NEW & CURRENT PATIENTS
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- Opal Ward
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1 Patient Registration Update: NEW & CURRENT PATIENTS General Information: First Name: MI: Last Name: Prefix: Suffix: Address: Zip Code: City: State: Contact: Cell: Home: Work: Insurance Information: (This used for referral information only.) Primary: Secondary: Policy Holder Name: Policy Holder Date of Birth: Policy Holder SS#: Policy Holder Employer: Basic Information: Gender: Male Female Date of Birth: Employer: Emergency Contact: Relation: Emergency Phone: Responsible Party: First Name: Last Name: Address: Zip Code: City: State: HIPPA: I hereby acknowledge that I have a received the Access To The Hope Family Center Notice of Privacy Practices. Date: Signature: Authorization to Release Information: I authorize the release of any medical information necessary for a referral to another medical provider. I permit a copy of this authorization to be used in place of the original. Date: Signature:
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4 New Patient Survey We would appreciate you taking the time to answer the following questions. How did you learn about Access To The Hope Family Center? Circle Yes or No Did anyone refer you to us? Yes No Did you visit our website? Yes No Did you see us on Facebook? Yes No Did you hear about us on the radio? Yes No Did you find us in the phonebook? Yes No Thank you for taking this survey!
5 MEMBERSHIP CONTRACT $48 Monthly Membership Fee Plus a $20 appointment scheduling fee for each office visit. You now have a Medical Home Membership, which will allow you to be scheduled for routine doctor visits for a fee of only $20 per visit. There is no extra charge for most basic lab work for our members. Some non-routine lab work that is sent out is based on actual cost at approximately a 75% discount. All Annual Healthcare Memberships are nonrefundable once any office visits or lab work has been completed. This represents a private contract between Access To The Hope Family Center and the patient, which is executed after membership payment has been made and initial services rendered. Insurance will not reimburse for the prepaid plans and this is not a type of insurance. Access To The Hope Family Center does not file insurance claims or sign insurance contracts. Medicare and Medicaid recipients are not allowed to file claims for Medicare/Medicaid covered services. Basic lab work that can be performed at no additional charge for members include: Strep Test, CMP, Lipid Panel, TSH, PSA Screening, HgA1C, Urine Dip, CBC, and an Annual Pap Smear. Members receive an annual EKG at no additional charge. We have arranged for significantly discounted rates at participating facilities for other diagnostic tests such as X-ray, MRI, and Ultrasound testing. Services such as sutures or supplies like injections are not included or discounted with membership. *There is a No-Show fee for missed appointments of $20.00 per episode. Please SELECT One Option Below: I, (print name) agree to pay $499 in full, for the year starting / /20 for this membership and ending on / /20. OR I, (print name) agree to pay $48 per month (with the first 3 months paid in advance for new patients) for one year starting / /20 for this membership and ending on / /20. This fee will be drafted from the bank account that you provide on every 1st of the month. Either prepaid plan entitles me to discounted fees on services at this location only. I will still be responsible for other services not discounted as specifically mentioned above. At the end of one year, this contract will automatically renew unless you inform us in writing to cancel; however, fees and terms may change annually. CONTROLLING LAW: This agreement shall be construed and interpreted in accordance with the laws of the State of North Carolina. As used in this agreement, the singular shall include the plural and the plural shall include the singular and the use of any genders shall be applicable to all genders. SEVERABILITY/INVALID CLAUSES: The provisions of this agreement are severable and should any provision, clause, sentence, section, or part thereof be found to be invalid, illegal, unconstitutional, inapplicable to any person or circumstance, or otherwise unenforceable, the remainder of the agreement shall not be affected thereby and each term, provision, sentences, clauses, sections or parts of the agreement herein shall be valid and enforceable to the fullest extent permitted by law. I understand that if I receive services under this agreement and then either fail to make a monthly payment or full annual fee that I will responsible for all charges I have incurred at the normal non-discounted rate. Signature Date
6 IMPORTANT INFORMATION All payments must be current to be seen, to receive prescription refills, and/or receive referrals. Bring ALL medications and vitamins to EVERY VISIT! Make sure ALL of your contact information is updated. Come in a week BEFORE follow-up appointment for blood work, if blood work is necessary. Make sure your Credit Card, Debit Card, or Bank account information is current, including the EXPIRATION DATE, for monthly billing to avoid additional service fees. A service fee of $15.00 is charged on all banking returned charges. Please notify us at least 24 hours before an appointment if you need to cancel or reschedule to avoid a $20.00 service fee. There is a $20 NO SHOW FEE for each missed appointment. Important understanding for members paying monthly. If you do not fulfill your terms of payment, you will be help responsible for all unpaid annual charges or you will be charged NON-MEMBER rates. Non-member rates are currently $ per visit plus any additional services. We require new monthly members to pay the first 3 months in advance ($144). After the first 3 months, you will begin paying $48 per month on the first of each month. Failure to make your payment on time may result in being sent to collections and reported to the credit bureau. Understand that billing may come directly from our office or you may receive bills from our authorized external billing company TWIN OAKS. All office visits have a $20 scheduling fee. We appreciate you taking the time to review the additional information. We find this important to review so we can do everything possible to help keep our prices reasonable for all of our members. Patient s Signature Staff member that reviewed this with patient
NEW PATIENT DEMOGRAPHICS
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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
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NAME (LAST, FIRST, MIDDLE) SSN# BIRTHDATE SEX NAME (LAST, FIRST, MIDDLE) SSN# BIRTHDATE SEX
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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
(Please Print using Black or Blue Ink) SEX: GENDER IDENTITY: MARITAL STATUS: SINGLE MARRIED OTHER
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Today s Date (mm/dd/yyyy):
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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
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
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
OUR 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
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:
PATIENT REGISTRATION (Please Print) Social Security # Address City State Zip. Address
PATIENT REGISTRATION (Please Print) Date Name (Last) (First) (MI) Clinician Social Security # Address City State Zip Email Address Home Phone ( ) Mobile/Alt. Phone ( ) Work Phone ( ) PLEASE IDENTIFY WHICH
Instructions for Needs Processing
Instructions for Needs Processing The sharing turnaround time is between 14 and 60 days, depending on the receipt of all required information and whether your bills go through negotiation. If your Needs
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
BARACLUDE PATIENT ASSISTANCE PROGRAM HOW DO I APPLY? FAX OR MAIL APPLICATION
BARACLUDE PATIENT ASSISTANCE PROGRAM The Baraclude Patient Assistance Program is designed to provide free medication to qualifying patients who do not have prescription drug coverage and are having a hard
Patient Name: Last First Middle Address: Marital Status: (circle one) Single Married Divorced Widowed Other Gender: Female Male
Patient Information Patient Name: Last First Middle Address: City: State: Zip Code: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Email Address: of Birth: / / Social Security #: - - Marital Status:
550 Pharr Rd NE, Suite 605 Atlanta, GA Office Fax pathgroupatl.com
550 Pharr Rd NE, Suite 605 Atlanta, GA 30305 Office 404.235.5982 Fax 678.705.2756 pathgroupatl.com ADULT PATIENT REGISTRATION INFORMATION AND GUARANTOR AGREEMENT Which Provider are you seeing today? Smitha
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:
Today s date: PATIENT INFORMATION. Address:
Today s date: PATIENT INFORMATION Patient s last name: First: Middle: Please send appointment reminders to: Mobile phone #: Email Address: Mr. Mrs. Registration and Medical History Marital status Single