KIDS PLACE ORTHOPEDICS 3742 KATELLA AVE., STE 303, LOS ALAMITOS, CA ORTHOPEDIC HEALTH HISTORY
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1 KIDS PLACE ORTHOPEDICS 3742 KATELLA AVE., STE 303, LOS ALAMITOS, CA ORTHOPEDIC HEALTH HISTORY Today s Date: Name Date of Birth Reason for Visit: Past Medical History: List your child s prior and current illnesses and injuries Past Surgical History/Hospitalizations: Current Medications: Medication and Food Allergies: Birth History: Born at weeks. Vaginal or C-section Breech? Yes No Pregnancy complications(y/n)list: Developmental History: How old was your child when they first sat crawled walked Social History: What grade is your child in? Does anyone in the house smoke? What sports does your child participate in? Family History: (List any health problems the parents or siblings see a doctor for) Review of Symptoms:(please indicate if your child has a health problem in any of these areas) General (fatigue, unexplained appetite or weight loss) Eyes (glaucoma, glasses) Ear/Nose/Throat (deafness, ear infections, sinus infections) Heart (murmur, irregular heart beat) Lungs (asthma, bronchitis, tuberculosis) Abdomen (hepatitis, colitis, severe constipation) Kidneys/Bladder (reflux, incontinence, urinary tract infections) Muscles/Bones (fractures, joint problems) Skin (rashes, burns) Neurologic (seizures, headaches, delay, shunt) Psychological: (ADHD, depression) Endocrine (diabetes, thyroid disease) Hematologic (anemic, leukemia, lymphoma) Infectious/Inflammatory Disease (HIV, eczema, latex allergy) Formed completed by Relationship to patient
2 PATIENT INFORMATION Patient s Last Name First Name Middle Initial Patient s Date of Birth Patient s Gender Patient s Primary Care Physician/Pediatrician PARENT/GUARDIAN INFORMATION Who has legal custody of patient? Mother Father Guardian Other, please list relationship Who does the patient live with? Mother Father Guardian Mothers/Guardians Last Name First Name Middle Date of Birth Mailing Address City, State, Zip Home Phone Work Phone Mobile Phone Fathers/Guardians Last Name First Name Middle Date of Birth Mailing Address City, State, Zip Home Phone Work Phone Mobile Phone ADDRESS Other Emergency Contact Information Is this person authorized to bring child for medical treatment? Yes No Name Relation to Patient Home Phone Mobile Phone Who else is authorized to bring this child in for medical treatment?
3 Kids Place Orthopedics Financial Policy Thank you for choosing Kids Place Orthopedics as your healthcare provider. We are committed to providing your child with the best orthopedic treatment possible. The following is a statement of our Financial Policy, which we require you to read and sign prior to any treatment. Participating Insurance Plans: We accept assignment on some insurance, but not all. Due to the frequent changes in health insurances, we are not able to keep up with the task of knowing all insurances, or your specific plan s details. It is your responsibility to confirm with your insurance whether or not Dr. Pike is in your network. Please remember that an insurance policy is a contract between you and the insurance company. We are not a party in that contract. We will file your claims to your insurance company. In order to do so, we must have a copy of your insurance card. We reserve the right to refuse to file claims to out of state insurances and secondary insurance. Upon request, we can provide you with a copy of a detailed receipt with which you may file your claim. Non-participating Insurance Plans: Patients who are insured by carriers that the practice does not participate with are considered self-pay. We offer a 10% discount for self-pay and cash patients. If your insurance pays for out of network providers, we will submit a bill to your insurance company for you. Referrals and Authorizations: If you have HMO insurance you must have an approved authorization to see Dr. Pike prior to scheduling an appointment. Co-payments: Co-payments, co-insurance, and deductible charges are due at the time of service. Our office accepts Visa/MasterCard or cash. If you are unable to pay at the time of service we will ask you to re-schedule your appointment. Durable Medical Equipment: Payment for durable medical equipment (tape, waterproof cast material, crutches, etc.) are due at the time of service. Self-pay accounts: Self-pay charges and balances are due in full at the time of the visit. Kids Place Orthopedics reserves the right to send overdue accounts to a Collection Agency. Patient Refunds: The following criteria must be met prior to Kids Place Orthopedics issuing a patient refund: 1) there are no outstanding insurance claims on the patient s account 2) there are no outstanding patient balances on the account. Financial Responsibility: A parent or legal guardian must accompany patients who are minors on the patient s first visit. This accompanying adult is responsible for payment of the account, according to the financial policy outlined on the previous page. If someone other than the parent or legal guardian will be bringing the patient to subsequent appointments, we must have a written consent to treat the child from the parent and the adult must bring payment for the visit. Medical Records: There is a charge for medical records. Records are $1.00 per page for the first 25 pages and.25 cents thereafter. Please allow 2-3 days to obtain school forms, 1-2 days for prescription refills and 4-7 days for other requests.
