Seth S. Schurman, M.D. WELCOME TO OUR OFFICE! Patient Information Date: Gender: ( ) M ( ) F DOB: Age: Patient's Name: First Middle Last
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- Bartholomew Powers
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1 Seth S. Schurman, M.D. WELCOME TO OUR OFFICE! Patient Information Date: Gender: ( ) M ( ) F DOB: Age: Patient's Name: First Middle Last Address: Home Phone: Are You On Medicare? ( ) NO ( ) YES: Medicare #: Social Security #: Marital Status: ( ) married ( ) separated ( ) divorced ( ) single ( ) widow ( ) minor Spouse's Name: For Children (Please Complete The Following) Mother's Name: Address: Home Phone: Father's Name: Address: Home Phone: Person Responsible For Bills: Method Of Payment Today: ( ) cash ( ) check ( ) credit card 1
2 If Using Insurance, You Are Responsible For Any Deductible &/or Co-pay on day of service All HMO/POS Patients Must Have Valid Authorization with Them On The Day of Service! ( ) Primary Care or Referring Physician ( ) Name: Office Address: Office Phone: Pharmacy Name: Pharmacy Address: Pharmacy Phone: Insurance Company: Insured's Name: Birth Date: Insured's Employer: Are You A: ( ) permanent resident: # of years ( ) seasonal visitor: # of months Patient's Responsibility I Understand That I Am Responsible For Paying For Appointments Not Canceled 24 Hours In Advance! Signature: Insurance Assignment I request that "A Adult & Pediatric Allergy & Asthma Associates", apply to my medical insurance carrier on my behalf for payment of all charges incurred. I understand that I must first meet my deductible and any co-payment required by my carrier, as well as pay all charges not fully paid by my insurance company. I further understand that what my insurance company considers reasonable, may fall far short of the actual charges, and that I will be responsible for the difference in costs. I further certify that all charges regarding my medical care have been previously explained in full. Patient: Date: Witness: Medicare Lifetime Authorization I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act, is correct. I authorize any holder of medical or other information about me, to release to the Social Security Administration or it's intermediaries or carriers, any information needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for physician services to the physician or organization furnishing the services or authorize such physician or organization to submit a claim to Medicare for me. Patient: Date: 2
3 Seth S. Schurman, M.D. Patient's Name: DOB: First Middle Last Personal Medical History Have you ever had (" " ALL THAT APPLY): ( ) Asthma ( ) Hives ( ) Eczema ( ) Frequent Colds ( ) Frequent Sore Throat ( ) Frequent Infections ( ) Pneumonia ( ) Hay Fever ( ) Heart Disease ( ) Rheumatic Fever ( ) High Blood Pressure ( ) Low Blood Pressure ( ) Anemia ( ) Jaundice ( ) Hepatitis: A B C ( ) Pleurisy ( ) Prostate Trouble ( ) Meningitis ( ) Tuberculosis ( ) Gonorrhea/Syphilis ( ) Cancer: ( ) Arthritis/ Rheumatism ( ) Frequent Boils ( ) Diabetes ( ) Bone/Joint Disease/Bursitis ( ) Neuritis/Neuralgia/Sciatica ( ) Broken Bones/Broken Nose ( ) Hyperthyroidism (high) ( ) Hypothyroidism (low) ( ) Unconscious/Head Injury Other Medical Problems (Please List): Medications Current Medications (Please List Name, Dose & Frequency): Do you use the following Non-Prescription Drugs? (" " ALL THAT APPLY): ( ) Vitamins ( ) Antacids ( ) Tylenol ( ) Aspirin/Ibuprofen ( ) Laxatives ( ) Decongestants Allergy History Are you allergic to ( " " ALL THAT APPLY & Describe Reaction): ( ) Penicillin: ( ) Cosmetics: ( ) Sulfa Drugs: ( ) Adhesive Tape: ( ) Aspirin/Ibuprofen: ( ) Codeine/Narcotics: ( ) Any Foods: Other Drugs/Immunization Reactions: Ever stung by a: ( ) Bee ( ) Wasp ( ) Yellow Jacket ( ) Hornet ( ) Fire Ants? Describe Any Reactions: Localized Reactions Only: ( ) NO ( ) YES Social/Immunization History Unusual hobbies/habits: Drink Alcohol? ( ) NO ( ) YES: # of drinks: /day /month /Year Do you smoke? ( ) Never ( ) In the Past ( ) Now If so, packs/day, for years Do you use other recreational/non-prescription drugs? ( ) NO ( ) YES: Frequency: Have you had Tetanus shot/booster in the last 10 years? If so, when? 3
4 Have you ever had? Surgical History Tonsillectomy/Adenoidectomy: ( ) NO ( ) YES Nose/Sinus Surgery: ( ) NO ( ) YES Hysterectomy/Ovaries Out: ( ) NO ( ) YES Other Surgery (Please List): Family Medical History " " Boxes if Yes Father Mother Sibling(s) Spouse Children Age (if living) Health (G) Good (B) Bad Cancer Tuberculosis Diabetes Heart Disease High Blood Pressure Hives Asthma Hay Fever Eczema Other (Please List) Age (At Death) Cause of Death Environmental Survey (" " & Write-In Appropriate Response): Dwelling: ( ) House ( ) Apartment ( ) Condo Age of Building: years old Heating: ( ) Electric/Forced Air ( ) Steam ( ) Baseboard ( ) Radiators ( ) Oil Heat Flooring: ( ) Carpeted/Minimal Tile ( ) Half Carpet/Half Tile ( ) All Tile/Hardwood Window Treatments: ( ) Drapes ( ) Vertical Blinds ( ) Horizontal Blinds ( ) Other: Your Bedroom: ( ) Carpeted ( ) Hardwood/Tile ( ) Books ( ) Stuffed Animals ( ) Table Items Mattress: ( ) Conventional ( ) Waterbed Age: years old Pillows: ( ) Feather ( ) Synthetic Age: years old Pets (List): ( ) Indoors ( ) Outdoors Smokers in home? ( ) NO ( ) YES: # of smokers: Occupation/Specific Work: Symptoms Worse: ( ) At Work ( ) At Home ( ) Can't Tell ( ) Anywhere ( ) Outdoors ( ) Indoors Anything in or out of home that might be contributing to your symptoms: Explain Briefly The Main Problems You Are Having & What Brings You In To See Us Today: 4
5 FINANCIAL POLICY Thank you for choosing "A Adult & Pediatric Allergy & Asthma Associates" as your Allergy providers. We are committed to the success of your treatment and care. Please understand that payment of your account is part of the process. The following is our financial policy. Please read the information and let us know immediately if you have any questions regarding the information. Thank you. Payment Is Expected At The Time Services Are Rendered: At the time services are rendered, we will collect your co-payment or co-insurance, as well as any balance due from a previous date of service. We accept cash, check, credit card (Visa, MasterCard) and debit cards. Failure to pay your co-payment or co-insurance at the time of service will result in a billing service fee of $ We participate with Medicare, specific commercial insurance plans and networks. Please ask our office if we participate with your insurance provider. We make every effort to comply with the terms and conditions of the plans with which we do business. However, it is solely your personal responsibility to determine whether your insurance company participates with "A Adult & Pediatric Allergy & Asthma Associates", or with any laboratory, radiology, hospital or other facility at which medical services may be scheduled on your behalf. "A Adult & Pediatric Allergy & Asthma Associates" assumes no financial responsibility for charges related to services rendered at non-participating facilities. Insurance Claims: As a courtesy to you, if "A Adult & Pediatric Allergy & Asthma Associates" is a participating provider with your insurance plan, we will file your insurance claim for you. Your insurance company makes the final determination regarding your eligibility and benefits. You agree to pay any portion of the charges that are not covered by your insurance company. If we are not participating with your insurance plan, we may file the initial claim, but, if payment is not received in 45 days, we will transfer the unpaid balance to you and require you to pre-pay for any future services before they are rendered. If your insurance requires a referral or pre-authorization prior to a visit or procedure, you are responsible for obtaining it. Failure to obtain the referral and/or pre-authorization may result in a lower payment from your insurance company and a higher "out-of-pocket" cost to you. Returned Checks: ** We Charge A Fee For All Returned Checks! ** Past Due Balances: We will take the necessary steps to collect "past due" balances. If we need to refer your account to a collection agency, you agree to pay all of the collection costs that are incurred. If your account is referred for legal action, you agree to pay all of the legal fees that we incur plus court costs. In the event of litigation, you agree the venue shall be in Lee County, Florida. You understand that if your account is submitted to an attorney, collection agency, litigated in court, or "past due" status is reported to a credit reporting agency, the fact that you received treatment at "A Adult & Pediatric Allergy & Asthma Associates" will become a matter in the public record. Appointments: We understand that unexpected circumstances can sometimes interfere with your scheduled appointments; however, you are responsible for contacting the office to: ** Cancel your scheduled appointment at least 24 hours before the scheduled service to avoid having a late cancellation fee added to your account. ** I have read and understand the Financial Policy of "A Adult & Pediatric Allergy & Asthma Associates". I agree to abide by the terms and conditions contained herein. I also acknowledge receiving a copy of this Policy for my records. / / PATIENT/PARENT/LEGAL GUARDIAN NAME DATE / / PATIENT/PARENT/LEGAL GUARDIAN SIGNATURE DATE 5
6 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I have been presented with a copy of A Adult & Pediatric Allergy & Asthma Associates Notice of Privacy Practices. Further, I permit a copy of this authorization to be used in a place of the original, and request payment of medical insurance benefits either to myself or to the party who accepts assignment. Regulations pertaining to medical assignment of benefits apply. May we mail to your home, or other designated location, any items that assist the practice in carrying treatment/ healthcare operations, such as appointment reminders, insurance items and lab results? ( ) YES ( ) NO May we leave a message with a member of your household regarding appointments, lab results and insurance? ( ) YES ( ) NO If yes, whom: Relationship: If yes, whom: Relationship: May we leave a message on an answering machine regarding appointments, lab results and insurance? ( ) YES ( ) NO If employed, may we contact you at your work place? ( ) YES ( ) NO I understand the contents of this notice? ( ) YES ( ) NO PATIENT OR LEGAL GUARDIAN SIGNATURE (IF UNDER 18, PARENT OR LEGAL GUARDIAN SIGNATURE & STATE YOUR RELATIONSHIP TO PATIENT) 6
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Thank you for selecting our team for your dental care. We are pleased to welcome you to our practice! To help us better serve you and meet your dental healthcare needs, please complete the following forms.
Patient Demographics
211 East Butler Road, Suite A-2 Mauldin, SC 29662 (864) 281-9171 Phone (978)-327-7938 Fax Dr. Brad Lindstrom, DPM Dr. Jamelah Lemon, DPM P.O. Box 1113, Mauldin, SC 29662 www.footclinicsc.com Patient Demographics
PATIENT INFORMATION. Race: Ethnicity:
PATIENT INFORMATION Last name: First: MI: Today s Date: SS#: Mailing Address: Date of Birth: City: State: Zip: Sex: Primary Phone: Home Work Mobile Secondary Phone: Home Work Mobile Tertiary Phone Home
Laguna Woods Dermatology
Laguna Woods Dermatology Patient Registration Form Visit date: Name: First Middle Last of Birth: Social Security Number: Nickname (optional): Sex: M F Address: Street City State Zip Mr. Mrs. Dr. Home Phone:
Welcome to Rosenman & Leventhal, P.C.
Welcome to Rosenman & Leventhal, P.C. Thank you for choosing our practice for all of your dermatological needs. Please have ALL of the attached paperwork filled out completely before arriving to our office.
PATIENT INFORMATION DEMOGRAPHICS. First Name Middle Initial Last Name Gender. Mailing address: Apt # City: State: ZIP Code: Home Phone Cell Phone
PATIENT INFORMATION Gary S. Fields, DPM, FACFAS Kenneth M. Danis, DPM, FACFAS DEMOGRAPHICS First Name Middle Initial Last Name Gender SSN Birthdate Age Email M F Mailing address: Apt # City: State: ZIP
4. Who Is Accompanying the Child Today? 5. Responsible Party Information Name Name Relationship Birth Date Home Phone
Dr. Jeffrey D. Singer Specialty Permit # 5722 1001 Laurel Oak Road Suite C-2 Voorhees, NJ 08043 Phone: (856) 783 3515 Fax: (856) 783 3517 www.abcchildrensdentist.com PATIENT REGISTRATION 1. Tell Us About
PLEASE PRINT & FILL OUT COMPLETELY PATIENT/PARENT INFORMATION ADDRESS:
2150 S. Eastern Avenue 7180 Cascade Valley Ct. #180 Las Vegas, Nevada 89104 Las Vegas, Nevada 89128 Phone (702) 641-2150 Phone (702) 641-2150 Fax (702) 641-8667 Fax (702) 228-1043 PLEASE PRINT & FILL OUT
PATIENT REGISTRATION
PATIENT REGISTRATION Last Name First Name Middle or Maiden Mailing Address City County State Zip Physical Address (if different) Telephone: Home( ) Cell ( ) Work ( ) Preferred Contact: Home Cell Text Message
Colorado Clinics for the Foot and Ankle Dr. Erik Ouderkirk, DPM Dr. Corey Bess, DPM
Date: Colorado Clinics for the Foot and Ankle Dr. Erik Ouderkirk, DPM Dr. Corey Bess, DPM 2373 Central Park Blvd. Ste. 201 Denver CO 80238 11310 N Huron St. Ste. 20 Northglenn CO 80234 4185 East Wildcat
Denver Pediatrics, PC Patient Registration
Denver Pediatrics, PC Patient Registration Date PATIENT INFORMATION Legal Name Last First Middle Initial Street Address Apt/Unit # City State Zip Code Birth Date Age SS# Home Phone Sex Male Female Responsible
CITRUS ORTHOPAEDIC AND JOINT INSTITUTE PATIENT INFO. SHEET
CITRUS ORTHOPAEDIC AND JOINT INSTITUTE PATIENT INFO. SHEET DATE: TIME: DR: PATIENT INFO: PRIMARY CARE DOCTOR: REFERRING: NAM E: First Middle Last SEX: AGE: DOB: SS# RACE: ETHNICITY: Hispanic Non Hispanic
Patient s Name: Age: Social Security: Height: Weight: Street Address: City: State: Zip: Mailing Address (if different): City: State: Zip:
PATIENT INFORMATION: Patient s D.O.B: Age: Social Security: Height: Weight: Street Address: City: State: Zip: Mailing Address (if different): City: State: Zip: Home Phone: Cell Phone: Work Phone: Email
Advanced Periodontics & Implant Dentistry of Westchester
Advanced Periodontics & Implant Dentistry of Westchester Patient Name: Social Security #: David L. Sandak, DDS, PC Fara Vossughi, DDS, MS 10 Old Mamaroneck Road, White Plains, NY 10605 Phone: 914-997-1111
FOOT AND ANKLE WELLNESS CENTER DR. LEONARD E. VEKKOS
FOOT AND ANKLE WELLNESS CENTER DR. LEONARD E. VEKKOS NAME: LAST FIRST MIDDLE ADDRESS: STREET APT# CITY STATE ZIP HOME # ( ) WORK# ( ) CELL# ( ) E-MAIL: PREFERENCE: HOME: AGE: DATE OF BIRTH: SS NO.: MALE
Patient s name. Date of Birth Male [] Female [] Married [] Single [] Widowed [] Child [] Street Address City State Zip. Phone: Hm Wk Cell
![Patient s name. Date of Birth Male [] Female [] Married [] Single [] Widowed [] Child [] Street Address City State Zip. Phone: Hm Wk Cell](/thumbs/95/122853379.jpg "Patient s name. Date of Birth Male [] Female [] Married [] Single [] Widowed [] Child [] Street Address City State Zip. Phone: Hm Wk Cell")
Patient s name Date Date of Birth Male [] Female [] Married [] Single [] Widowed [] Child [] Street Address City State Zip Phone: Hm Wk Cell E-mail Social Security # Spouse s name Patient employed by Referred
EAR, NOSE, AND THROAT ASSOCIATES, PC Financial Policy Effective September 1, 2014
EAR, NOSE, AND THROAT ASSOCIATES, PC Financial Policy Effective September 1, 2014 Patient name: Account# Ear, Nose and Throat Associates, PC, believes that in the interest of good health care practices,
JUST US KIDS PEDIATRICS NEWBORN HISTORY FORM
JUST US KIDS PEDIATRICS NEWBORN HISTORY FORM DATE: PATIENT NAME: D.O.B BIRTH HISTORY WAS YOUR BABY FULL TERM? PRE-TERM? ADOPTED? IF PRE-TERM, HOW MANY WEEKS? IF ADOPTED, AT WHAT AGE? TYPE OF DELIVERY:
Green Hills Plastic Surgery Stephen M. Davis, MD, FACS
Green Hills Plastic Surgery Stephen M. Davis, MD, FACS General Information Date: Patient Name: Date of Birth: Age: M.I. How would you like to be addressed by our office staff? Sex: Marital Status: Spouse
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
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM Patient s SSN: Patient s Name: Date of Birth: Male Female Address: Phone: _ Cell: _ If Minor, Name of Parent/Guarantor: Billing Address, If not as above: Patient s Relationship
Street Address: Apt. # City State Zip. Employer Name and Address. City State Zip. Name of Spouse or Guardian. Emergency Contact Name and Phone
Patient Name Social Security Number: Date of Birth: Age: Street Address: Apt. # City State Zip Home Phone: ( ) -- Mobile Phone: ( ) -- Employer Name and Address City State Zip Business Phone ( ) -- Occupation
Patient Registration Form 8/12/2014 PATIENT INFORMATION (Person seeing the Doctor today) Last Name First Name Middle Initial
Patient Registration Form 8/12/2014 PATIENT INFORMATION (Person seeing the Doctor today) Last Name First Name Middle Initial Janis Black, D.O. Family Health Center at Port St. John 3740 Curtis Blvd, Suite
Marco A. Vargas, DPM, FACFAS Alicia E. Johnson, DPM W. Grand Parkway South Suite 530 Sugarland, TX Phone: Fax:
For your convenience, and to simplify the billing process, our practice keeps credit cards securely on file This is done to cover incidental charges, such as copayment, coinsurance, and deductible. Please
DENTISTRY RALEIGH PATIENT INFORMATION INSURANCE INFORMATION IMPLANT & FAMILY. Primary Insurance: (PLEASE PRESENT INSURANCE CARD TO RECEPTIONIST)
, RTH CAROLINA 27609 WWW.IMPLANTANDFAMILY.COM PATIENT INFORMATION Preferred Date of Birth: Male Female Married Single Address: Street Phone: Home: City Work: Zip Code Cell: SPOUSE INFORMATION Place of
PATIENT HISTORY FORM. DOB: Age: Male Female Marital Status. Address: Preferred Method of Contact: Home Cell Work Text
PATIENT HISTORY FORM Name: SSN: (Last) (First) (MI) DOB: Age: Male Female Marital Status Address: (Street) (City) (State) (Zip) Home Phone: Cell: Work: Email Address: Preferred Method of Contact: Home
Patient Information. Last First MI (Preferred Name) Male Female Married Single Child. City State Zip Code Emergency Contact/Relation Phone
LEWIS C. COLE DMD Family and Cosmetic Dentistry 525 ENERGY CENTER BLVD SUITE 1603 NORTHPORT, AL 35473 PHONE 205.344.6900 FAX 205.344.6910 www.lewiscoledentistry.com Patient Name: Patient Information Date:
Patient Name: M F LAST FIRST MI. Mailing Address: City: State: Zip: Home Phone: ( ) Work Phone: ( )
Ahwatukee Family Medical Center Patient Information Date: Patient Name: M F LAST FIRST MI Mailing Address: City: State: Zip: Home Phone: ( ) Work Phone: ( ) EMAIL: Date of Birth: / / SS# Marital Status:
1500 E. Woolford Rd. Ste. #101 Show Low, AZ [Phone] (928) [Fax] (928) OFFICE POLICIES
![1500 E. Woolford Rd. Ste. #101 Show Low, AZ [Phone] (928) [Fax] (928) OFFICE POLICIES](/thumbs/93/113391533.jpg "1500 E. Woolford Rd. Ste. #101 Show Low, AZ [Phone] (928) [Fax] (928) OFFICE POLICIES")
1500 E. Woolford Rd. Ste. #101 Show Low, AZ 85901 [Phone] (928) 537-4111 [Fax] (928) 532-1123 Email: jcollins@hallfootandankle.com OFFICE POLICIES PATIENT NAME: DOB: 1. WE REQUIRE PRE-REGISTRATION! ALL
10485 N. PENNSYLVANIA ST, SUITE 150 BOOTH DERMATOLOGY GROUP 320 N. MERIDIAN ST. SUITE 110 INDIANAPOLIS, IN INDIANAPOLIS, IN WELCOME
WELCOME Appt. & Time: Patient s : Welcome to Booth Dermatology & Cosmetic Center. Thank you for choosing us for your dermatological needs. Please note, if a patient is under 18 years of age, a parent or
Do you have or have you ever had any of the following: Circle Yes (Y) or No (N)
PATIENT MEDICAL HISTORY FORM West Georgia Urology Associates, P.C. 150 Clinic Avenue, Suite 202 Carrollton, GA 301117 Phone:( 770) 834-6988 Fax: (770) 834-1090 Today s Date: Name: _ (Last) (First) (Middle
PATIENT INFORMATION NOTICE OF PRIVACY POLICY PATIENT ACKNOWLEDGEMENT
PATIENT INFORMATION ( MR / MRS / MS / DR ) FIRST MIDDLE LAST DATE OF BIRTH AGE MARITAL STATUS (circle one) Married / Divorced / Single / Widowed STREET ADDRESS APT/LOT/ROOM/SUITE CITY STATE ZIP GENDER