PATIENT INFORMATION AND ACKNOWLEDGEMENT OF PRIVACY NOTICE RECEIPT
|
|
|
- Audra Blankenship
- 5 years ago
- Views:
Transcription
1 PATIENT INFORMATION AND ACKNOWLEDGEMENT OF PRIVACY NOTICE RECEIPT 1. Patient s Name Last First MI Address Street & Apt # City State Zip Hme Phne Cell Phne Other Phne Any restrictins fr cntacting yu? N Cntact Restrictins: address Age Birthdate / / SS# - - Pt. s Gender: Female Male Marital Status: Married Single Spuses Name: Primary Care Physicians name & phne: Other referral surce: 2. Patient s r Parent s Emplyer Occupatin Wrk Phne Ext: Is it kay t call yu at wrk? N Wrk Address Street & Suite # City State Zip 3. Emergency Cntact Relatinship t Patient Hme Phne Wrk Phne Other Phne Address Street & Apt # City State Zip 4. Name f Pharmacy: Address: Street City State Zip Telephne 5. Current Medicatins: 6. Allergies: ename: New Patient Packet EFF Page 1 f 9
2 7. Primary Health Insurance Cmpany Subscriber/ Member ID # Grup/ Accunt ID # Ins. Phne 8. Primary Plicy Hlder s Name: DOB / / Address: Telephne Street City State Zip Scial Security # - - Plicy Hlder s Relatinship t Patient: 9. Secndary Health Insurance Cmpany Subscriber/ Member ID # Grup / Accunt ID # Insurance Phne Secndary Plicy Hlder s Name: DOB / / Address: Telephne Street City State Zip Scial Security # - - Plicy Hlder s Relatinship t Patient: 10. AUTHORIZATION FOR INSURANCE TO PAY I hereby authrize payment f medical benefits billed t my insurance cmpany t be paid directly t Skin Specialists PA, the ffice f Tanya Reddick Rdgers, MD, FAAD. I hereby agree t prmptly pay fr any service(s) prvided t me nt cvered by my insurance plicy. I agree t pay all c-payments, deductibles, cinsurance, and fr csmetic services and/r prducts sld thrugh Skin Specialists PA. If/when any f the abve infrmatin changes, I will prvide the updated infrmatin prmptly. I als understand that I may change my emergency cntact infrmatin at any time, by asking fr and cmpleting a new emergency cntact frm. Signature f Patient (if ver 18) r parent/legal guardian Date 11. PATIENT ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE I understand that as part f the prvisin f healthcare services, Skin Specialists PA, the ffices f Tanya Reddick Rdgers, MD, FAAD, creates and maintains health recrds describing my health infrmatin. This includes, but is nt limited t, my health histry, symptms, diagnses, examinatins, test results, treatment and any plans fr treatment. I have read and been prvided with a cpy f the Ntice f Privacy Practices which prvides a cmplete descriptin f the uses and disclsures f certain healthcare infrmatin. By signing belw, I cnsent t the use and disclsure f prtected health infrmatin abut me fr the purpses f treatment, payment, and healthcare peratins. I have the right t revke this cnsent in writing except where disclsures have already been made in reliance n my prir cnsent. Signature f Patient (if ver 18) r parent/legal guardian Date If signed by parent/legal guardian, please print name ename: New Patient Packet EFF Page 2 f 9
3 FINANCIAL AND OFFICE POLICIES We wuld like t welcme yu t ur ffice and are happy that yu have chsen us fr yur dermatlgy needs. Our gal is t prvide the best pssible medical care fr yu and yur family. In rder t meet this gal, we need yur assistance and understanding f ur Financial and Office plicies. Our Financial Plicy is a necessary part f assuring the financial resurces needed t maintain this healthcare facility fr ur patients. Office Visits - Private Pay Patients Full payment f services is due at the time f yur visit. We accept cash, checks, Visa, MasterCard, Discver, and debit cards. Csmetic Prcedure & Prducts As we are all aware, csmetic prcedures and skin care prducts are nt cvered benefits under medical insurance. Therefre, payment is due at time f service r prduct purchase. We accept cash, checks, Visa, MasterCard, Discver, and debit cards. Insurance Cmpanies We cannt guarantee hw yur insurance cmpany prcesses and