4 X-rays: There is a charge of $7.00 per print for copies of X-rays. Missed appointments: For rescheduling or canceling an appointment, please call our office 24 hours in advance. A $20.00 fee may be charged for missed visits that were previously confirmed. This financial policy helps the practice provide quality care to our valued patients. If you have any questions or need clarification of any of the above policies, please feel free to contact us. Consent to Disclosure of Protected Health Information I consent to the disclosure of my child s protected health information (PHI) for the purpose of treatment, payment, or health care operations. My child s PHI refers to health and demographic information collected from me and created or received by my provider, another health care provider, a health plan, an employer, a health care clearinghouse, or a third-party administrator. This PHI relates to my child s past, present, and/or future physical or mental health and identifies my child. I hereby authorize Kids Place Orthopedics to release my health information to my insurance company for the purpose of obtaining reimbursement for health care provided. I understand that I have the right to review the Kids Place Orthopedics Privacy Notice for a more complete description of uses and disclosures and that I have the right to review the notice prior to signing this consent. I understand that I have the right to request that Kids Place Orthopedics restrict how my child s protected health information is used or disclosed to carry out treatment and pay health care operations. I further understand that Kids Place Orthopedics is not required to agree to requested restriction(s), but if Kids Place Orthopedics agrees to a requested restriction, the restriction is binding on Kids Place Orthopedics. I understand that I have the right to revoke this consent in writing except to the extent that Kids Place Orthopedics has already taken action in reliance to this consent. I understand that Kids Place Orthopedics reserves the right to change the privacy practices described in its Privacy Notice and that I may obtain a revised notice by accessing the Kids Place Orthopedics Web site, calling the office and requesting that a revised notice be sent in the mail, or requesting one at my next appointment.
5 LIFETIME AUTHORIZATION FOR PATIENT OR RESPONSIBLE PARTY (A copy of this form will be considered acceptable as the original) I have read Kids Place Orthopedics Financial Policy and Consent to Disclosure of Protected Health Information, and agree to comply with the policies of this office. I authorize direct payment of medical benefits to Leah M. Pike, M.D, P.C/Kids Place Orthopedics for any and all services rendered to me. If any insurance claim is filed on my child s behalf, I understand that I am fully responsible for any charges not covered or paid by my insurance carrier. Any charge incurred to recover unpaid debts relating to my account will be my responsibility. AUTHORIZATION TO LEAVE MESSAGES I give my permission to the staff of Kids Place Orthopedics to leave messages on my telephone answering machine regarding my health care, insurance benefits, bills, or regarding an appointment. My signature below will acknowledge that I have carefully read the above statements and attached documents and agree with the content provided. Signature Date
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NORTHSIDE PRIMARY CARE
NORTHSIDE PRIMARY CARE Dr AAZRUM I. SYED, M.D. 11820 Northfall Lane Suite 1103 ACKNOWLEDGEMENT OF RECIEPT OF NOTICE OF PRIVACY PRACTICES **You may refuse to sign this acknowledgment** I, have received
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Providence Medical Park / 3841 Piper Street, Suite T300 / Anchorage, AK 99508 Alaska Regional Campus / 2925 DeBarr Road, Suite 250 / Anchorage, AK 99508 Ph: (907)-563-3103 F: (907)-561-1862 Mat-Su Regional
We look forward to serving you and your ophthalmic needs. Please do not hesitate to contact our office if we can be of any further assistance.
ANN BULLINGTON, M.D. ROBERT H. BULLINGTON, JR., M.D. Cornea and External Diseases AILEEN F. VILLAREAL, M.D. ROBERT E. FINTELMANN, M.D., F.A.C.S. Cornea, Cataract, and Refractive Surgery Welcome to Biltmore
Patient Information Last Name First Name Middle Initial
Patient Information Last Name First Name Middle Initial Street Address Apt# City State Zip Code Social Security # Home Phone Cell Phone Email D.O.B Sex(M/F) Occupation Relation to Insured Self Spouse Child
Thomas Yoon Dental Patient Information. Health Information
Patient Name: Thomas Yoon Dental Patient Information Last First MI (Preferred Name) Social Security #: Date of Birth: / / Gender: Male Female Marital status: Phone # (Home): (Cell): (Work): Ext: E-mail
HEALTH QUESTIONNAIRE NAME SEX AGE DOB HEIGHT WEIGHT PLACE OF BIRTH REASON FOR VISIT
HEALTH QUESTIONNAIRE NAME SEX AGE DOB HEIGHT WEIGHT PLACE OF BIRTH REASON FOR VISIT LIST OF MEDICATIONS: (IF ADDITIONAL SPACE IS NEEDED, PLEASE CONTINUE ON THE BACK OF THIS PAGE) DRUG DOSE FREQUENCY YEAR
Arthur M. Cotliar, M.D. & Staff
Dear Patient: Thank you for taking time to schedule an appointment at one of our offices. Please fill out the enclosed forms and bring the forms with you on the day of your appointment. In addition, please
Child s Name: (First) (Middle) (Last)
Child s Name: (First) (Middle) (Last) Sex: M F Age: Birth date: / / Place of Birth: School: City: Pediatrician Name: Whom may we thank for referring you to our office? Name(s) of Sibling(s): WHAT IS YOUR
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M a u r i c i o R o n d e r o s, D D S, M S, M P H I. PATIENT INFORMATION: Last Name: First Name: MI: Mr. Mrs. Ms. Male Female Birth date (M/D/Y): Marital status: Dr. Other: Address: City, State: Zip:
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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
NEW YORK CORNEA, PLLC
Demographic Information: First Name: Middle: Last name: Birth date: Sex: M F Social Security #: Local Address: City: State: Zip: Secondary Address: (if applicable) Home Phone #: Work Phone#: Cell Phone
PATIENT 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
Haroon Rehman, MD 3200 Talon Drive. Suite 300 Richardson, TX Phone: Fax: Address: City: ST: ZIP:
Haroon Rehman, MD 3200 Talon Drive. Suite 300 Richardson, TX 75082 972-649-5937 Fax: 972-807-0385 Patients General Information Last Name: First Name: Patient s SSN: of Birth MM/DD/YYYY: / / Age: Sex: M/F
APPLETON PLASTIC SURGERY CENTER, S. C. (920)
APPLETON PLASTIC SURGERY CENTER, S. C. (920)738-7200 Please print legibly and fill in or correct all fields. Patient Name Parent/Legal Guardian Name Address Last First Middle Last First Middle Street &
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2150 S. Eastern Avenue 7180 Cascade Valley Ct. #180 Las Vegas, Nevada 89104 Las Vegas, Nevada 89128 Phone (702) 641-2150 Phone (702) 641-2150 Fax (702) 641-8667 Fax (702) 228-1043 PLEASE PRINT & FILL OUT
HUNTSVILLE PEDIATRIC AND ADULT MEDICINE ASSOCIATES PATIENT INFORMATION
HUNTSVILLE PEDIATRIC AND ADULT MEDICINE ASSOCIATES PATIENT INFORMATION Patient s Name Sex Male Female Date of Birth Address City/State Zip Code Home Phone Cell Phone E-mail address Driver License # Marital
Caritas Medical Center, LLC
Caritas Medical Center, LLC KIDNEY DISEASE AND HYPERTENSION SPECIALIST 105 NORTH PARK TRAIL SUITE 300 STOCKBRIDGE, GA 30281 OFFICE: 678 284 0800 FAX: 678 284 9299 WWW.CARITASMED.COM DR. LEO OVADJE DR.
ROCKWALL SURGICAL SPECIALISTS
PATIENT REGISTRATION FORM Patient s name (Last, First, Middle Initial) Sex (M or F) Date of Birth Address City State Zip Home Phone Cell Phone Email Marital Status Social Security Number Driver s License
PATIENT INFORMATION. Child s Name: DOB: Address: Phone: Zip: School: Emergency Contact: Phone: Relationship to Patient:
PATIENT INFORMATION Child s Name: DOB: Address: Phone: Zip: School: Father s Name: Occupation: Phone: (work) Email Address: Mother s Name: Occupation: Phone: (work) Email Address: DOB: Social Security
ROCKWALL SURGICAL SPECIALISTS
ROCKWALL SURGICAL SPECIALISTS Dr. David Ritter Dr. Ashley Egan Dr. Jon Harris Phone (972) 412-7700 Fax (972) 412-7710 PATIENT REGISTRATION FORM Patient s name (Last, First, Middle Initial) Sex (M or F)
Consent For Treatment
Consent For Treatment I hereby give my permission for Piedmont Neurology, LLC (the Practice) to provide diagnostic services and medical treatment. I permit the Practice to file for insurance benefits to