SKINNER FAMILY PRACTICE 1
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- Cory Bailey
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1 SKINNER FAMILY PRACTICE 1 Health History Patient Name: DO YOU HAVE A PERSONAL HISTORY OF DIABETES (E11.9) COPD (J44.9) BLOOD PRESSURE (I10) CROHNS DISEASE (K50.10) HEART DISEASE (I51.9) TUBERCULOSIS (A15.9) DIVERTICULITIS (K57.90) KIDNEY STONES (N20.2) HEART ATTACK (I21.3) LIVER DISEASE (K76.9) ULCERATIVE COLITIS(K51.90) SEIZURES (R56.9) HIGH CHOLESTEROL (E78.5) THYROID DISEASE (E07.9) ASTHMA (J45.998) AIDS/HIV (B20) STROKE (I63.9) HEPATITIS (K71.6) MIGRAINES (G43.009) CHRONIC PAIN* (G89.29) CANCER (C80.1) BACK INJURY (S39.92XA) ULCERS (K12.1) KIDNEY DISEASE (N28.9) History of surgeries (please include year): Medication Allergies: Do you use tobacco? Type and amount: Do you drink alcohol? Amount and frequency: Have you ever been treated for drug or alcohol abuse? FAMILY HISTORY (PLEASE LIST ANY SIGNIFICANT HEALTH CONDITIONS) FATHER: MOTHER: GRANDPARENTS: SIBLINGS: *PLEASE NOTE: SKINNER FAMILY PRACTICE DOES NOT PROVIDE PAIN MANAGEMENT. PLEASE INITIAL HERE INDICATING YOUR UNDERSTANDING OF THIS: DATE:
2 SKINNER FAMILY PRACTICE 2 DEMOGRAPHIC INFORMATION First: MI: Last: Preferred Name: Maiden name: Social Security #: Date of Birth: Gender: Marital Status: Ethnicity (optional): Home Address: City: State: Zip: Phone: Mobile: Other: Emergency Contact: Relationship: Phone: Preferred pharmacy: Please list other family members that are patients at Skinner Family Practice: RESPONSIBILITY OF PAYMENT: Please list the person responsible for your medical bills. If your insurance is not in your name, this section is mandatory. Name: Social Security #: Date of Birth Gender: Address: City: State: Zip: Relationship:
3 Patient Name: SKINNER FAMILY PRACTICE 3 INSURANCE INFORMATION Please provide a copy of your card for our files. If you have NO insurance, please indicate by initialing here:. By initialing, you accept responsibility for all amounts billed for services provided. Payments are due at the time of service. If other services are provided, billing may be delayed and therefore payment will be expected upon receipt of the final bill. Primary Insurance: Name of insured: Insured date of birth: Insured SS#: Relationship to insured: Self/ Spouse / dependent / other Secondary Insurance: Name of insured: Insured date of birth: Insured SS#: Relationship to insured: Self/ Spouse / dependent / other Authorization and assignment: I hereby authorize Skinner Family Practice to furnish any information to my insurance carrier(s) and health care administrators or agents concerning my illness and/or treatment. I hereby assign to Skinner Family Practice all payments for services rendered to me/my covered dependents. I understand that I AM RESPONSIBLE FOR ANY AMOUNTS NOT COVERED BY INSURANCE AND THAT MY COPAYMENT IS DUE AT THE TIME OF SERVICE. I further understand that Skinner Family Practice is filing my insurance as a courtesy and convenience for me and that I am ultimately responsible for all billed amounts for services provided. Signature: Date:
4 Patient Name: SKINNER FAMILY PRACTICE 4 HIPPA PRIVACY ACT By signing below, I acknowledge that I have been notified of the availability of the Notice of Privacy Practices and a copy has been made available to me by Skinner Family Practice. I also authorize Skinner Family Practice and any authorized staff members to share pertinent protected health information with those listed below. I also understand that, with written request, I can amend or withdraw any names listed below at any time and that it is my responsibility to ensure the persons listed below do not divulge or use the information provided in any way without my authorization. Please list below any individuals to which health information may be freely shared without further notification. Please DO NOT list other physicians of medical facilities. By initialing here, I am requesting that NO ONE receive health information about me without advanced notice by me. Initials: Date: The following individuals may freely receive any information regarding my health without further notice Signature: Date:
5 SKINNER FAMILY PRACTICE 5 MEDICATION LIST Medication Name: Dosage: How taken:
Referring Physician: Primary Care Physician: Other Physician(s)/Specialty: EMERGENCY CONTACT INFORMATION INSURANCE INFORMATION
