WELCOME- OUR PHILOSOPHY
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- Francis Mosley
- 5 years ago
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1 WELCOME- OUR PHILOSOPHY Dear Patient, Thank you for choosing me to provide your orthopedic care. My team and I will make every effort to treat you with courtesy, respect and kindness, while providing the highest level of care possible. I truly understand the frustration of having to complete new forms each time you see another physician; however, in order to help me treat you accurately and efficiently, I would appreciate it if you would take a few minutes to complete the attached forms as accurately and completely as possible. Please be sure to fill out a separate history sheet for each area of the body for which you have been scheduled for your appointment. I have found that two of the factors that create the greatest delay during office hours are the necessity for me or my physician assistant to personally complete these forms with or for the patient, and the insistence by patients that they be seen for a problem for which they are not scheduled as long as they are here. As a result the waiting time for other patients is increased as is the level of frustration for all of us. Your cooperation will enhance your experience with my practice. My staff and I spend a great deal of the time during the first visit educating our patients about their diagnosis and together determining a customized treatment plan that will best suit their needs. We feel that when our patients understand their own bodies and the numerous treatment options, they have more control of their problem and can be proactive in their treatment. I have found that if patients write down their questions it helps insure that they don t forget to ask for information that is important to them. As a result of this philosophy, and the occasional need to fit in patients with emergency conditions, we will at times find it hard to stay on schedule. Please know that we do respect your time, and we will make every effort to see you as close to your scheduled time as possible. We understand that schedules change and that there may be a need to cancel or reschedule your appointment. Please give us at least 24 hours notice so that we can offer your appointment time to another patient. I look forward to getting to know you and helping you with your orthopedic problem. Sincerely, Ben Rubin, M.D.
2 YOUR FIRST VISIT 1. Please read the patient welcome letter on our website which explains our philosophy of care. 2. Please complete the forms on our website: OSI Patient Registration Form Orthopedic Questionnaire General Health History 3. Insurance information Please bring your insurance card and a photo ID 4. Imaging studies Please bring any recent x-rays, MRI or CT scans related to your injury. Please bring a CD of the studies or the actual films, not just the reports 5. Clothing Female shoulder patients - please bring or wear a tank top, halter or sports bra Hip, knee and ankle patients please bring or wear a pair of shorts Neck and back patients will be provided with examination gowns
3 verified by: Insurance Information verified by: Patient Information Patient Registration First Name Middle Initial Last Name Date of Birth Social Security Number Gender Male Female Street Address City State Zip Code Marital Status (circle one) Primary Care Physician Married Single Divorced Widowed Phone number : Home Cell Work address Driver s License # Employer Emergency Contact Name Relationship Phone Date of injury/onset of symptoms Primary Insurance Carrier Was this an injury? NO YES If yes, Where did your injury occur? WORK AUTO HOME SCHOOL OTHER: Secondary Insurance Carrier Insured s Name: Insured s Date of Birth: Insured s Social Security number Insured s Name: Insured s Date of Birth: Insured s Social Security number ID # ID # Group # Group # Claims Address: Claims Address: Phone: Phone: Guarantor Responsible Party Patient Other (if other please fill in information below) Name: Date of Birth Relationship to patient: Street Address City State Zip Code Phone number Social Security Number Employer I hereby assign the insurance benefits to which I am entitled, directly to ORTHOPAEDIC SPECIALTY INSTITUTE, a medical group. I understand that I am financially responsible for all charges regardless of insurance verification, benefits and eligibility. I authorize release of medical records and information regarding medical history that is requested by the insurance company. A photocopy of this authorization is accepted with the same authority as original. Photo identification and insurance cards must be presented at the time of service to enable OSI to submit claims to your insurance carrier. Should identification and insurance cards not be presented, you will become a cash patient with payment in full due at the time of service. This agreement will remain valid from this day forward to include all future services relating to the above patient. SIGNATURE OF PATIENT/GUARDIAN DATE
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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)
NOTICE TO OUR PATIENTS
NOTICE TO OUR PATIENTS Although we participate with most insurance plans, you as the patient and/or insured party are responsible for co-pays, deductibles and any non-covered services, which are outlined,
for / / at in (Provider name) (date) (time) (location)
Welcome to our practice. We strive to make the registration process go as quickly for you as possible on the day of your appointment with for / / at in (Provider name) (date) (time) (location) In order
FREDERICKSBURG ORTHOPAEDIC ASSOCIATES, P.C. PHYSICAL THERAPY INSTITUTE PATIENT INFORMATION SHEET
PATIENT INFORMATION SHEET Chart #: Today s : FOA Initials: PATIENT INFORMATION Last Name, First Name, MI: Home Phone: Cell Phone: SSN: Birth (MM/DD/YYYY): Age: Sex: Marital Status: Single Separated Male
If patient is under 18 y/o, name of Parent/Guardian: Relationship to Patient: Address: (street) (city/state) (zip code)
At both New Tampa Foot & Ankle AND South Tampa Foot & Ankle, we are committed to getting you back on your feet free of pain and injury so that you can get back to your activities and back into life! We
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.
PATIENT REGISTRATION
TIME 10:15 AM PATIENT REGISTRATION DATE 6/15/2016 ID: Chart ID: First Name: Last Name: Middle Initial: Patient Is: Policy Holder Responsible Party Preferred Name: Responsible Party ( if someone other than
EMERGENCY CONTACT INFORMATION PATIENT EMPLOYER INFORMATION GUARANTOR / POLICY HOLDER INFORMATION INSURANCE INFORMATION
Physician Name: David R. Lionberger, M.D. PATIENT DEMOGRAPHIC INFORMATION SHEET Last Name First Name Middle Social Security No. Date of Birth Age Male or Female (Please circle one) Marital Status: M S