LOGO. Financial Policy
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- Leonard Webb
- 6 years ago
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1 LOGO Financial Policy Please read this financial policy carefully. If you have any questions about this policy, a member of our office staff will be glad to assist you. 1. Payment for Services: Our office staff will inform you of the amount due when you check out. This amount is due at the time of service. Co-payment is also due at the time of service. When calling to schedule your appointment, we encourage you to inquire about the estimated charge for your visit. We will be able to provide you with an estimate of your charges so that you may make arrangements to pay at that time or to set up a payment plan. 2. Methods of Payment: You may pay your bill with cash, personal check, or credit card. For your convenience, we accept Visa, MasterCard, and American Express. 3. Charges: As a courtesy to you, we file your insurance claims if you are seen for an office visit, but you must provide the appropriate insurance information and a copy of your insurance card. 4. Returned Checks: A $30.00 service charge will be added on all checks returned to us for insufficient funds. 5. Special Needs: We realize that temporary financial problems may make it difficult to pay your balance immediately. If such problems should arise, please contact us promptly so that we may set up a payment plan that will meet your needs. We are willing to work with you on your account, but it is your responsibility to inform us of any reason that you are unable to pay the outstanding balance. 6. Collection Policy: Delinquent accounts will be forwarded to a collection agency. We will inform you of your account status on your statement, and we will attempt to contact you by letter before your account is forwarded. If you are unable to your balance promptly, please call us so that we may arrange to hold your account. 7. Questions: We are here to help should you have any questions regarding your statement or insurance. You may contact us at any time, but we are best able to assist you between the hours of 8:30 AM and 4:00 PM, Monday through Thursday. *Note: Any concern with our financial policy should be brought to the attention of the business office. We will be glad to discuss these concerns with you in private.
2 Prescription Policy o Just a reminder, we do not call in prescriptions. Please be sure to get all of your prescriptions from your doctor at the time of your visit. Please check your prescriptions before you leave the office to be certain you have all of them. If you have any questions please ask for the nurse. This will allow us to focus our attention on the patients scheduled to be seen that day. o If you do forget a prescription, please call and it will be ready 24 hours later for pick-up. o There will be a $15.00 charge upon pick-up. (Except for ADHD Medications) o We will not call you unless we have a problem with your request. *Requests for refills on controlled drugs that have been lost or stolen will not be honored. *Some of your prescriptions will expire 60 days from the date signed by your doctor. Be sure to fill them before they expire to avoid a trip back to our office. THANK YOU FOR YOUR COOPERATION.
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4 HISTORY & PHYSICAL (Adult) Name: SSN: Date: Chief Complaint (Tell us about patient s difficulties, when and how they began): Previous Evaluation or Treatment (Has the patient seen another mental health professional, psychiatrist, therapist, had testing; please list who, where, and when): Medical History Current Medications: Drug Allergies/Adverse Reactions: Hospitalization/Surgery (List dates and reasons): Please Circle ALL that apply Head Ache Shortness of breath Heart Palpitations Heart Murmur Chest Pain Dizziness/Fainting Peripheral Vascular Disease Allergies/Hay Fever Asthma Bronchitis Pneumonia Ulcer GI Disorder Lactose Intolerance Hepatitis Gallbladder Disease Prostate Disease Bowel Irregularity Incontinence Gout Sexual/Menstrual Dysfunction Venereal Disease Frequent Infections Mumps Anemia Arthritis Osteoporosis Nervousness Depression Scarlet Fever Chronic Rashes Rheumatic Fever Measles Rubella Polio Diphtheria Comes in Contact with Blood/Body Fluids at Work Difficulty Falling Asleep Snoring Early Morning Awakening Daytime Drowsiness Other: Habits Smoke: How Long Packs Daily Interested In Stopping Coffee/Cola: Cups Daily Other Caffeine: Alcohol: Type Amount Interested in Stopping Street Drugs: Diet Salt Intake: Fat Intake: Other: Exercise Routine: Family History (List any family member that has been treated for each illness, mother, father, sister, child, etc.) Heart Disease High Blood Pressure Stroke Cancer Diabetes Epilepsy/Convulsion Bleeding Disorder Kidney Disease Thyroid Disease Mental Illness Osteoporosis
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8 Upstate Psychiatry, P.A. Insurance Form Patient Name: Date: Acct#: Primary Insurance Information: Insurance Company Name: Effective Date: Insurance Company Phone #: ( ) Insurance Claim Mailing Address: City: State: Zip Code: ID#: Group#: Insured/Subscriber Name (as it appears on card): Relationship to Patient: Subscriber s Address: City: State: Zip Code: Subscriber s Phone #:( ) Subscriber s Date of Birth: Subscriber s Sex: M or F Subscriber s Social Security #: Subscriber s Employer: Secondary Insurance Information: Insurance Company Name: Effective Date: Insurance Company Phone #: ( ) Insurance Claim Mailing Address: City: State: Zip Code: ID#: Group#: Insured/Subscriber Name (as it appears on card): Relationship to Patient: Subscriber s Address: City: State: Zip Code: Subscriber s Phone #:( ) Subscriber s Date of Birth: Subscriber s Sex: M or F Subscriber s Social Security #: Subscriber s Employer: Please return this form to the receptionist along with all insurance cards for copies. It is very important that you provide us with your complete, accurate, and current insurance coverage. We are participating providers with many insurance companies and as part of our contracts we are required to file your claims to these companies. WE MUST HAVE A COPY OF ALL INSURANCE CARDS.
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PATIENT REGISTRATION
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Name: Date of Birth: First Middle Last Residence: Street City Zip Code Home Phone Number Social Security: - -
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Cardholder Name: Patient Name: Relation to Patient: Sex: Cardholder s DOB: Co-pay: Member ID#: Group #:
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Marco A. Vargas, DPM, FACFAS Alicia E. Johnson, DPM W. Grand Parkway South Suite 530 Sugarland, TX Phone: Fax:
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EMERGENCY CONTACT Name of relative/friend not living with you. Home Phone Cell INSURANCE
DATE PATIENT INFORMATION Name Date of Birth Home# Work# Cell# Do you receive text messages? Address City State Zip SS# email Sex Marital Status Employer If Student, what school? Spouse s Name Who may we
SILVERDALE EYE PHYSICIANS PATIENT REGISTRATION FORM
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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
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Patient Information Date: Name: SSN (Last) (First) (MI) Address City State Zip Code Home # Cell # Work Sex Male Age DOB Married Single Divorced Female Widowed Other Email Address Employed? No Yes Employer
Please Present Insurance Card at Each Office Visit
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Patient Last Name: First MI. Responsible Party (if a minor) Address: (Street or PO Box) (City) (State) (Zip) Home Phone: Cell Phone: Work Phone:
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Any pertinent medical records
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Christine LaComb, RN, FNP-C th Street Suite B Groves, TX (409) Phone (409) Fax
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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
GRAHAM CHIROPRACTIC CENTER, INC. BRYAN GRAHAM, DC, CCSP
GRAHAM CHIROPRACTIC CENTER, INC. BRYAN GRAHAM, DC, CCSP 34 Long Pond Road Plymouth, MA 02360 (508) 747-1434 New Patient Intake Form Patient Information Thank you for choosing our practice for your chiropractic
Welcome to our Practice:
Welcome to our Practice: We are pleased you have chosen Partners In Internal Medicine to be your primary care provider. We have practice information as well as the necessary forms you will need to complete
Georgia Foot & Ankle
Georgia Foot & Ankle PLEASE PRINT CLEARLY Today s Date / / Name Date of birth / / First MI Last SSN Marital Status M S D W Age Weight Height Male Female Address City State Zip Phone (Home) (Work) (Cell)
PODIATRIC REGISTRATION AND HISTORY Dr. Peter F. Gregory, D.P.M.
Dr. Peter F. Gregory, D.P.M. Patient s Name: Date: / / Address: City State Zip Date of Birth: / / Sex: Male Female Home Phone: Cell Phone: Business Phone: Email: (Please check preferred method of contact
375 East Main Street East Islip, NY Welcome!
375 East Main Street East Islip, NY 11730 631-581-5121 www.drforlano.com Welcome! NAME & ADDRESS PATIENT S NAME DATE OF BIRTH WHAT DO YOU PREFER TO BE CALLED? IF PATIENT IS A MINOR, PARENT/GUARDIAN S NAME
LERGIES (please list name of medication and what happened when you took it. I d codeine)
NAME DATE OF BIRTH ADDRESS LERGIES (please list name of medication and what happened when you took it. I d codeine) Please complete all of the following questions Have you or any family members ever had
Name Relationship Did you hear about us in any other way?
PATIENT INFORMATION Personal Information Patient s Name Today s Date Nickname/Preferred Name (if any) Birth date S.S. # - - Status (please circle) Child / Adult Single Married Divorced Widowed Parent s/spouse
Patient Information. Health Information
PLEASE COMPLETE PRIOR TO YOUR APPOINTMENT. Return Via: Email:crosspatientcoordinator@verizon.net Fax: 301-662-4945 OR Bring to your appointment Patient Information Patient Name: Date: Last First MI Preferred
RESPONSIBLE PARTY DEMOGRAPHIC INFORMATION
BRYAN LEATHERMAN, M.D. PATIENT DEMOGRAP H I C INFORMATION Last Name First Name Middle Preferred Name Maiden Prefix Suffix DOB Sex SSN Ethnicity Marital Status Driver s License # Primary Language English
CENTRAL FLORIDA ORAL & MAXILLOFACIAL SURGERY, PA PATIENT REGISTRATION Date: PATIENT INFORMATION
CENTRAL FLORIDA ORAL & MAXILLOFACIAL SURGERY, PA PATIENT REGISTRATION Date: Pre-fix: Patient s Legal First Name: PATIENT INFORMATION Legal Last Name: Nickname: Mr Mrs Ms Dr Street Address: Home Phone #:
Brighter Smiles Family Dentistry
Brighter Smiles Family Dentistry Welcome To Our Office! Our team believes that our patients are the most important people in the world. We appreciate that you have chosen our team as your dental family.
PLEASE GIVE YOUR INSURANCE CARD(S) AND DRIVER S LICENSE TO THE RECEPTIONIST FOR INSURANCE BILLING PURPOSES
Georgia Spine and Sports Rehab Dr. Joseph A. Krzemien WELCOME TO OUR OFFICE PATIENT INFORMATION FORM NAME DATE OF BIRTH AGE SEX M F ADDRESS CITY STATE ZIP HOME PHONE WORK PHONE CELL SOCIAL SECURITY NUMBER
Has a family member been a patient in our office? Yes No
Patient Information *Please complete all pages First Name M.I. Last Address Sex M / F Age City State Zip Code Date of Birth Social Security Marital Status S M W D Primary Phone Alternate Phone E-mail Physician
ROBERT H. OLIVER, M.D., PLLC Otolaryngology Head And Neck Surgery Otolaryngic Allergy Chart #
Chart # PATIENT INFORMATION Please Print, Complete Fully, And Return To The Front Desk Circle One: Mr. Mrs. Ms. Miss. Dr. Child Please Circle: Sex: Male Female Marital Status: S M Other Widowed Patient