PATIENT INFORMATION Name: Date of Birth: Sex: Male Status: Single Married Divorced Widowed Other 502 Elm Street NE Language: Female Race: American Indian or Alaska Native Native Hawaiian or Or Pacific
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AUBURN URGENT CARE. Patient Information. Name: Last First Middle. Permanent Address: Apt #: Zip: City: State: Employer: Phone: ( )
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PATIENT REGISTRATION
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Name: Date of Birth: Sex: Language: Race: Ethnicity: Home Address: City: State: Zip: Home Phone #: Marital Status: SS #:
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Chiropractic Case History / Patient Information
Chiropractic Case History / Patient Information Date: Name: Social Security #: Home Phone:( ) Address: City: State: Zip: E mail address: Cell Phone:( ) Age: Birth Date: / / Marital Status: M S W D Occupation:
Patient Name: M F LAST FIRST MI. Mailing Address: City: State: Zip: Home Phone: ( ) Work Phone: ( )
Ahwatukee Family Medical Center Patient Information Date: Patient Name: M F LAST FIRST MI Mailing Address: City: State: Zip: Home Phone: ( ) Work Phone: ( ) EMAIL: Date of Birth: / / SS# Marital Status:
Patients 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
PATIENT INFORMATION. Last Name: First Name: M.I. DOB: Gender: Marital Status: Cell phone: - - Home phone: - - SSN: - - Driver s License Number:
PATIENT INFORMATION Last Name: First Name: M.I. DOB: Gender: Marital Status: Cell phone: - - Home phone: - - SSN: - - Driver s License Number: Mailing Address: Physical Address: Emergency Contact: Phone:
Christine LaComb, RN, FNP-C th Street Suite B Groves, TX (409) Phone (409) Fax
Christine LaComb, RN, FNP-C 6000 39 th Street Suite B Groves, TX. 77619 (409) 962-8509 Phone (409) 962-0763 Fax Welcome To Our Practice! In Order To Properly Serve You, Please Complete The Following Forms
To: Our Medicare Patients Re: Medicare Annual Wellness and Other Preventive Visits
To: Our Medicare Patients Re: Medicare Annual Wellness and Other Preventive Visits Beginning January 1, 2011 Medicare began covering an Annual Wellness Visit in addition to the one-time Welcome to Medicare
Do 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
ASSIGNMENT OF BENEFITS/FINANCIAL RESPONSIBILITIES
Duncan Lahtinen, D.O. Paul Piper, M.D. Rebecca Johnson, PA C Tobias Lopez, PA C 220 E. Rowan, Ste 300 Spokane, WA 99207 Phone: (509) 489 3554 Fax: (509) 489 3558 ASSIGNMENT OF BENEFITS/FINANCIAL RESPONSIBILITIES
PATIENT INFORMATION PATIENT NAME Last First M.I. Social Security Number
PATIENT INFORMATION PATIENT NAME Last First M.I. Social Security Number ADDRESS Street DATE OF BIRTH SEX Female Male City State Zip Home Phone Cell Phone Work Phone EMAIL Marital Status Single Widowed
Patient Demographics Last Name First name M.I D.O.B Age Gender(circle) SSN M- F
Patient Demographics Last Name First name M.I D.O.B Age Gender(circle) SSN M- F Home Address: Apt/Lot City State Zip code Occupation: (circle) Student - Full Time - Part Time - Retired - Unemployed Marital
PLEASE ARRIVE TO THE CLINIC 30 MINUTES EARLY FOR YOUR APPOINTMENT
130 North Broadway Table Grove, IL 61482 Telephone: (309) 758-5070 Fax: (309) 758-5007 www.cmhospital.com Thank you for choosing Table Grove Community Medical Clinic for your Healthcare needs. We always
REGISTRATION FORM. Physician (PCP): PATIENT INFORMATION. Last Name: First Name: MI: Billing Address: City: ST Zip Code:
: REGISTRATION FORM Physician (PCP): PATIENT INFORMATION Last Name: First Name: MI: Social Security #: DOB: Sex: M F Billing Address: City: ST Zip Code: Home Phone#:( ) Cell Phone#:( ) Work Phone#:( )
Chief Complaint Form: Patient Name: Age: DOB: Occupation: Employer: Referring Physician: Town: Primary Care Physician: Town: Y N
Chief Complaint Form: Patient Name: Date: First MI Last Preferred Name Age: DOB: Occupation: Employer: Send Note? Referring Physician: Town: Y N Primary Care Physician: Town: Y N Coach/ Trainer/ Team Doctor:
PATIENT INFORMATION. Preferred Name: Age: Gender: M F TG. Responsible Guardian(s) Relationship. Billing Address if different: City State Zip
PATIENT INFORMATION Name: Last First MI Address: Street Unit# City State Zip Preferred Name: Date of Birth: _ Age: Gender: M F TG Marital Status: S P M D W Responsible Guardian(s) _ Relationship Billing