Office and Financial Policies
|
|
|
- Malcolm Robinson
- 5 years ago
- Views:
Transcription
1 Office and Financial Policies Thank you for reviewing the following office and financial policies. We commit to put forward our best efforts to provide you with the most up to date, skilled, and compassionate health care possible. We also agree to: Provide you and/or your insurance company with a timely and accurate statement of all charges for services rendered. Explain fully all charges for services rendered and acceptable payment methods. Secure all pre-authorizations and/or referrals that your health insurance plan requires us to obtain for your ongoing care or treatment. In return we respectfully ask you to agree to the following: All appointments must be cancelled 24 hours prior to your scheduled appointment. Failure to cancel within this time frame will result in a charge to your account. If you are an established patient a $30.00 fee will be charged to your account. If you are a new patient or are scheduled for a procedure, a $ fee will be charged to your account. If you are a patient who we requires an in-person interpreter, you will be responsible for the full fee for the interpreter if you no show your appointment or fail to cancel with greater than 24 hours notice. If you are more than 15 minutes late for a medical appointment, you may be asked to reschedule or to see a different provider. Since our ultrasound schedule is generally full, we are unfortunately not able to accommodate patients who are running late, or to wait for family members to arrive. If you or your family members are more than 10 minutes late for an ultrasound appointment we will not be able to complete your procedure without affecting other patients, and will reschedule your appointment to the next available date. If you need to be rescheduled and our schedule is full, this may require scheduling you at a different facility which may results in higher charges to you. For these reasons we strongly recommend arriving minutes prior to your ultrasound scheduled time. It is your responsibility to inform us of any changes to your account, such as phone number, insurance, or address changes. If you do not provide us with the correct information and we are unable to receive payment as a result, you will be responsible for the balance. As a courtesy to you, we will file your insurance claim for you. If your insurance is inactive or does not cover the services provided, you will be responsible for payment. Any balances older than 90 days, which have not been paid by your insurance company, may be billed to you. Any balances remaining after your insurance has paid will be due on receipt of a statement from our office. If your payment is not received within 60 days your account may be referred to a collections agency. If your insurance doesn t pay under the pre-existing clause then all services will be the patient s financial responsibility.
2 It is your responsibility to confirm with your insurance if we are in or out of your network, and if the service you request is covered by your insurance. All co-pays, co-insurance and deductibles must be paid at the time of service. If you are having a baby, having surgery or being admitted to the hospital, we will collect your deductible before your delivery or procedure. Any accounts with outstanding balances must be paid prior to any additional services being rendered. A $25.00 charge will be charged for any returned checks. Checks will be processed electronically. For your personal use there is a $25.00 charge for the first 20 pages of your medical records and $0.50 for each page thereafter, unless requested by another physician. If you require short term disability, FMLA or other forms to be filled out by us, these forms will be completed for a fee of $10.00 per form. As a convenience to our patients, we provide a MedFusion blood draw station in our office. Charges for most lab tests, including pap smears, are not included in the charges from our office and are billed separately by MedFusion. These charges are NOT included in your regular statements from Complete Women s Care Center. It is your responsibility to understand your insurance benefits for lab work. Certain tests, including tests for vaginal infection, are billed by our office. These charges ARE included in your regular statements from Complete Women s Care Center and any payment due is expected at the time of service. It is your responsibility to understand your insurance benefits for lab work. For all services rendered to minor patients, we will look to the adult accompanying the patient and/or the parent or guardian with custody for payment. We make every attempt to code and file claims accurately according to the services rendered and your healthcare provider s documentation in your medical record. We are required to code and bill for the type of visit that is performed, not the type of visit that is scheduled. Laws regarding insurance fraud and abuse prohibit us from changing your procedure and/or diagnosis code in order to get the claim paid. Our office prefers to use to notify patients of lab results, reminders and other important office information. Please allow 2 weeks to receive notification of your lab or test results. I understand that this office cannot be responsible for information loss or delays that are due to technical factors beyond this office s control. Please clearly print your preferred address below if you consent to using for these preferred communications: I have read and understand the above office and financial policies and agree to be bound by these terms. I also understand and agree that Complete Women s Care Center may amend such terms from time to time. I have received/read a copy of the HIPAA statement.
