CALIFORNIA ORTHOPAEDIC INSTITUTE MEDICAL ASSOCIATES, Inc.
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1 CALIFORNIA ORTHOPAEDIC INSTITUTE MEDICAL ASSOCIATES, Inc. (PLEASE PRINT & COMPLETE ALL QUESTIONS) PATIENT INFORMATION DATE ACCOUNT TYPE DR. NO. ACCOUNT NO. PREFERRED LANGUAGE PATIENT S NAME LAST FIRST MIDDLE GENDER q MALE q FEMALE HOME / MAILING ADDRESS CITY STATE ZIP CODE DATE OF BIRTH SOCIAL SECURITY # DRIVER LIC # MARITAL STATUS q S q M q W q D q SEP PHONE # HOME WORK CELL ADDRESS EMPLOYER OCCUPATION (INDICATE IF A STUDENT) RESPONSIBLE PARTY q SELF q OTHER IF OTHER: NAME ADDRESS PHONE RELATIONSHIP EMERGENCY CONTACT NAME PHONE RELATIONSHIP REFERRING MD REFERRED BY, OTHER THAN MD MEDICARE MEDICARE NUMBER MEDI-CAL MEDI-CAL NUMBER # # q INSURANCE INFORMATION (OFFICE USE ONLY) NAME OF INSURANCE COMPANY (PRIMARY) SECONDARY / SUPPLEMENTAL INSURANCE COMPANY q STREET ADDRESS STREET ADDRESS CITY, STATE & ZIP CODE CITY, STATE & ZIP CODE GIVE NAME OF POLICY HOLDER GIVE NAME OF POLICY HOLDER GROUP / POLICY NO. SUBSCRIBER / I.D. NO. GROUP / POLICY NO. SUBSCRIBER / I.D. NO. q ACCIDENT q AUTO/VEHICLE q JOB RELATED q OTHER, Explain DATE OF INJURY PLEASE SIGN THE FOLLOWING FORM I hereby authorize California Orthopaedic Institute Medical Associates, Inc., to furnish to my insurance company or to a designated attorney, all information which the insurance company or attorney may request. I hereby assign to the above referenced physicians all monies to which I am entitled and/or surgical expense relative to the services rendered by either of them. It is understood that any money received from the abovenamed insurance company, over and above my indebtedness will be refunded to me when my bill is paid in full. I understand I am financially responsible. WHETHER MY INSURANCE COMPANY PAYS OR NOT, for all costs incurred by me. I further agree that in the event of non-payment, I will bear the cost of collection and/ or Court cost and reasonable legal fees should such court action be required. I agree that a photocopy of this authorization shall be as valid as the original. Insured or Guardian Signature Patient s Signature
2 Orthopaedic INSTITUT E f~ntcrlco11 no.1rd of Orthorw~dk Surgc:r1,1 lljllll"lrn 'i, flcj 11 1 M.f' NOTICE OF DISCLOSURE f 11plr,1n 1I IJJr.ln trl<ji. IJrc.u1 n P1~1c1 ;oo, M D. i l1plr itl 11 Under California Business and Professions Code 654.2, the physicians of California Orthopaedic Institute are required to inform you that they have a financial interest in Mission Valley Heights Surgery Center (MVHSC). ldintj,:, $dwlt.:, M.fJ St~vc:n!)if. 1. m.. 11 norjoml<v. M,tJ P1pl,nir11.:: Michael Ii. Oulno, 0.1'1.M. Dl(>lr; mutr:: Should you require outpatient surgery, it is possible that your surgery would be scheduled at MVHSC. By signature below, you are confirming that you have read and understand this notice of disclosure. You may opt to have your surgery performed at a different outpatient facility. An alternative will be discussed with you upon your request. Sincerely, William S. Adsit, M.D. William L. Tontz, Jr., M.D. Michael H. Quinn, D.P.M. L. Randall Mohler, M.D. Jeffrey E. Schultz, M.D. Drew A. Peterson, M.D. Steven Tradonsky, M.D. Patient's signature
3 Qrthopaedic N S Ir 4 1 ii T f!ii Consent to the Use and Disclosure of Health Information for Treatment, Payment, or Healthcare Operations I understand that a part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as: A basis for planning my care and treatment A means of communication among the many health professionals who contribute to my care A source of information for applying my diagnosis and surgical information to my bill A means by which a third-party payer can verify that services billed were actually provided And a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals I understand that I have the right to view and/or request a Notice of Privacy Practices that provides a more complete description of information uses and disclosures prior to signing this consent. I understand that the organization reserves the right to change their notice and practices, and prior to implementation will post and make available, the revised notice at physical practice site(s). I understand that I have the right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that the organization is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I request the following restrictions to the use or disclosure of my health information. I have read and understand the Notice of Privacy Practices. Signature of Patient or Legal Representative Witness Notice Effective
