. Dean A. Cione, M.D. Jeremy S. Carrasco, M.D. Ramsey A. Stone, M.D
PATIENT REGISTRATION FORM First Name: MI: Last Name: Date of Birth: Address: Apt#: City: State: Zip: Home Phone: ( ) Cell Phone: ( ) Work Phone ( ) SS#: - - SEX: Female Male E-mail Address: Ethnicity: