GWINNETT PEDIATRICS & ADOLESCENT MEDICINE
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1 GWINNETT PEDIATRICS & ADOLESCENT MEDICINE PATIENT REGISTRATION INFORMATION Date Patient Acct # PATIENT INFORMATION Name: Date of Birth: First Middle Initial Last Sex: Male Female Home Phone: Mom Work Phone: Mom s Cell: Dad s Work Phone: Dad s Cell: We can text appointment reminders. (We send out appointment notices via ) GUARANTOR INFORMATION (Responsible Party / Will be SELF if patient is 18 yrs or older) Name: First Middle Initial Last Date of Birth: Sex: Male Female Social Security#: Marital Status: Single Married Divorced Other EMERGENCY CONTACTS Emergency Contact Name: Phone #1: Phone #2: Nearest Relative (not living with you): Phone #1: Phone #2: INSURANCE INFORMATION (copy of insurance card required to file insurance) Primary Insurance Carrier Name: Insurance Phone #: Effective Date: Policy Holder Name: Group #: Patient ID#: Relationship to Patient: Birthdate: Social Security #: Name & Address of Employer Your signature below indicates your consent for treatment of /as patient and responsibility for the payment of the bill. Thank you. Guardian or Patient Signature Date:
2 GWINNETT PEDIATRICS & ADOLESCENT MEDICINE FINANCIAL POLICY Gwinnett Pediatrics is committed to providing you with the best possible medical care for your child. We believe that an informed consumer is a more satisfied consumer. Therefore, in our effort to communicate, we offer you our Financial Policy in writing to keep with your family s medical receipts. The following information is provided to avoid any misunderstandings or disagreement concerning payment for professional services. I understand that whoever brings my child in for visits is authorized to receive financial and medical information. FINANCIAL INFORMATION: Payment is required at the time services are rendered. If you are unable to pay your bill today, please ask to speak with a Financial Advocate. He/She will assist you with arranging a payment plan, discussing financial assistance, or rescheduling an appointment for a time when you are prepared to pay. Regardless of your insurance coverage, you are ultimately responsible for full and timely payment of all charges incurred at Gwinnett Pediatrics. If you fail to make payment in full or arrange for a payment plan with our financial department for the services that are rendered to you, your outstanding balance may be sent to a collection agency and you may be terminated from our Practice. You may be responsible for the fees assessed by the collection agency. Because our practice is charged per call for after-hour calls to the CHOA advice line, we request that you contact your insurance advice line first. You may be charged $15.00 for calls that are routed to the CHOA line or the physician on call. INSURANCE INFORMATION: Our practice participates with a variety of insurance plans and it is your responsibility to: Be familiar with the requirements of your specific plan. We handle families covered by more than 1,000 health plans and cannot be responsible for understanding the current details of every plan. You are required to present your current insurance card at every visit. Your co-payment, coinsurance and/or deductible are required at each visit. Payment can be made by cash, check, or credit card. If you do not bring payment to your visit and we have to bill you, your visit may be rescheduled or you may be assessed a $5 processing fee. For medical care not covered under your insurance, payment in full is due at the time of the visit. Secondary medical insurance will be filed upon your request only and we will be happy to provide you with a claim form in case that you want to submit to your secondary carrier yourself. Please ask the financial advocate for assistance. If you have insurance that we do not participate in, we will file the claim upon request; however, payment in full is expected at the time of service. If you change insurance, please be sure to notify our billing office with this information as soon as possible otherwise you may be responsible for the entire bill. If you have questions regarding your insurance, we will be happy to help you; however, specific coverage issues should be directed to your insurance company member services department. CANCELLATIONS AND MISSED APPOINTMENTS: If it is necessary to cancel your check up appointment, please do so 24 hours prior to your appointment or your account may be assessed a $50 late cancellation/missed appointment fee. If you miss your sick child appointment your account may be assessed a $25 fee. If you are divorced, please note that the party that brings the child to the office will be the responsible party on record. We will not be involved in parental court cases. Our practice firmly believes that a good physician/patient relationship is based upon understanding and good communication. How should we contact you: home cell text Please sign below to acknowledge that you have read and agree to this financial policy. Signature of Patient or Responsible Party Date Patient Name: Date of birth:
3 RECEIPT OF NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGEMENT FORM The Privacy Act requires that you be informed of your rights to patient privacy. In order to demonstrate that you were advised of your right to privacy of your medical records, we ask that you complete the following: I, (Legal Guardian s Name) am the responsible party for Child s Name Date of Birth I am related to the child by (Indicate Relationship). Please list who IS NOT ALLOWED to have access to your child s financial and medical history: 1. Offered (but refused to read/sign) (check here) or--, 2. Reviewed, (check here), --or-- 3. Received (for take-home) (check here), A copy of GWINNETT PEDIATRICS & ADOLESCENT MEDICINE s Notice of Privacy Practices. Lab Results: May we leave your child s lab results on your voic ? Yes No If yes, what telephone number should we leave the results on? Date: Signature: The American Recovery and Reinvestment Act of 2009 requires that we gather additional information from you about your background. Thank you for answering the following 3 questions: Race: Unknown African American Asian Caucasian Filipino Hispanic Japanese Chinese Native American Native Hawaiian Pacific Islander Indian Other Ethnicity: Hispanic Non-Hispanic Unknown/Decline Primary Language: English Spanish Other Unknown/Decline How did you hear about our office? Website Friend Ad Facebook Festival Other
4 G A P M GWINNETT PEDIATRICS & ADOLESCENT MEDICINE LATE ARRIVALS Our primary concern is the safe, efficient delivery of medical care for all our patients. We have set Appointment Times for our patients and do our best within the limits of circumstances that we can control to see our patients on time. Please understand that this policy is in place to prevent the Doctors from falling extremely behind during the day. We ask all out parents to abide by this and all of our office policies. Chronically ignoring or failing to follow our office policies may result in our requesting that you find another pediatric group for your child s healthcare. We encourage and expect our patients to arrive in a timely manner as late arrivals interfere with the Doctor being able to stay on his/her schedule. We feel that patients deserve our attention during the appointment time we have reserved for them. If you arrive late for an appointment, out staff will check with the Doctor to see if we will be able to see you at this time, at a later time during that day, or the next available appointment. Thank you for helping us to maintain an efficient patient schedule. Gwinnett Pediatrics & Adolescent Medicine
5 G A P M GWINNETT PEDIATRICS & ADOLESCENT MEDICINE WALK IN POLICY Our primary concern is the safe, efficient delivery of medical care for all of our patients. We do not have Walk In Hours. We have many resources for you to schedule appointments. You can call, , or download our Itune app. Please check out our website at gwinnettpeds.com and click on the Sun. We see our patients by appointment and do our best within the limits of circumstances that we can control, to see our patients on time. We feel that patients deserve our attention during the appointment time we have reserved for them. We do not encourage walk in appointments, as it interferes with our ability to deliver safe medical care in a timely manner to all our patients. We request that all patients call for an appointment time before coming to our offices. There are very rare instances in which it is appropriate to come in before calling. A life threatening or potentially life-threatening situation is not one of these instances. Anytime that a parent feels that a life threatening medical condition is present, the appropriate course of action is to immediately call 911. EMT s responding can assess the situation and provide emergency care and transport the patient to an Emergency Room for further evaluation. It is NOT appropriate to come to the office in such situations. This will needlessly delay adequate medical evaluation and treatment and may put your child in a dangerous situation. If you arrive at our office without an appointment, we will have our staff assess your child and determine the degree of urgency of your child s illness. We will triage your child to an appropriate appointment time. You may be asked to return at another time or day. If we feel that the most appropriate and safest course of action is to have your child evaluated and/or treated in an emergency room, we will refer you accordingly. We ask that all our patients abide by this and all of our office policies. Chronically ignoring or failing to follow our office policies may result in our requesting that you find another pediatric group for your child s healthcare.
ADULT PATIENT REGISTRATION
PATIENT NAME: (LAST) (FIRST) (M) CELL: ( ) HOME: ( ) PERSONAL E-MAIL: (FOR PATIENT PORTAL) DATE OF BIRTH: / / AGE: GENDER: MALE FEMALE SOCIAL SECURITY: - - MARITIAL STATUS: SINGLE MARRIED WIDOW(ER) OTHER
Patient Name: DOB: Sex: Male/Female. Primary Address: Home Phone: Mobile Phone: Address: Emergency Contact Name and Phone Number:
Patient Registration Patient Name: DOB: Sex: Male/Female Primary Address: Home Phone: Mobile Phone: Email Address: Emergency Contact Name and Phone Number: Primary Language: Race(s): (Circle all that applies)
C.A.I. A Cardiovascular & Arrhythmia Institute
Acknowledgement of Receipt of Notice of Privacy Practices By signing below I acknowledge that I have received the Notice of Privacy Practices of Cardiac Arrhythmia Institute, LLC, which explains its legal
(Please Print using Black or Blue Ink) SEX: GENDER IDENTITY: MARITAL STATUS: SINGLE MARRIED OTHER
PATIENT INFORMATION (Please Print using Black or Blue Ink) LAST NAME: FIRST NAME: MIDDLE INITIAL: ADDRESS: CITY: STATE: ZIP: SEX: GENDER IDENTITY: MARITAL STATUS: SINGLE MARRIED OTHER RACE (OPTIONAL):
PATIENT REGISTRATION
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PEDIATRIC PATIENT REGISTRATION GALEN MEDICAL GROUP, PC
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PHARMACY INFORMATION
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Patient Registration PATIENT INFORMATION Name: (Last, First, MI) Address: City: State/Province: Zip: Country: Mailing Address (if different from above): Home Phone: Work: Mobile: Email: SSN: Birth Date:
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PATIENT MEDICAL RECORD # DATE OF BIRTH / / Male: Female: PATIENT NAME LAST FIRST MI FORMER LAST NAME MAILING ADDRESS CITY STATE ZIP
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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
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PATIENT PROFILE. Marital Status: Please Check One [ ] Single [ ] Married [ ] Divorced [ ] Widowed. Address: City: Zip: Address: City: Zip:
![PATIENT PROFILE. Marital Status: Please Check One [ ] Single [ ] Married [ ] Divorced [ ] Widowed. Address: City: Zip: Address: City: Zip:](/thumbs/82/85694847.jpg "PATIENT PROFILE. Marital Status: Please Check One [ ] Single [ ] Married [ ] Divorced [ ] Widowed. Address: City: Zip: Address: City: Zip:")
PATIENT PROFILE PATIENT INFORMATION: Name: Date of Birth: Marital Status: Please Check One [ ] Single [ ] Married [ ] Divorced [ ] Widowed Address: City: Zip: Home#: Message#: Name of Primary Physician,
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
Please print and complete all the enclosed forms and bring them to your first appointment.
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PATIENT INFORMATION INSURANCE INFORMATION
PATIENT INFORMATION RECORD (Please Print or Write Legibly) DATE ACCT # PATIENT INFORMATION NAME First Middle Init. Last MAILING ADDRESS CITY STATE ZIP SEX RACE Ethnicity: q hispanic/latino q Not Hispanic/Latino
PLEASE PRINT AND COMPLETE ALL ENTRIES
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Patient Information Referred by: Primary Care Physician: Last Name: First Name: Mr. Mrs. Miss Other Middle Name: Preferred Name: Date of Birth: / / Age: SSN: - - Address: City: County: State: Zip: Email
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PATIENT REGISTRATION
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VEIN CENTER OF VENTURA
168 N. Brent St., #508 Ventura, CA 93003 Tele: (805) 643-2855 Fax: (805) 643-3511 PATIENT INFORMATION Name of Birth SS # Marital Status: Sex: Home Address City State Zip Email Mailing Address (if different)
Doctors/Providers. Augusta Mayfield, MD; Paul Kniery, MD; Kelly Kries, MD; Casey Miles, MD; Ashley Parrigin, APRN; Emily Cope, APRN; Kyla Byard, APRN
New Patient Information Name (Last, First, MI): D.O.B. Sex: Social Security Number: Student: Yes/No Name of School: Provider: Primary Language: Lives w/parent/guardian: *Ethnicity: Hispanic or Non-Hispanic
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:
California Cardiovascular and Thoracic Surgeons
California Cardiovascular and Thoracic Surgeons 168 North Brent Street, Suite 508 Ventura, CA 93003 Telephone (805) 643-2375 Fax (805) 643-3511 Your assistance in completing the following information thoroughly
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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:
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PATIENT REGISTRATION FORM RONALD J ESCUDERO, MD, FACS Please print clearly and fill out completely Patient Legal Name Birthdate Age Address Social Security # City ST ZIP Email Phone Numbers ( ) Home (
HARBORSIDE COUNSELING SERVICES CLIENT REGISTRATION
HARBORSIDE COUNSELING SERVICES CLIENT REGISTRATION Thank you for choosing our office. In order to serve you properly, we will need the following information. PLEASE PRINT: Name: Date: (Parents/caregivers):
Sinha Clinic Foxfield Road, Suite 240, St. Charles, IL Office: (630) Fax: (630)
2560 Foxfield Road, Suite 240, St. Charles, IL 60174 Office: (630) 762-9606 Fax: (630) 762-9605 www.sinhaclinic.com info@sinhaclinic.com Patient Name: Date: Home Phone: ( )- Cell Phone: ( )- Preferred
MEMORIAL AND KATY SURGICAL SPECIALISTS. Patient Information
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Bucci Lancer Pediatrics Patient Registration
Bucci Lancer Pediatrics Patient Registration Jeffries Bucci, M.D. 7600 Osler Drive, Suite 310 111 Mount Carmel Road, Suite 500 Melissa Lancer, M.D. Towson, MD 21204 Parkton, MD 21120 Melissa Hays, C.R.N.P.
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FINANCE INSURANCE ORTHOPEDIC SPINE AND SPORTS MEDICINE CENTER 2 FOREST AVEPARAMUS, NJ 07652 PATIENT QUESTIONAIRE Patient s Name: Last First (legal): Middle Initial: Address: City: State: Zip: Date of Birth:
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Patient Registration Form Please present insurance cards and photo ID to the receptionist so copies may be made.
Patient Registration Form Please present insurance cards and photo ID to the receptionist so copies may be made. Name: Jr. Sr. Last First Middle Prefer to be called: Married Single Date of Birth / / Patient
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SOUTH SHORE NEPHROLOGY, P.C.
SOUTH SHORE NEPHROLOGY, P.C. Please fill out this form along with all the documents included in the patient packet and bring it with you for your upcoming appointment. Be sure to bring your insurance card(s)
PATIENT REGISTRATION FORM Patient Information. Last Name: First Name: MI: Date of Birth: Gender: M F Social Security #: Address: Street
Today s Date: Patient ID # [for office use only] Referring Physician PATIENT REGISTRATION FORM Patient Information Last Name: First Name: MI: Date of Birth: Gender: M F Social Security #: For Minors please
NARRA DERMATOLOGY AND AESTHETICS (425) Patient Information as of (enter today s date) (Please Print Legibly & Fill In or Correct All Fields)
NARRA DERMATOLOGY AND AESTHETICS (425) 677-8867 Patient Information as of (enter today s date) (Please Print Legibly & Fill In or Correct All Fields) Patient s Name Address Last First Middle Street & Apt
This is an application for PCIP and MRMIP. Tell us which health insurance program you prefer.
Application Fill out this form to apply for PCIP and MRMIP. Complete all questions on the application, as they must be fully answered. If you do not provide all necessary information, the processing of