Bellingham Arthritis & Rheumatology Center. 470 Birchwood Avenue, Suite C, Bellingham, WA (P) (F)
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1 Bellingham Arthritis & Rheumatology Center 470 Birchwood Avenue, Suite C, Bellingham, WA (P) (F) Patient Name SSN Last First M.I. Date of Birth Age Sex: Male Female Address Street City State/Zip Home Phone Cell Phone Preferred Phone Leave detailed message? Y N Preferred Pharmacy How did you hear about us? Primary Care Physician Referring Physician Occupation Employer Phone Address Spouse/Partner Name Spouse/Partner Employer: Main Phone / Alt Phone Emergency contact (not living with patient) Phone Health Insurance Information Primary Insurance Carrier Group # Subscriber Name Employer Insurance ID # Secondary Insurance Carrier Group # Subscriber Name Employer Insurance ID # I certify that the information I have given above is true and correct. I authorize release of my medical information to my insurance company for claims processing and I assign my insurance benefits to Bellingham Arthritis and Rheumatology Center. Signature of Patient or Responsible Party Date
2 History is probably the most important part of a diagnostic evaluation. Certain background information is necessary. Please fill out this worksheet. If you are unsure about something, mark it with a question mark. We will discuss it during your appointment. Thank you. Patient Name: Age: Date: Reason for today s visit If you have had the following, circle it and note the approximate year when it occurred. Stroke Seizures Psychiatric illness Depression Eye redness or inflammation Iritis Radiation treatment of neck or tonsils Thyroid disease or goiter Pneumonia Pleurisy Asthma Rheumatic fever Heart murmur Coronary artery disease High cholesterol History of heart attack High blood pressure Bleeding disorder Melanoma Do you have any of the following? (Please circle) Anemia Stomach ulcer Crohn s disease or ulcerative colitis Hepatitis Liver disease Yellow jaundice Kidney disease Kidney stone Urinary infections Diabetes Varicose veins Phlebitis or blood clot Arthritis Gout Cancer Psoriasis Positive T.B. skin test Tuberculosis Lymphoma Weight loss Irregular heartbeat Pain in joints Fever Chest pain Stiffness in joints Chills Shortness of breath Pain in back Skin rash Cough Pain in neck Hair loss Wheezing Pain in arms Headache Abdominal pain Pain in legs Dizzy spells indigestion/heartburn Difficulty sleeping Trouble with vision Change in bowel habits Fatigue Dry eyes Constipation Numbness Dry mouth Diarrhea Pins and needles Oral ulcers Trouble urinating Sun sensitivity Trouble with hearing Genital ulcers Abnormal bleeding/bruising Trouble swallowing Ankle swelling Fingers turn white with exposure to cold Please list the medications you are taking and dosages: (CONTINUED ON REVERSE)
3 Have you noticed any change in height? Y N Have you noticed any change in weight? Y N If yes, increase or decrease of lbs? Are you allergic to any medications? Y N If yes, please list Have you had any operations? Y N What kind, when and where? Any other hospitalizations? Y N For what reason, when and where? Occupation: Health Maintenance Date of last colonoscopy: Past or current tobacco use? Y N If yes, how much? / When Quit Do you drink? Y N If yes, how much? Past or current recreational drug use? Y N Do you have a family history of any illness such as gout, diabetes, high blood pressure, arthritis, cancer, rheumatoid arthritis, lupus, psoriasis, scleroderma, muscle disease, heart disease, or inflammatory bowel disease? If so, what disease and which member of your family? FEMALES: How many pregnancies? Number of miscarriages Any trouble with pregnancies? Date or age of last menstrual period: Date of last Pap: Result: Date of last Mammogram: Result:
4 Current Medications List Name: Date Prescription Medications / Over The Counter / Herbs & Supplements: Name of Medication Strength and Frequency Condition Medication Taken For Physician who Prescribed Med Notes Allergies
5 BELLINGHAM ARTHRITIS AND RHEUMATOLOGY CENTER FINANCIAL POLICY Thank you for choosing Bellingham Arthritis and Rheumatology Center as your health care provider. We look forward to being of service to you and providing you with quality care. We believe that it is important that our patients have a clear understanding of our expectations regarding billing and payment. Please read and sign the following Financial Policy prior to your treatment. Should you have any questions, please feel free to ask our office staff. Bellingham Arthritis and Rheumatology Center is contracted with various insurance companies, which may change from time to time. Please check with our office staff to find out if we are contracted with your insurance plan. For patients who are insured through non-contracted insurance companies, we will be happy to courtesy bill your insurance company for you one time only. It will be your responsibility to follow up with your insurance company and pay the bill in a timely manner. Please present your insurance card at every visit. Failure to present your insurance card may mean you will be billed the services you receive. If you have DSHS, CHPW or Molina, failure to present your Provider One ID card may mean that you will not be seen. Your copay is due at the time of your visit. Some insurance plans do not cover certain procedures. In such cases you will be asked to sign a waiver agreeing to pay for the visit at the time of service. You may want to call your insurance company in advance of your visit to determine if the service is covered. For our private pay patients, we expect payment in full at the time of service. If you pay for your services by check and that check is returned for non-sufficient funds (NSF), we will charge an additional $40.00 to your account. If that happens, you will be asked to remit the amount of the check plus the service charge in cash within 10 days. If your account has not been paid in full by then it may be referred for collection action. After receiving a statement, failure to make payment or contact with our office within 60 days will begin our collection process on your account. Repeat failure to pay may result in the dismissal from Bellingham Arthritis and Rheumatology Clinic and the assignment of your account to a collection agency. When a child of divorced parents is seen, we expect payment from whichever parent accompanies the child. We will not bill ex-spouses or parents who live outside of the area. We require 24-hour notice if you are unable to keep your appointment. Failure to appear for your appointment may result in a no show charge or dismissal from the practice. Same day cancellations are also considered failure to appear. If you are having financial difficulty, our office staff will be happy to work with you. You may want to establish a payment plan. If so, we ask that these payments be made as scheduled, each month and on time. We do monitor these accounts, and non-payment may jeopardize your ability to be seen by our physicians. Thank you for reviewing our Financial Policy. Please let us know if you have any questions. I HAVE READ AND FULLY UNDERSTAND THE BELLINGHAM ARTHRITIS AND RHEUMATOLOGY CENTER FINANCIAL POLICY. I AUTHORIZE THE BELLINGHAM ARTHRITIS AND RHEUMATOLOGY CENTER TO RELEASE INFORMATION AND ASSIGN BENEFITS PER CONTRACT/AGREEMENT. I hereby authorize Bellingham Arthritis and Rheumatology Center to release to my primary and secondary insurance company any medical information necessary to process my insurance claim. My signature also authorizes any insurance benefits to be paid on my behalf to be paid to the physicians of the Bellingham Arthritis and Rheumatology Center. I hereby agree to full responsibility for all expenses incurred by myself, or minor child, including services not covered by my insurance. I understand that a rebilling fee-finance charge complying with Washington State Law will be applied to any overdue balance. In the event of non-payment, I will bear the cost of collection and /or court costs and reasonable legal fees should this be required. MEDICARE: I understand my provider agrees to accept the Medicare allowed charge as the full charge, and I am only responsible for the deductible, co-insurance and non-covered services. Signature, Responsible Party Date: Please Print Full Name:
6 Notice of Privacy Practices Acknowledgment Bellingham Arthritis and Rheumatology Center We keep a record of the health care services we provide you. You may ask to see and copy that record. You may also ask to correct that record. We will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels us to do so. You may see your record or get more information about it by contacting our Office Manager, Brandy VanDeKop. Our Notice of Privacy Practices describes in more detail how your health information may be used and disclosed, and how you can access your information. By my signature below I acknowledge receipt of the Notice of Privacy Practices. Patient or legally authorized individual signature Date Time Printed name if signed on behalf of the patient Relationship (parent, legal guardian, personal representative) This form will be retained in your medical record.
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PATIENT REGISTRATION FORM Account #:
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Address. City/State/Zip. Marital Status: S M D W Sex: M F Date of Birth / / Age. Primary Phone Secondary Phone. Employer PARENT/GUARDIAN
PATIENT INFORMATION First Name M.I Last Name Address City/State/Zip SSN.#_ Marital Status: S M D W Sex: M F of Birth / / Age Primary Phone Secondary Phone Employer Email PARENT/GUARDIAN Name of Birth /
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PATIENT INFORMATION. Last Name: First Name: Middle Initial: Address:
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19455 Deerfield Avenue Suite 312 Lansdowne, Virginia 20176 24430 Stone Spring Blvd, Suite 345 Dulles, VA 20166 Patient Information: Last Name: First Name: Middle Initial: Date of Birth: / / Age: Social
PATIENT INFORMATION FORM PLEASE COMPLETE THE FOLLOWING INFORMATION
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.
PATIENT REGISTRATION
TIME 2:51 PM DATE 6/26/2013 ID: Chart ID: First Name: Patient Is: Policy Holder Responsible Party Responsible Party (if someone other than the patient) First Name: PATIENT REGISTRATION Last Name: Preferred
Any pertinent medical records
Hello, and welcome to Arizona Pulmonary Specialists, Ltd. You are scheduled to see on at. Please plan to arrive 20 minutes prior to this time. If you are unable to keep this appointment for any reason,
Patient Registration
Patient Registration ID: Chart ID: First Name: Last Name: Middle Initial: Patient is: Policy Holder Preferred Name: Responsible Party Responsible Party (if someone other than the patient) First Name: Last
Patient Information Form
ALASKA DIGESTIVE AND LIVER DISEASE, LLC Ronald J Boisen, M.D. Daryl M. McClendon, M.D. Jeffrey W. Molloy, M.D. Patient Information Form Patient s Name: Age: DOB: Sex: Male Female Marital Status: S M W
MICHAEL J. FRANK, D.P.M., MARC GOLDBERG, D.P.M., ADAM LOWY, D.P.M.