4 Orthopaedic INS T I T U T E FINANCIAL POLICY Our office will be happy to bill your primary and secondary insurance carrier as a courtesy if the proper information has been provided. If you do not have insurance, payment is due at the time of service. If you are a Medi-cal patient and do not have your eligibility card, you will be considered a "cash" patient and will be responsible for the balance due. Several insurance companies have a "co-payment" that the patient is responsible for at the time of service. The office will bill the insurance company for the difference and you will not receive a statement. We will bill you for any services that are not covered. Please let the office know if you participate in this type of insurance plan or if you are required to have a referral authorization. If you feel that your insurance company has not responded to your claim, or if you question the amount covered, please contact your insurance company. It is your responsibility to follow-up on claims submitted. We will be happy to assist you if necessary. To our HMO and EPO patients: Please read and sign the following liability statement. I, will assume full financial liability for any non-covered benefit or service denied by my Health Plan. Example: Medical equipment, elective surgeries, etc. Signature Release of Information/ Assignment of Benefits I hereby authorize California Orthopaedic Institute to furnish to my insurance company or to a designated attorney, all information which the insurance company or attorney may request. I hereby assign to the above-referenced physicians all monies to which I am entitled and/or surgical expense relative to the services rendered by either of them. It is understood that any money received from the above-named insurance company, over and above my indebtedness will be refunded to me when my bill is paid in full. I understand I am financially responsible, WHETHER MY INSURANCE COMPANY PAYS OR NOT. for all charges incurred by me. I further agree that in the event of non-payment, I will bear the cost of collection and/or Court cost and reasonable legal fees should such court action be required. I agree that a photocopy of this authorization shall be as valid as the original. Insured or Guardian Signature Patient's Signature :
5 Qrthopaedic N S T T U T E IMAGING CENTER Accredited Magncrit Rtson nte Facility We are required, by law, to disclose the following: (1) California Orthopaedic Institute (COi) has ownership in the MRI facility on these premises located in suite 101. (2) You may obtain ancillary services (MRI) from another facility of your choosing and below are five options. (3) Other facilities and their location may be obtained from your insurance company. Please note that COi obtains authorization for your MRI prior to your scan here at our facility. We cannot guarantee that the other facilities are contracted with your insurance company. If you choose another option, please contact your insurance company for assistance. Other options: Open Air MRI - (800) Imaging Healthcare Specialists - 5th & Upas - (619) Imaging Healthcare Specialists - Alvarado Court - (619) Sharp & Children's MRI Center Frost Street - (858) Regents MRI La Jolla Village Drive, Suite (858) We are pleased to provide the MRI service as requested by your physician. If you have questions regarding this information, please ask your doctor or the medical assistant. William S. Adsit, M.D. Jeffrey E. Schultz, M.D. William L. Tontz, Jr., M.D. L. Randall Mohler, M.D. Steven Tradonsky, M.D. Drew A. Peterson, M.D. Michael H. Quinn, D.P.M. Patient Signature DAP:vv 7485 Mission Vollev Rood. Suite l 04. San Diego. California (619) fox: (619)
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Welcome to Our Practice Greater Baltimore Medical Center (GBMC) welcomes you to our practice. We are dedicated to providing you with the kind of care that we would want for our own loved ones. This Information
KRAIG R. PEPPER, D.O. P.A.
Thank you for choosing Dr. Kraig Pepper, D.O. P.A. for your care. The following is required to provide you with the quality medical care. The doctor and staff will review this information and place it
NAME (LAST, FIRST, MIDDLE) SSN# BIRTHDATE SEX NAME (LAST, FIRST, MIDDLE) SSN# BIRTHDATE SEX
PATIENT INFORMATION NAME (LAST, FIRST, MIDDLE) SSN# BIRTH SEX ADDRESS CITY, STATE & ZIP CODE EMAIL: MAILING ADDRESS (IF DIFFERENT FROM ADDRESS) CITY, STATE & ZIP CODE HOME PHONE CELL PHONE OTHER PHONE
Jeffrey L. Brooks, M.D. (707)
(707) 252-4955 Welcome to our practice! First, let us thank you for choosing Napa Vascular & Vein Center as your healthcare provider. We are dedicated to providing premier vascular assessment and treatment
Dr. Ingvoldstad Peachtree Women s Specialists Dr. Roberts. Dr. Knoer
Dr. McSwain Dr. Dozier Dr. Ingvoldstad Peachtree Women s Specialists Dr. Roberts Dr. Knoer Today s date Please print and fill out completely. Referred by Account # Legal Name Date of birth Name we should
PATIENT INFORMATION FORM
PATIENT INFORMATION FORM NAME: Age: DATE OF BIRTH: SSN: Sex: MARITAL STATUS: PRIMARY CARE PHYS: DRIVER S LICENSE # STATE IF CHILD, GUARDIAN S NAME: ADDRESS: City State Zip Code PHONE: Home Phone Cell Phone
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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 Demographic Form
Patient Demographic Form PARTNERS IN CARE VASILY J. ASSIKIS, M.D. W. PERRY BALLARD, M.D. JONATHAN C. BENDER, M.D. CHARLES A. HENDERSON, M.D. ERIC D. MININBERG, M.D. R. MARTIN YORK, M.D. Please print clearly
Dear Patient, Now that you are 18 years old we need a signed copy from you on file. Attached is a copy of the HIPAA form.
Dear Patient, We have a signed consent form on file that one of your parents has signed giving us consent to treat you and, if covered, to bill the Insurance Company. Now that you are 18 years old we need
Associates in Plastic & Aesthetic Surgery PATIENT REGISTRATION
PATIENT REGISTRATION Name Date Date of Birth Age Social Security No Demographics Male Female Single Married Divorced Widowed Reason for your Visit Who referred you to this office Doctor Patient Web Site
Today s Date (mm/dd/yyyy):
115 Christopher Columbus Drive, Suite 301 Jersey City, New Jersey 07302 201-706-3808 http://www.drsmedicalassociates.com/ WELCOME TO DRS MEDICAL ASSOCIATES LLC. PLEASE COMPLETE THE FORM LEGIBLY AND ENTER
Family Physicians of Johnson City 303 Med Tech Parkway, Suite 100 Johnson City, TN 37604
Family Physicians of Johnson City 303 Med Tech Parkway, Suite 100 Johnson City, TN 37604 Patient Registration Form Last Name First Name Middle Initial Sex: M F of Birth Address City State Zip Code Social
New Patient Registration. Employer Info Occupation Employer Work Phone #
New Patient Registration Name (last, first, middle initial) DOB Address City State Zip Code Social Security # Sex (M/F) Marital Status Last Tetanus Email Address Home Phone # Cell Phone # Employer Info
WELCOME TO BRAZOSPORT CARDIOLOGY Office of Dr. Scott Harris and Dr. Nabil Baradhi INSURANCE INFORMATION
WELCOME TO BRAZOSPORT CARDIOLOGY Office of Dr. Scott Harris and Dr. Nabil Baradhi Patient s Name Date of Birth / / Home Phone ( ) - Daytime or Cell Phone( ) - YES NO Brazosport Cardiology May Leave Results
My Doctor at WIM is: Dr. Azam Dr. Cohen Dr. Huynh Dr. Jacobellis Dr. McCarthy Dr. Taylor (CIRCLE ONE)
In order to serve you promptly, we need the following information. Fill out each item or put N/A (not applicable). Please Print Clearly. WESTFORD INTERNAL MEDICINE, P.C. My Doctor at WIM is: Dr. Azam Dr.
PHARMACY INFORMATION
NAAMAN CLINIC TODAY S DATE: Prefix Mr. Mrs. Miss Ms. Dr. Preferred Name: Patient s Name Address: First Middle Last Street & Apt # City State Zip SS# Birthdate Age: Sex: Female Male Marital Status: Single
PATIENT INFORMATION : Please present insurance cards to receptionist. INSURANCE: Please fill out only if you re NOT the subscriber
PATIENT INFORMATION : Please present insurance cards to receptionist First Name: Last Name: Date of Birth: - - Sex: Male Female Address: City: Cell Phone #: ( ) - M.I.: APT: State: Zip Code: Home #: (
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
Dental Insurance: Primary Carrier: Employee #: Insured s SSN #: Insured Birth date: Group #: Phone #: Insurance Company Address: City: State: Zip:
First Name: Middle: Last: Nickname: Date of Birth: Drivers License #: Male Female Single Married SSN #: Address: City: State: Zip: Home Phone: Work: Cell: Email address: Employer: Occupation: Spouse Name:
Notice to Patients 4. COMMUNITY FIRST PATIENTS MUST PRESENT CURRENT MONTHLY SHEET AND ID CARD TO BE VERIFIED BEFORE SERVICE CAN BE PERFORMED.
Notice to Patients 1. PLEASE SIGN IN UPON ARRIVAL. PARENT OR LEGAL GUARDIAN MUST BE PRESENT. ANYONE OTHER THAN THE PARENT MUST PROVIDE DOCUMENTATION AUTHORIZING CARE OF THE PATIENT. 2. PAYMENT IS DUE AT
Felix Linetsky, M.D. 611 Druid Road East, Suite 303 ~ Clearwater, Florida ~ (727) ~ Fax (727)
New Patient Information Form Patient Name: Today s Date: / / Is your problem related to: Job Injury (date) Car Accident (date) Other (date) Address: City: State: Zip: Date of Birth: / / Age: Social Security