3 Thank you. We look forward to having you as our patient. Notice of Cancellation Fees As a courtesy, we request that if you must cancel you do so 24 hours prior to your scheduled appointment. Failure to cancel within this time frame will result in a fee charged to your account. Established Patients - $30.00 New Patients - $ Procedures - $ Cosmetic Gyn - $ If you are a patient who requires an in-person interpreter and you noshow your appointment or fail to cancel with greater than 24 hours notice, you will be responsible for the full interpreter fee, as assessed by Language Acquisition Services. We understand that unforeseen circumstances may arise. For your convenience, a member of our staff will contact you by telephone shortly after a missed appointment to assist you with rescheduling. The fee will be assessed to your account and we request payment prior to scheduling a future appointment. I have read and understand the above Notice of Cancellation Fee policy presented by Complete Women s Care Center.
4 Medical Records Policy As a patient, you have the right to request a copy of your Medical Records. You may do so by completing an Authorization to Release Healthcare Information form, which is located on our website Please allow 3 5 business days to process your request. As a courtesy, we will request or send your Medical Records to an outside physician s office. For your personal use, there is a $25.00 charge for the first 20 pages of your medical records and $0.50 for each page thereafter. I have read and understand the above Medical Records Policy presented by Complete Women s Care Center.
5 Ultrasound Appointment Policy Since our ultrasound schedule is generally full, we are not able to accommodate patients who are running late, or to wait for family members to arrive. If you or your family members are more than 10 minutes late for an ultrasound appointment we will not be able to complete your procedure without affecting other patients, and will reschedule your appointment to the next available date. If you need to be rescheduled and our schedule is full, this may require scheduling you at a different facility (for example at the hospital or at free standing ultrasound facility) which may results in higher charges to you. For these reasons we strongly recommend arriving minutes prior to your scheduled ultrasound time. Thank you for your assistance in maintaining our schedule and keeping your care on schedule. I understand the above policy and that I will not be able to have an ultrasound performed if I am more than 10 minutes late for my scheduled appointment, and will not be able to wait for family member who are late. Name Signature Date
Financial Policy and Patient Agreement
Financial Policy and Patient Agreement YOUR RESPONSIBILITY You are financially responsible for the services we provide to you. We understand that many patients arrange for insurance companies to pay for
PEDIATRIC PATIENT INFORMATION
PEDIATRIC PATIENT INFORMATION Due to new HIPPA regulations ALL information must be filled out, otherwise we will not be albe to process your claim and you will be billed for the medical services. LAST
Welcome to Sibley Primary Care
Welcome to Sibley Primary Care We are pleased to have you join our practice. We understand that starting with a practice can be overwhelming and we ve provided this welcome packet to aid with your first
PATIENT INFORMATION PATIENT INFORMATION. Middle Initial: Nickname: Date of Birth: Marital Status: Address: City: State: Zip Code:
PATIENT INFORMATION PATIENT INFORMATION First Name: Last Name: Middle Initial: Nickname: Date of Birth: Sex: Marital Status: Address: City: State: Zip Code: Home Phone: Cell Phone: Email: How did you hear
PATIENT REGISTRATION INFORMATION Initial
PATIENT REGISTRATION INFORMATION Date Initial PATIENT S PERSONAL INFORMATION Please complete both sides of this form. Marital Status: Single Married Divorced Widowed Male Female Name: ( ) last name first
By signing this form, I acknowledge that I have been advised of all applicable policies. Patient Signature. Patient Name (printed) Witness Signature
5000 Brittonfield Parkway* Suite A 128 (315) 446-4400 phone * (315) 446-4201 fax By initialing below, I am indicating that I have been given an opportunity to read the policies, relevant to me, set forth
The Pediatric Center of Stone Mountain, LLC. General Pediatrics, Adolescent Medicine & Behavioral Health Services
Patient Name DOB Print First and Last Name of Patient Date of Birth MM/DD/YYYY Our goal is to provide and maintain a good provider-patient relationship. Letting you know in advance of our office policy
Patient Welcome Form!
Arthritis and Rheumatology Clinical Center of Northern Virginia, PLLC 8130 Boone Blvd suite 340 Vienna VA 22182 Mahsa Tehrani MD 703-734-2222 Mahnaz Momeni MD Patient Welcome Form Dear new patient, Welcome
PATIENT REGISTRATION
First Name Middle Name Last Name Preferred Name PATIENT REGISTRATION Patient Information Byron C. Cotton, M.D., FAAP Gayla Woodson, MSN, CPNP First choice for infants thru young adult! First Patient Second
Sierra Endocrine Associates Endocrinology, Diabetology & Metabolism
Patient Name: Consultation Date: Next 2 week Appointment: Provider: Arrival Time: Arrival Time: Thank you for choosing Sierra Endocrine Associates as your specialty endocrine provider. Enclosed is your
Advanced Podiatry. W E A R E V E R Y P L E A S E D T O H A V E Y O U W I T H U S! Please answer the following questions to help us become acquainted.
W E A R E V E R Y P L E A S E D T O H A V E Y O U W I T H U S! Please answer the following questions to help us become acquainted. Date How did you hear about us? (Be Specific Please) First Name Last Name
PRIMARY CARE PHYSICIAN
PATIENT INFORMATION OFFICE USE ONLY HIPAA No-Show form Patient Financial form Referral LRYGB / LVSG / LAGB / DOS: SELF LAST NAME FIRST ADDRESS CITY DATE OF BIRTH PLEASE LIST PREFERRED NUMBER OF CONTACT
Authorization to Release Health Information
Authorization to Release Health Information Patient Information: Name of Patient Date of Birth Address City, State, Zip Phone At my request, may release the following information: (Name of the entity)
Bergen County Gynecology, P.C.
PATIENT INFORMATION LAST NAME FIRST NAME MIDDLE MAIDEN NAME (IF ANY) DATE OF BIRTH SS# PLACE OF BIRTH MARITAL STATUS RACE ETHNICITY PREFERRED LANGUAGE OTHER LANGUAGES SPOKEN ADDRESS CITY ST ZIP HOME PHONE
Singh Family Dental Dr. P. Singh, PLLC
Singh Family Dental Dr. P. Singh, PLLC 25 Country Club Road, #301 Gilford, NH 03249 (603)524-7455 251 Mayhew Turnpike Plymouth, NH 03264 (603)536-7600 260 Route 16B Center Ossipee, NH 03814 (603)539-4995
Trinity Family Physicians
Trinity Family Physicians Consent and Authorization for Minors By law, a healthcare provider must attempt to contact a birth / custodial parent or legal guardian prior to rendering treatment to a minor
Who to call for an emergency: Name: Relationship: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) -
4425 Ponce de Leon Blvd., Suite 115 Email:info@ Dr. Mercedes Gonzalez, Pediatric Dermatologist Patient Information: Patient Name: Social Security Number: / / Date of Birth: / / Sex: M / F (Circle one)
LAS VEGAS ENDOCRINOLOGY
Today s Date: Primary Care Provider: Patient Information Last Name: First Name: Date of Birth: Sex: M F Social Security #: Street Address: City: State: Zip: Occupation: Employer: Home Phone: Cell Phone:
PLEASE PRINT CLEARLY
PATIENT INFORMATION FORM Rev. 02/2018 PLEASE PRINT CLEARLY New Patient Name Change Address Change Insurance Policy/Holder Change PATIENT INFORMATION Last Name: _ First Name: Middle Initial: DOB: Sex: Male
Please print and complete all the enclosed forms and bring them to your first appointment.
Dear Valued Patient, Thank you for requesting an appointment in our office. Please print and complete all the enclosed forms and bring them to your first appointment. When you arrive at our office for
A SAMPLE FINANCIAL POLICY SHEET
A SAMPLE FINANCIAL POLICY SHEET Our Practice Financial Policy In order to reduce confusion and misunderstanding between our patients and the practice we have adopted the following financial policy. If
Premier Internal Medicine of Alpharetta, PC FINANCIAL POLICY
Premier Internal Medicine of Alpharetta, PC FINANCIAL POLICY Thank you for choosing Premier Internal Medicine of Alpharetta, PC for your health care needs. We are committed to building a successful physician-patient
Hello and Welcome to Soft Tissue Solutions
Hello and Welcome to Soft Tissue Solutions This information sheet is designed to make your visits hassle-free. If you have any questions, please feel free to email or call us before your appointment. Appointments:
FILING- THE PATIENT IS ULTIMATELY RESPONSIBLE FOR PAYMENT IN FULL OF THEIR ACCOUNT, NOT THE INSURANCE COMPANY.