MICHAEL J. FRANK, D.P.M., MARC GOLDBERG, D.P.M., ADAM LOWY, D.P.M. 10801 Lockwood Drive, Suite 260 Silver Spring, Maryland 20901 (301) 439-0300 3408 Olandwood Ct., Suite 204 Olney, Maryland 20832-1367
Jandali Plastic Surgery
Jandali Plastic Surgery PATIENT INFORMATION FORM : FirstMiddle Last Address: City State Zip Code Home Phone #( ) - Work #( ) - Cell #( ) - Emergency # ( ) - Emergency Contact Social Security Number - -
Patient Information Sheet PLEASE PRINT LEGIBLY AND COMPLETE ALL INFORMATION. Patient s Name: Nickname (if any): Address: City: State: Zip:
Patient Information Sheet PLEASE PRINT LEGIBLY AND COMPLETE ALL INFORMATION Today s : Patient s Name: Nickname (if any): Address: City: State: Zip: Phone ( primary number): Home:( ) Cell:( ) By providing
Secondary Insurance Co. Name & Address: Subscriber s Name: Subscriber Soc. Sec. No. Group number:
M a u r i c i o R o n d e r o s, D D S, M S, M P H I. PATIENT INFORMATION: Last Name: First Name: MI: Mr. Mrs. Ms. Male Female Birth date (M/D/Y): Marital status: Dr. Other: Address: City, State: Zip:
PATIENT INFORMATION PATIENT NAME Last First M.I. Social Security Number
PATIENT INFORMATION PATIENT NAME Last First M.I. Social Security Number ADDRESS Street DATE OF BIRTH SEX Female Male City State Zip Home Phone Cell Phone Work Phone EMAIL Marital Status Single Widowed
Worthington Family Dentistry, P.C Greystone Way Valdosta, GA (229)
Worthington Family Dentistry, P.C. 3362 Greystone Way Valdosta, GA 31605 (229) 242-0063 Patient Information Date Name Home Phone Cell Phone (Last) (First) (Initial) Work Phone Other/Fax Sr., Jr., III,
PATIENT REGISTRATION SOCIAL SECURITY NUMBER:
PATIENT REGISTRATION LAST NAME FIRST NAME MI M/F ADDRESS APT CITY STATE ZIP BIRTHDATE AGE MARITAL STATUS HOME PHONE SOCIAL SECURITY NUMBER: OCCUPATION: EMPLOYER NAME: WORK ADDRESS: WORK PHONE: PLEASE INDICATE
2345 Court Drive Gastonia, NC Phone: Fax:
Patient Name: Address: Street City State Zip SSN: Home #: Birth Age: Sex: Male Female Email Address: Marital Status: Single Married Divorced For X-ray purposes, are you pregnant? Yes No Patient s Employer:
Taylor Family Dental Dr. Randy K. Taylor, DMD Dr. Richard L. Vonnahme, III, DMD Dr. Anna M. Jayjock, DMD
Taylor Family Dental Dr. Randy K. Taylor, DMD Dr. Richard L. Vonnahme, III, DMD Dr. Anna M. Jayjock, DMD Patient Information Name Preferred Name [ ] Male [ ] Female First MI Last SS# Birth Date Status
Here is a quick review of all the things you will need to make your first visit go smoothly. We hope you find this helpful.
Smith Tower 6550 Fannin St., Suite 2237 Houston, TX 77030 Ph: 713-790-4600 Fax: 713-793-1229 Appointment Date: Time: Doctor: Dear New Patient: Welcome to our practice and thank you for giving us the opportunity
Patient Information. Dental Insurance. Phone Numbers
Our goal is to provide you with the safest, most comfortable experience a dental office can provide. If you have any questions please do not hesitate to call us. Patient Information Date: SS/Patient ID:
Patient Registration Form This form is posted on our website
Patient Registration Form This form is posted on our website www.kidseyecare.net Caring For the Vision of Our Future Patient Last Name: First Name: Sex : Male / Female Date of Birth: SS #: - - Phone: (
PATIENT REGISTRATION / INFORMATION SHEET
PATIENT REGISTRATION / INFORMATION SHEET Name: LAST FIRST MIDDLE Date of Birth: Gender: M F Marital Status: Social Security Number: Email Address*: Street Address: City: State: Zip: Home Phone: Cell Phone:
PATIENT REGISTRATION
PATIENT REGISTRATION Name: Date: First MI Last Preferred Name: RESPONSIBLE PARTY: (if someone other than the patient) First Name: Last Name: Middle Initial: Address: City: State: Zip: Home #: Work #: Ext:
FOOT & ANKLE SPECIALISTS OF THE TWIN TIERS, PC 455 MAPLE STREET, SUITE 2 BIG FLATS, N.Y PATIENT INFORMATION FORM (PLEASE PRINT) DATE: / /
FOOT & ANKLE SPECIALISTS OF THE TWIN TIERS, PC 455 MAPLE STREET, SUITE 2 BIG FLATS, N.Y. 14814 DATE: / / PATIENT INFORMATION FORM (PLEASE PRINT) PATIENT NAME: LAST FIRST MI DATE OF BIRTH: / / AGE: SEX: