Telephone #: (336) Fax #: (336) Referring Physician: PATIENT NAME: APPOINTMENT DATE: PLEASE ARRIVE AT: FOR YOUR APPT.
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1 William W. Truslow, MD PLLC Practice of Rheumatology 409 Parkway Drive, Suite A Office Hours: 9 AM-5 PM (M-Th)/closed on Friday Greensboro, NC Telephone #: (336) Fax #: (336) Referring Physician: PATIENT NAME: APPOINTMENT DATE: PLEASE ARRIVE AT: FOR YOUR APPT. Dr. Truslow is dedicated to providing you with the best possible medical care. Dr. Truslow is a rheumatologist, which is a specialist that treats patients with various forms of arthritis. If you have any questions prior to your appointment, please do not hesitate to contact our office. Please complete the enclosed forms and bring them with you for your appointment. Our office has agreements with the following Insurance companies: AARP Complete, Advantra Medicare, Aetna, Blue Cross Blue Shield, Cigna, Coventry National Network, First Health, Humana, Medicare (including most replacement plans), Medcost, Multiplan, PHCS, Unicare, United Healthcare, UMR, Wellcare, and Wellpath. OUR OFFICE DOES NOT FILE WORKER S COMPENSATION CLAIMS. Please be prepared to present a valid photo ID and current insurance card in order to be seen & file insurance: otherwise your appointment will be rescheduled. FOOD AND DRINKS ARE NOT PERMITTED IN THIS OFFICE. *Please bring a written list of any medications that you are currently taking and the bottles for those medications, as well as any medical information provided by your referring physician. *Please refrain from wearing any strong perfumes, lotion, colognes, or smoking prior to coming in our office. Many of our patients have adverse reactions to these odors. *As a courtesy, we ask that you notify our office at least 24 hours in advance if you are unable to keep your appointment. Thank you for your consideration of other patients and the Doctor. New patient appointments that are not kept will not be rescheduled. Please call and reschedule if the appointment date and time will not work for you. DIRECTIONS: Our office is located off of Wendover Avenue, and is close to Moses Cone Hospital. Turn onto Cridland (right if you are eastbound, left if you are westbound) beside the Marathon gas station. Then take the immediate right to continue on Cridland. Our office is the third building on the left, and can be entered from the left side of the building. The Latham Park Tennis Facilities are located across the street from our building.
2 OFFICE POLICIES AND PROCEDURES Please read the following information and keep it for future reference regarding our office policies and procedures. INSURANCE PLANS AND MANAGED CARE: Please contact your insurance company to verify that Dr. Truslow is a participating physician in their network if you are unsure that we will accept your insurance plan. This telephone number, in most cases is printed on your insurance card. We will file your insurance claim if we participate with your insurance plan. It is the patient s responsibility to obtain a referral from your primary care physician if required by your HMO or POS to see a specialist. Medicare and Supplements: We do accept assignment from Medicare. You are required to pay your deductible that has not been met and any co-pay/co-insurance at the time services are rendered. The 2015 Medicare deductible is $ Most Supplemental plans are crossed over automatically after Medicare has processed the claim. Payment: Payment of applicable copays and/or coinsurances & deductibles will be expected at the time of service.. We will be glad to reschedule your appointment if necessary. If you have a private/group insurance plan that we do not participate with, full payment is due at the time of service. We will provide you with a document that you can use to file your own insurance claim with your insurance carrier. In the event that we filed and your insurance carrier determines that a service that you received is not a covered service, you will be responsible for the full payment. If your insurance carrier pays only a percentage of your bill leaving a balance on your account, you will receive a bill from our office which will be payable upon receipt. We accept cash, check, money order, Discover, Visa and MasterCard. Credit & debit cards are accepted. Prescription Refills: Dr. Truslow provides enough medication on his prescriptions to last until the patient s next return appointment. Please bring all of your current medications with you to each visit to our office. Prescriptions written by Dr. Truslow become the patient s responsibility to get filled by a pharmacy. Please inform Dr. Truslow during your office visit if you are using a mail order pharmacy with special requirements. This will eliminate extra work and phone calls for our office. Please do not contact our office requesting refills for prescriptions that Dr. Truslow did not prescribe. Contact the doctor s office that wrote your prescription because we cannot refill something that Dr. Truslow did not prescribe. We do not refill prescriptions after hours or during the weekend. Please have your pharmacy contact us directly for refill requests. We submit all prescriptions electronically to both local and mail order pharmacies. EMERGENCIES: Dr. Truslow can be contacted at his office during normal business hours; however, in the event that an emergency occurs during the hours that the office is closed, please call your primary care physician. If you don t have a PCP, please go to an urgent care near you. Call 911 if you are having a life-threatening emergency. Hospital admissions are performed by a hospital based Hospitalist group, and Dr. Truslow will be available for consultative services. If your problem is not an emergency, please contact our office during normal office hours. Please call to leave any none emergency message with our answering service. MISSED APPOINTMENTS: Patients that miss 3 appointments with less than a 24 hour notice will be dismissed from our practice. A fee of $10.00 will be charged for all missed appointments. If you have any questions, please contact someone in our business office. Our normal business hours are: 9:00 AM to 5:00 PM Monday- Thursday. Our office is closed on Friday. Our office telephone number is (336) I have read and agree to accept the terms of the office policy of Dr. William Truslow: Signature of patient: Date:
3 PATIENT INFORMATION DATE Patient Age Birth date Sex M / F Last First Middle Address Number Street City State Zip Code Home Phone Work Phone Social Security # Cellular Phone Marital Status: Single( ) Married( ) Widowed( ) Divorced( ) Other ( ) Race: Occupation Employer Spouse s Name Birth Date Last First Middle Initial Spouse s Employer Social Security# Emergency Contact ph# Relationship Person Responsible For Bill Relationship to Patient Referred By Primary Physician Does you insurance (HMO/ POS) require an authorization from your primary care physician to see a specialist? Y / N Referring Physician s Address Phone Primary Insurance Secondary Insurance Name Name Address Address Policy Holder Policy Holder Policy # Policy # Group # Group # Please indicate how you plan to pay your bill before leaving the office? CASH ( ) CHECK ( ) CREDIT CARD ( ) Do you have Medicare? YES ( ) NO ( ) Is Medicare your PRIMARY insurance? YES ( ) NO ( ) Do you have additional insurance other than Medicare? YES ( ) NO ( ) WILLIAM W. TRUSLOW, M.D A Parkway Drive Greensboro, NC (336) phone (336) fax AUTHORIZATION TO RELEASE MEDICAL INFORMATION: The undersigned authorizes the release of all or parts of the patient s medical records by telephone or writing to applicable professional review organizations, or a person or corporation, which is or may be liable under a contract with William W. Truslow, MD or to the patient, authorized family member, or employer of the patient or insurance company. Patient authorizes access to pharmacy history records when medications are prescribed. GUARANTEE OF PAYMENT: For medical services rendered to the above named patient including telephone consults and missed appointment fees, the undersigned guarantees payment to Dr. William W. Truslow, MD. ASSIGNMENT OF INSURANCE BENEFITS: I hereby assign all of my right, title and interest in and to any insurance benefits, and direct payment to Dr. William W. Truslow, MD of insurance benefits, including Major Medical or any other insurance payable to or on behalf of the undersigned by virtue of services rendered by Dr. William W. Truslow, MD. Signature of Patient Date This authorization/ release shall remain valid until rescinded at another date.
4 NAME AGE DATE WHAT ARE YOUR SYMPTOMS? HISTORY OF ILLNESS MUST ANSWER ALL THE FOLLOWING QUESTIONS WHERE IS YOUR PROBLEM? WAS THIS AN ACCIDENT? DATE OF ACCIDENT HOW LONG HAVE YOU HAD THIS PROBLEM? HOW SEVERE IS YOUR PROBLEM? HOSPITALIZATION OR SURGERY DATE REASON DR. DATE REASON DR. MEDICINES: List ALL current medicines, even over the counter. This is very important. Show number of milligrams and how often you take the medicine (attach a list if there is not enough space to list all) DRUG ALLERGIES Please list drug name and type of reaction: HABITS: SMOKING: YES ( ) NO ( ) Packs per day How many years ALCOHOL: YES( ) NO( ) Type Amount CAFFEINATED DRINKS (Cups per day): WOMEN ONLY: Number of pregnancies Miscarriages? Last menstrual period Planning pregnancy? Last bone density test FAMILY HISTORY: Father: Living ( ) Deceased ( ) Age at death Cause of death Mother: Living ( ) Deceased ( ) Age at death Cause of death Brothers: Number living Number deceased Sisters: Number living Number deceased Number of Children: Is there a family history of ARTHRITIS? Relatives Type of Arthritis Cancer Diabetes Stroke High blood pressure/heart disease WEIGHT: Current: Weight one year ago: HEIGHT: FOR OFFICE USE ONLY: BP: HT: feet inches Pulse: BMI: LB: Initials:
5 For Physician Use AM Stiffness Joint Swelling F,S,C Anorexia, insomnia, fatigue, weight loss, depression Rash Psoriasis Photosensitivity Oral Ulcers Alopecia Pleurisy HA, migraine, vision Raynaud s Myalgia and weakness Dysphagia, diarrhea, const, HB, melena, BRB Conjunctivitis Urethritis, hematuria Heel or Achilles tendon Back pain Tick exposure Tryptophan Miscarriage, menses
6 William W. Truslow, M.D. 409-A Parkway Drive Greensboro, NC PATIENT CONSENT Patient Name: Date of Birth: By signing this consent you are giving the providers and office staff permission to use and disclose your health information. Your health information will be used and disclosed to provide your care and treatment, to bill and collect payment for the services provided, and to perform necessary routine office operations. You have been provided with a copy of our Notice of Privacy Practices that contains a complete description of the uses and disclosures covered under this consent. You have been given time to review the Notice of Privacy Practices and we have encouraged you to read it and ask any questions that you may have prior to signing this consent. Our office reserves the right to change the privacy practices as stated in the Notice of Privacy Practices. You will be given a copy of the revised notice with your first office visit following any change. You have the right to request that we restrict how your health information is used or disclosed. We are not required to agree to your requested restriction, but if we do agree to the restriction, we will honor the restriction. You have the right to revoke this consent except to the extent that we have already taken action covered under the consent. If you choose to revoke this consent, you must do so in writing. This consent will remain in effect until revoked. I give permission for Dr. Truslow or his staff to leave a message on a home/work/cell answering device. Please list the preferred number on which you would like for us to leave the message. Please specify if there are any restrictions. I give permission for Dr. Truslow or his staff to leave messages with my spouse, family member, or friend, etc regarding my personal information. Please specify the name(s), relationship, and telephone number(s) of the individuals you wish to authorize. Sign and Date below Relationship if Not Patient
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W E L C O M E PATIENT INFORMATION Name Date Address Apt # City State Zip Code Phone #: Home Cell Work Referred By Date of Birth Social Security # - - Gender: Male Female Marital Status (please circle):
More informationAnoop K. Reddy, MD NEW PATIENT INFORMATION PERSONAL INFORMATION
Anoop K. Reddy, MD NEW PATIENT INFORMATION PERSONAL INFORMATION NAME: _~ ~~~~~~~ ~~ ~~~~~~~~~~~_~_~ DATE OF BIRTH: AGE: -- ~~~~~~~~----~- --~-- SEX: o MALE o FEMALE SOCIAL SECURITY: ~ CURRENT ADDRESS:
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PATIENT INFORMATION FORM PATIENT INFORMATION Patient Name Last First Date of Birth Age Street Address Male Female City State Zip Code Social Security Number Home Phone Work Phone Cell Phone E-Mail Employer
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Patient Health History Form PATIENT INFORMATION Patients Legal Name: Name that child likes to be called (Nickname): DOB: Current Age: SOURCES OF INFORMATION Name of Person Providing Information: Relationship
More informationMICHAEL 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
More informationCENTRAL 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 #:
More informationPATIENT 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:
More informationPATIENT 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
More informationOUR POLICIES. Prior Authorization for prescriptions is $10.00 for each authorization completed.
OUR POLICIES Effective April 1, 2008, due to continued decreasing insurance reimbursements, we will begin strictly enforcing fees for certain tasks that we perform on behalf of our patients. Phone calls
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Patient Registration Form Patient Information Patient Name (Last, First, M.I.): Birth Date: / / Social Security Number: Sex (Circle One): Male / Female Race (Circle One): Asian/African American/American
More informationDo 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
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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:
More informationKalpana Thakur, M.D. PA Registration Form
Registration Form (Please Print): : Patient Information Last Name: First: Middle: of Birth: Age: Sex: M F Marital Status: Single Married Other S.S. Number Home phone: Mobile: Street Address: City: State:
More informationDear. If you have any questions, feel free to call our office. We look forward to seeing you. Sincerely,
Dear We would like to welcome you to our office and thank you for choosing Heritage Valley Medical Group Internal Medicine Associates. Our hours of operation are Monday through Thursday 8am-5pm, and Fridays
More informationQuick Patient Registration Form Patient Information:
Quick Patient Registration Form Patient Information: Legal First Name: MI: Legal Last Name: Sex: M F Date of Birth: Primary Language: Marital Status: Married Single Partner Divorced Widowed Race: Ethnicity:
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Demographic Information Name Sex Male / Female Social Security Number Email Marital Status Single / Married / Widowed / Divorced / Other Mailing Address City/State Zip Code Primary Phone Secondary Phone
More informationMESSIEH ORTHOPEDICS Page 1 MICHAEL S. MESSIEH, M.D. DEMOGRAPHICS/INSURANCE INFORMATION. Patient name: Date of Birth: / / SS#: Race:
MESSIEH ORTHOPEDICS Page 1 MICHAEL S. MESSIEH, M.D. DEMOGRAPHICS/INSURANCE INFORMATION Date: Patient name: Date of Birth: / / SS#: Race: Ethnicity: Language: Home address: City: State: Zip code: Email:
More informationPATIENT INTAKE AND MEDICAL INFORMATION
PATIENT INTAKE AND MEDICAL INFORMATION PATIENT INFORMATION: Todays Date: DOB: GENDER: M F SSN (required): Marital Status: Divorced Married Separated Single Widowed Address: City: State: Zip: Phone (H):
More informationPatient Registration. Patient Information. Guarantor Information (skip if same as patient) Emergency Contact Information. Insurance Information
Patient Registration Patient Information Patient name (Last, First) Patient date of birth Patient gender (M / F) Patient marital status Mailing address (address number & street) Patient Social Security
More informationPrimary Care Physician Cardiologist Referring Physician PROTECTED HEALTH INFORMATION AUTHORIZATION
DEMOGRAPHIC INFORMATION Name Sex Male / Female Social Security Number Email Marital Status Single / Married / Widowed / Divorced / Other Mailing Address City/State Zip Code Primary Phone Secondary Phone
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AUBURN URGENT CARE Patient Information Name: Last First Middle Date of Birth: / / Social Security: Permanent Address: Apt #: Zip: City: State: Race: Gender: M F Undifferentiated Home Phone: ( ) Cell:(
More informationPatients who are running 20 minutes late for his/her scheduled appointment will be rescheduled to the next available appointment/ day.
Orthotics/ Durable Medical Equipment Policy H2T is NEVER able to guarantee payment by medical insurance carriers for Orthotics and/or Durable Medical Equipment. H2T will bill your medical insurance as
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MORE MD Patient Information Date: Patient Name: (Last) (First) (Middle) Mailing Address: City: State: Zip: SS# DOB: Age: Home Ph #: Cell Ph#: Work Ph#: Race: White Asian Africian-American American Indian
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Personal Medical History Form Please Print PATIENT S LEGAL NAME: REFERRED BY: REASON FOR VISIT: TODAY S DATE: BIRTH DATE: PLEASE ANSWER ALL OF THE QUESTIONS AS ACCURATELY AS POSSIBLE. IF YOU DO NOT UNDERSTAND
More informationPlease be aware that payment of all office visits and services are due at the time of your visit.
Dr. David A. Amato All About Faces Community Dermatology 1 West Main Street Hummelstown, PA 17036 (717) 547-9220 www.communityderm.com (717) 260-3711 www.allaboutfaces.biz I would like to take this opportunity
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Prefix Last First Middle Suffix Maiden Gender SSN Marital Status Date of Birth Race Ethnicity Primary Language Address Line 1 Address Line 2 United States Zip City State Country Home Phone Cell Phone Work
More informationOffice Hours: Monday Friday from 8:30 am 5:00 pm, but are closed for major holidays.
Greetings from Barton Women s Health Health care is personal and we know you have many choices in your care. Thank you for choosing the practice of Barton Women s Health for your gynecological and/or obstetric
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PITTSBURGH FAMILY FOOT CARE, P.C. PATIENT INFORMATION FORM (PLEASE PRINT) IF WE NEED TO CONTACT YOU ASAP FOR SCHEDULE CHANGES, WHAT NUMBER SHOULD WE CALL? PRIMARY PHONE: PATIENT NAME: DATE OF BIRTH: /
More informationCardiology Consultants of North Morris, P.A.
In regard to your upcoming appointment, information sheets have been enclosed which may be completed at home. Please bring them and your MEDICAL INSURANCE CARDS with you on your appointment day. If you
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Patient Information: Patient Name: Social Security Number: / / Date of Birth: / / Sex: M / F (Circle one) Married/Single/Divorced/Widow Address: Zip Code: Home Phone: ( ) - E-mail Address: Cell Phone:
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Phone: 540-885-4500 Fax: 540-885-4600 PATIENT DEMOGRAPHIC INFORMATION PLEASE PRINT NAME: AGE: (LAST) (FIRST) (MIDDLE) SEX: M F (CIRCLE) DATE OF BIRTH: PERSON RESPONSIBLE FOR ACCOUNT: MAILING ADDRESS: (CITY)
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PATIENT INFORMATION First Name: MI: Last Name: Nick Name: Address: City: State: Zip: PHONE NUMBERS Date of Birth: / / Please Your Preferred Contact Number Cell: Sex: M F Work: Status: Single Married Widowed
More informationWelcome! 7000 W. Plano Parkway Plano, TX Please remember to bring: New Patient Paperwork. Current Insurance Card
7000 W. Plano Parkway Plano, TX 75093 SW corner of Plano Pkwy & Marsh Welcome! Thank you for choosing Dr. Christine Stiles to care for your child s plastic surgery needs. This is a satellite office of
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