FINANCIAL AGREEMENT- PAYMENT IS REQUIRED FOR ALL DENTAL SERVICES AT THE TIME TREATMENT IS RENDERED. We accept Visa, MasterCard, Discover, American Express, Care Credit, Cash or Check. INSURANCE FILING-
Last Name First Name M.I. Age. Address City State Zip Code. Home Phone Cell Phone Work Phone Date of Birth
29 Barstow Road, Suite# 201, Great Neck, NY 11021 Tel. 516482-5400 Fax 516-482-5401 PATIENT REGISTRATION: Primary Care Dermatology Last Name First Name M.I. Age Address City State Zip Code Home Phone Cell
GREENWOOD DERMATOLOGY
GREENWOOD DERMATOLOGY Larry J. Buckel, M.D. Thomas J. Eads, M.D. Laura T. Stitle, M.D. Thank you for choosing Greenwood Dermatology for your Dermatologic needs. Dermatologists are the experts in the diagnosis
Allergies None Penicillin Sulfa Drugs Codeine Aspirin Tape Latex Iodine-Shellfish. Other allergies: Medications
Today s Date: Height Weight Shoe size (CIRCLE) Allergies None Penicillin Sulfa Drugs Codeine Aspirin Tape Latex Iodine-Shellfish Other allergies: Medications SOCIAL HISTORY (CIRCLE) Do you smoke? No Yes
Please print and complete all the enclosed forms and bring them to your first appointment.
Dear Valued Patient, Thank you for requesting an appointment in our office. Please print and complete all the enclosed forms and bring them to your first appointment. When you arrive at our office for
NEW PATIENT PACKET includes the following forms:
Thank you for choosing U.S. Dermatology Partners! We appreciate the opportunity to care for your health. REQUIRED ITEMS NEEDED FOR YOUR APPOINTMENT Completed New Patient Packet (see below) Valid Government
Connecticut Asthma & Allergy Center LLC Registration Form
Name: Connecticut Asthma & Allergy Center LLC Registration Form Last First Middle Initial Date of Birth: / / Sex: Race: Ethnicity: Language: SS#: xxx-xx- Address: # Street Apt/PO Box Email: Town State
WOMEN S PREMIER OBGYN REGISTRATION FORM
WOMEN S PREMIER OBGYN REGISTRATION FORM Today s date: PCP: PATIENT INFORMATION Patient s last name: First: Middle: q Miss q Ms. Marital status (circle one) Single / Married / Divorced / Sep / Widow Is
Patient Registration Forms
Patient Registration Forms PATIENT INFORMATION First Name: Middle: Last: DOB: / / Sex: M/F Primary Language: Address: City: ST ZIP Ethnicity: Hispanic / Non-Hispanic / Unknown Race: Asian / White / African
We are limited, not by our abilities, but by our vision.
We are limited, not by our abilities, but by our vision. WELCOME Thank you for choosing Advanced Eye Care Center as your eye healthcare provider! On behalf of Dr. Lawrence Shafron, Dr. Rodgers Eckhart,
FINANCIAL POLICY. I understand and agree to Woodbourne Family Practice Financial Policy. Print Name Date. Signature
FINANCIAL POLICY Woodbourne Family Practice believes that communicating our financial policy is good healthcare practice. Charges incurred for services rendered are the patient s responsibility regardless
GENTLE DENTAL CARE OF ROCHESTER PC
Patient Rules GENTLE DENTAL CARE OF ROCHESTER PC 1. All Forms and letters require 1 week to complete. This includes school forms, dental records, copy of x-rays, prior authorization request, referrals,
PATIENT INFORMATION FORM
PATIENT INFORMATION FORM Last Name: First Name: MI: Status: SIN MAR WID DIV Address: Home Phone : Cell Phone: Work Phone: DOB: Age: Email Address: How Did You Find Out About Us? Friend/Family Co- Worker
Family address preferred for patient portal access:
: Patient Relationship to Guarantor: of Birth: Sex: M F Social Security Number: Home Address: City: State: Zip Code: Pharmacy of Choice: Pharmacy Address: Pharmacy Phone Number: Siblings: Name Sex DOB
PATIENT REGISTRATION INFORMATION FOR MINORS
Today s Date: / / 620 Dr. Calvin Jones Highway, Suite 212 Please fill out and sign all registration paperwork attached. This will help us better serve you during your time at our clinic. PATIENT REGISTRATION
PATIENT DEMOGRAPHICS. Primary Insurance: Policy #: Group #: Secondary Insurance: Policy #: Group #:
TEXAS DIABETES & ENDOCRINOLOGY, P.A. 6500 North Mopac*Bldg. 3, Ste. 200*Austin, TX 78731 5000 Davis Ln*Ste 200*Austin, TX 78749 170 Deep Wood Dr*Ste. 104*Round Rock, Tx 78681 Phone: (512) 458 8400*Fax:
Phoenix Orthopaedic Surgeons Joseph S. Gimbel, M. D. PATIENT REGISTRATION
Phoenix Orthopaedic Surgeons Joseph S. Gimbel, M. D. PATIENT REGISTRATION DATE Chart # PATIENT NAME AGE DATE OF BIRTH MALE FEMALE PREFFERED LANGUAGE RACE/ETHNICITY SINGLE, MARRIED, DIVORCED, SEPARATED,WIDOWED
SHAKER URGENT CARE (AND FAMILY PRACTICE) FINANCIAL POLICY
SHAKER URGENT CARE (AND FAMILY PRACTICE) FINANCIAL POLICY Shaker Urgent Care PC believes that communicating our financial policy is good healthcare practice. Charges incurred for services rendered are
Total Care Family Practice 1701 N Green Valley Pkwy Bldg 5-C Evan C. Allen, MD Henderson, NV PH: (702) Fax: (702)
Demographics Last : First : What would you like to be called: Marital Status: Single Married Other Gender: Male Female DOB: Social Security: Email: Address: City: State: Zip Code: Home Ph: Cell Ph: Employment
NEW BREAST PROBLEMS (please describe):
BREAST HISTORY Today s : / / ID#: Name: of Birth: / / Age: Pregnant? YES NO Last menstrual (if applicable): / / Breast feeding? YES NO Age at First Period: Age at First Delivery: Hysterectomy? YES NO #
New Patient Intake Paperwork
New Patient Intake Paperwork NAME: Last First Middle DATE OF BIRTH: SEX: M / F ADDRESS: Street City State Zip PHONE: MOBILE: EMAIL ADDRESS: EMPLOYER NAME: PHONE: EMPLOYER ADDRESS: EMERGENCY CONTACT: PHONE:
TEXAS PEDIATRIC SPECIATLIES AND FAMILY SLEEP CENTER REGISTRATION FORM PEDIATRIC (Please Print) Referring Physician: _ Primary Care Physician: _
TEXAS PEDIATRIC SPECIATLIES AND FAMILY SLEEP CENTER REGISTRATION FORM PEDIATRIC (Please Print) Referring Physician: Primary Care Physician: Patient s LEGAL Last name: First: Middle Initial: Patient date
PATIENT REGISTRATION FORM
Today s Date / / PATIENT REGISTRATION FORM PATIENT INFORMATION Patient Name Last First Middle Is this your legal name? If not, what is your legal name? Birthdate Age Sex q YES q NO / / q M q F q T Street
Patient Guide to Billing and Insurance
Patient Guide to Billing and Insurance Patient Account Payment Policies December 2017 Lexington Clinic Central Business Office Payment Policies Customer service...2 Check-in...2 Plan participation, network
PATIENT INFORMATION. Name: Date of Birth: Age: Address: Social Security #: City: Sex: Marital Status: State: Zip: Language: GUARANTOR INFORMATION
PATIENT INFORMATION Name: Date of Birth: Age: Address: Social Security #: City: Sex: Marital Status: State: Zip: Language: Home Phone#: Race: Work Phone#: Ethnicity/Nationality: Cell Phone#: Employer:
Arthritis & Joint Center of Florida 2328 Medico Lane, Melbourne, Florida fax Financial Policy
Arthritis & Joint Center of Florida 2328 Medico Lane, Melbourne, Florida 32940 321.956.1501 fax 321.956.1502 Financial Policy We are committed to providing the best care at the most reasonable cost. We
First Name: Middle Name: Last Name: Preferred Name: Address: City: State: Zip: Mother s First & Last Name: Mother s Home Phone: Mother s Work Phone:
Patient Information First Name: Middle Name: Last Name: Date of Birth: Gender: M F Preferred Name: Address: City: State: Zip: Contact Information Mother s First & Last Name: Mother s Address (If different
COASTAL SKIN SURGERY & DERMATOLOGY
DEMOGRAPHIC INFORMATION Last Name: First: Middle: Date of Birth: Age: Sex: M F Marital Status: SSN: Race: Ethnicity: Hispanic or Latino Not Hispanic or Latino Language: Mailing Address: Street apt/unit#
SUBURBAN GASTROENTEROLOGY
SUBURBAN GASTROENTEROLOGY DARREN KASTIN, MD 1243 Rickert Dr. Telephone 630-527-6450 Naperville, IL 60540 Fax 630-527-6456 Suburban Gastroenterology, Ltd. would like to welcome you and confirm your appointment.
Catherine A. Casteel, DPM 7501 Lakeview Parkway, Ste. 135 Rowlett, TX Phone Fax
Catherine A. Casteel, DPM Authorization to Leave a Voicemail Please provide number(s) ONLY IF you approve us to leave DETAILED information related to appointments, billing, test results, diagnosis, and
2014 Established Patient Registration Welcome to the New Year! We ask that all of our patients provide us with updated information, such as phone number, address, insurance, etc, as well as sign an updated
Child s Name: Gender: M or F Last First MI. Date Of Birth: - - ADDRESS: CITY: STATE ZIP: REFERRING SOURCE. Physician Name Last First MI
PATIENT INFORMATION PATIENT INTAKE FORM DATE: PT/OT/ST Child s Name: Gender: M or F Last First MI Date Of Birth: - - SS# - - ADDRESS: CITY: STATE ZIP: REFERRING SOURCE Physician Name Last First MI Phone:
Financial Arrangements Birthing Center - $6575. What is Included
Financial Arrangements Birthing Center - $6575 The fee for comprehensive maternity care services with The Birth Place/ Commonsense Childbirth Inc. has been carefully determined to meet the needs of providing
Secondary Insurance Information: Name of Insured: Relationship to Insured: Self Spouse Child Other
PATIENT REGISTRATION First Name: Last Name: Middle: Preferred Name: Patient is: Responsible Party Policy Holder Responsible Party: ( if someone other than the patient ) First Name: Last Name: Middle Initial:
Office Policies. Clinic Timing: Monday to Friday: 8 am to 7 pm
Office Policies Thank you for choosing Progressive Medical Care (PMC) for your healthcare needs. Our mention is to provide you best available care in our resources and knowledge. Please take time to read/understand
New Client Information Sheet
New Client Information Sheet PSY Family Services Please complete ALL questions 301 W. Rosedale, Fort Worth, TX 76104 1. Client Demographics Patient Name: Last: First: Middle: Sex: ( )M ( )F DOB: Age: School
FLORIDA MEDICAL CLINIC, P.A. Your Life, Our Specialty
FLORIDA MEDICAL CLINIC, P.A. Your Life, Our Specialty Consent for Purposes of Treatment, Payment and Health Care Operations I consent to the use or disclosure of my protected health information by Florida
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:
DATE: PRIMARY LANGUAGE SPOKEN: PATIENT S LOCAL ADDRESS: (Street) (City) (Zip) PERMANENT ADDRESS (IF DIFFERENT):
DATE: PRIMARY LANGUAGE SPOKEN: PATIENT NAME: _ Nick Name: (Last) (First) (Middle) CHECK ONE: SEX: M F CHECK ONE: MARRIED SINGLE WIDOWED DIVORCED RACE: _ DATE OF BIRTH: SOCIAL SECURITY: PATIENT S LOCAL
PATIENT INFORMATION FORM
PATIENT INFORMATION FORM LAST NAME FIRST NAME M.I. ADDRESS: APT# CITY STATE ZIP (HOME) PHONE (WORK) E-Mail Address (CELL) PHONE SSN BIRTHDATE SEX (M) (F) PATIENT S EMPLOYER OCCUPATION EMPLOYER S ADDRESS
MacInnis Dermatology New Patient Registration Form
MacInnis Dermatology New Patient Registration Form Please print and answer all questions in full Date Patient Information (please complete using your name as listed on your insurance card) Patient First
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:
Island ObGyn Joseph F. Lang, MD
Island ObGyn Joseph F. Lang, MD Patient Name: Billing Address: City: ST: Zip: Other Address: City: ST: Zip: of Birth: Social Security Number: Home Phone #: Work Phone #: Cell Phone #: Email Address: Pharmacy:
Holistic Speech & Language Phone: (206) Fax: (206)
Client Intake Form Demographic Information Last Name: First Name: of Birth: Sex: Diagnosis (if known): Parent/Guardian Name(s): Home Address: Parent #1 Phone: Parent #2 Phone: Parent #1 Email: Parent #2
Patient Information Form
Patient Information Form Name Birthdate Social Security Number Age Address Occupation Phone Number Alt. Phone Number Email Emergency Contact & Phone Number How Did You Hear About Us What Are You Coming
ELYSE S. RAFAL, F.A.A.D.
ELYSE S. RAFAL, F.A.A.D. Welcome to our practice. Thank you for placing your trust in us. We look forward to serving you with quality and compassionate care. Patient Information Today s : First Name: M.I.
Please list all current medications and supplements that you are taking:
PATIENT HEALTH AND MEDICAL HISTORY Today s Date: Chief Complaint for Today s Visit: Was this injury gradual or sudden onset? Date of sudden onset: Please explain: Do you have a history of present symptoms?
PATIENT INFORMATION. Child s Name: DOB: Address: Phone: Zip: School: Emergency Contact: Phone: Relationship to Patient:
PATIENT INFORMATION Child s Name: DOB: Address: Phone: Zip: School: Father s Name: Occupation: Phone: (work) Email Address: Mother s Name: Occupation: Phone: (work) Email Address: DOB: Social Security
Tree House Pediatrics, PLLC
Tree House Pediatrics, PLLC Office Policies Our goal is to provide and maintain a good physician-patient relationship. Letting you know in advance of our office policies allows for a good flow of communication
Billing Address for responsible party (if different from home): Subscriber: DOB: Employer:
Today s D Today s Date: Parent/Guardian Name: DOB: Cell: Home: Work: Email: Preferred Method of Contact: Parent/Guardian Name: DOB: Cell: Home: Work: Email: Preferred Method of Contact: Patients Home Address:
Medical Information Release Form (HIPAA Release Form) Patient Name: Date of Birth: / / MR #: If minor, Parent/Guardian Name: Release of Information I authorize the release of information including diagnosis,
Obstetrics and Gynecology 50 Medical Drive Suite 100 (806) Borger, TX
PATIENT INFORMATION First Name MI Last Name Date of Birth Age: Social Security # Race Ethnicity: Sex: Female / Male Marital Status: S M W D Email Address: Mailing Address City State Zip Physical Address
Premier Obstetrics and Gynecology
, FL 33607, FL 33635 Patient General Information Name Birth date Age Social Security # Drivers License Home # Cell # Work # Street Address City State Zip Code Email Address Occupation Employer Spouse s
Dear Patient, Now that you are 18 years old we need a signed copy from you on file. Attached is a copy of the HIPAA form.
Dear Patient, We have a signed consent form on file that one of your parents has signed giving us consent to treat you and, if covered, to bill the Insurance Company. Now that you are 18 years old we need
PATIENT INFORMATION. PRIMARY INSURANCE Ins Co. Name: PRIMARY POLICYHOLDER PARENT/GUARDIAN INFORMATION (REQUIRED IF PATIENT UNDER 18 YEARS OF AGE)
PATIENT INFORMATION Name: Sex: of Birth: Social Security #: Address: Apt # City: State: Zip: Primary Phone: Primary Phone Type: Cell Home Work Secondary Phone: Secondary Phone Type: Cell Home Work Email:
Welcome to Hawaii Women s Healthcare
Cheryl Lynn T. Rudy, M.D. Cheryl L. Leialoha, M.D. Erin C. Gertz, M.D. Laura A. Spector, D.O. Andrea Wieland, APRN Welcome to Hawaii Women s Healthcare Hawaii Women s Healthcare strives to provide you
Child s Name Date of Birth. Address. City State Zip. Father s Name Phone (home) Phone (cell) Address. City State Zip.
Client Information Child s Name Date of Birth Address City State Zip Father s Name Phone (home) Phone (cell) Address City State Zip Email Father s Employer Mother s Name Phone (home) Phone (cell) Address
PEDIATRIC REGISTRATION FORM
PEDIATRIC REGISTRATION FORM **Today s Date: PATIENT INFORMATION: (Please use full legal name, no nicknames) *Last Name: *First Name: Middle Initial: *Address: City: State: Zip: *Sex: *Date of Birth: Age:
Ra m sd ell P ed iatrics, I nc.
Please Print Patient Information: Last Name First MI Address City State Zip - Home Phone Alt. Phone SSN Sex DOB / / Policyholder Information: Policyholder s Name Policyholder s Address Policyholder s DOB
Welcome to a Brighter Morgantown!
Welcome to a Brighter Morgantown! New Patient Information Payment Options E X C E L L E N C E I N D E N T I S T R Y S I N C E 1 9 2 7 Welcome to a Brighter Morgantown! Morgantown Dental Group would
Please plan to arrive 15 minutes prior to your scheduled appointment time.
Dear Patient: Welcome to our office. We want to thank you for choosing The Fertility Center of New Mexico for your healthcare needs. We have a dedicated team of professionals who are available and committed
See you soon, PAA Providers & Staff
Dear Parents, We look forward to meeting you and your child(ren). We are also pleased to be able to provide you with quality medical care that will promote the healthy growth and development of your child.
HEALTH HISTORY FORM. How Did You Hear About Us? Tell Us About Your Child. Person Respo sible for Account. Primary Dental Insurance
HEALTH HISTORY FORM 4 How Did You Hear About Us? 5 Who is Accompanying the Child Today? Name Today s 1 2 3 Tell Us About Your Child Patient s Full Name Preferred Name Male Female Siblings We Treat Patient
Sammy Lerma III, M.D. P.A. History and Physical Name: DOB: Age:
History and Physical Name: DOB: Age: Reason for Visit : Current Medications: Previous Hospitalizations: Last Physician's Name: Previous Surgeries: Reason for Changing Physicians: Current Specialists: Medication
PATIENT INFORMATION Patient Name: Last First Middle Initial. Address. Street or P.O. Box City, State Zip
PATIENT INFORMATION - 2018 Patient Name: Last First Middle Initial Address: Street or P.O. Box City, State Zip of Birth: / / Race: Gender: Male Female Social Security #: Marital Status: Single Married
DIABETES & ENDOCRINE CENTER OF ORLANDO, P.A. WELCOME LETTER 3113 LAWTON ROAD, SUITE 100 ORLANDO, FL
DIABETES & ENDOCRINE CENTER OF ORLANDO, P.A. 3113 LAWTON ROAD, SUITE 100 ORLANDO, FL 32803 407-894-3241 WELCOME LETTER We would like to take this opportunity to welcome you to our practice. Our records
MasterCare Physical Therapy, Inc.
Patient Financial Responsibility To all of our Patients: We will, as a courtesy, file your insurance claims for you. Please be advised that it is solely your responsibility to know and to understand your
Associates In Women s Healthcare PATIENT INFORMATION
(please print blue or black ink only) Associates In Women s Healthcare PATIENT INFORMATION Today s Date: Chart #: Name: Age: Birth Date: Last First MI Address: City: State: Zip: Home Phone: Cell Phone:
Willow Bend OB/GYN Obstetrics, Gynecology & Infertility
Dear Patient, Welcome to our medical office. We look forward to meeting you soon. In order to provide you with the best possible care, please complete our registration forms prior to your first visit and
W d/ Ed, >d,,/^dkzz &KZD Ͳ WůĞĂƐĞ ĂŶƐǁĞƌ ƚśğ ĨŽůůŽǁŝŶŐ ƋƵĞƐƚŝŽŶƐ ƚž ƚśğ ďğɛƚ ŽĨ LJŽƵƌ ĂďŝůŝƚLJ WĂƚŝĞŶƚ ĂƚĞ ŽĨ ŝƌƚś
Signature CONDITIONS OF REGISTRATION THE PRACTICE Sina J. Sabet, M.D. and/or its physicians, employees, agents or assignees will hereafter be referred to as The Practice. CONSENT FOR TREATMENT The undersigned
Benefits and Premiums are effective January 01, 2018 through December 31, 2018 PLAN DESIGN AND BENEFITS PROVIDED BY AETNA HEALTH PLANS INC.
Benefits and Premiums are effective January 01, 2018 through December 31, 2018 PLAN FEATURES Network Providers Annual Maximum Out-of-Pocket Amount $6,700 The maximum out-of-pocket limit applies to all
New Patient Information and Forms
350 S. Providence Rd. New Patient Information and Forms Please review, print, and sign the enclosed documents in advance of your first appointment. Our office staff will be happy to address any questions
1016 E. Spring Street 200 Brookstone Place Monroe, GA Social Circle, GA Phone Phone
1016 E. Spring Street 200 Brookstone Place Monroe, GA 30655 Social Circle, GA 30025 Phone 770-464-0280 Phone 678-871-7370 From: Michelle Plaster, MD Dear Valued Patient: Welcome to our practice. I am honored
EmployBridge Holding Company Associates Welfare Benefits Plan
EmployBridge Holding Company Associates Welfare Benefits Plan Summary Plan Description* *This document, together with the Certificate(s) and SPD Booklet(s) for the Benefit Program(s) in which you are enrolled,
BROKEN APPOINTMENT/LATE PATIENT POLICY
BROKEN APPOINTMENT/LATE PATIENT POLICY Reserved appointment time in any dental office is limited and valuable. It is extremely important that all patients honor their reserved dental appointments. Failure
Financial Policy Guidelines
Financial Policy Guidelines Welcome to The Women s Group of Northwestern. We strive to provide you with excellent medical care and our goal is to make your visit as convenient as possible. Please read
Welcome to Pediatric Therapy Center, PC!
Welcome to Pediatric Therapy Center, PC! We appreciate the opportunity to work with you and your child. Please read through and complete all paperwork before your arrival. We ask that you please arrive