pays yur claims. Yur insurance is a cntract between yu and yur insurance cmpany. We are unable t prvide yu with exact csts f prfessinal prcedures perfrmed by ur prviders due t the fact that insurance cmpanies deduct cntractual adjustments (cntract between the insurance cmpany and Skin Specialists PA), prir t applying any c-payments, cinsurances and r deductibles. Althugh we are participants in yur plan, yu will be respnsible fr all charges the insurance cmpany deems patient respnsibility. Office - Visits Insured Mst health plans require yu t make a c-payment with each visit. C-payment amunts cannt be billed and will be cllected at the time f yur visit. We accept cash, checks, Visa, MasterCard, Discver, and debit cards. In rder t be cnsistent with insurance regulatins, yu are required t pay yur c-payment befre yur ffice visit and deductibles are due at checkut, after services rendered. We accept checks, cash, credit and debit card payments. Nn-Cvered Services It is imprtant t understand that sme f the services prvided t yu may nt be cvered under yur current insurance plan. Therefre, it is imprtant that yu check with yur insurance cmpany t verify yur benefits. Yu will be respnsible fr full payment f any services nt cvered by yur insurance at the time f yur visit. Surgery Sme minr surgical prcedures are perfrmed in ur ffice. Mst insurance carriers put these in the categry f surgery, meaning that the prcedure may be applied t a surgical deductible r cinsurance. Therefre, yu may be billed fr an amunt ver and abve the usual visit c-payment. This may als mean that the prcedure will need t be pre-certified. If the prcedure is nt cvered by yur insurance we will require 100% payment at the time f the surgery. ename: New Patient Packet EFF Page 3 f 9
4 Labratry Services When yu have a skin bipsy r culture dne, we will send the specimen t an utside lab. Please nte that we DO BILL yur insurance fr specimen cllectin, BUT the labratry will bill yur insurance/yu separately fr prcessing and diagnsis f the specimen. Appintments It is ur gal t prvide services t yu in the mst cmfrtable and timely manner pssible. In rder t achieve this, we ask that yu be n time fr yur appintments. We realize yur time is valuable and we endeavr t keep n schedule, while prviding each patient with persnalized care. Hwever, emergencies d ccur, and may cause delays in ur schedule. We will try t keep yu infrmed f these delays shuld they arise. Cancellatin/N Shw Fees: There is a $50 nn-refundable fee ($100 fr surgery) fr each n shw ccurrence r untimely cancellatin (untimely cancellatin - any cancellatin that is nt prvided 24 hurs befre scheduled appintment.) Patient Services We are happy t ffer the fllwing services t ur patients fr a nminal fee: Medical Recrd Cpies up t 20 pages $15; Over 20 pages $25. Cmpletin f Disability, Insurance, FMLA, Medical LOA, Scial Security frms r dictated letters may incur a $25 fee. Please allw at least 48 hurs fr cmpletin. Prescriptin Refills Prescriptin refill r change requests will be handled within 24 hurs f the receipt f the request during regular ffice hurs. Please cntact yur pharmacy s that a written request can be faxed t ur ffice. N prescriptin refill r change requests will be handled after regular ffice hurs r n the weekend. Children Of curse we all lve t see children; hwever, we ask that yu mnitr them at all times while yu are in ur ffice. If yu are uncmfrtable having them with yu in the exam rms, please make ther arrangements fr their care during yur ffice visit. Ntificatin f Changes In rder fr us t maintain accurate financial recrds, we ask that yu ntify us in writing f any changes regarding yur insurance infrmatin and/r persnal infrmatin, i.e., address, name changes, phne numbers and all ther relevant infrmatin that may affect yur financial status. Thank yu fr chsing us fr yur dermatlgy needs. If yu have any questins regarding these plicies, please ntify a member f ur business ffice during regular hurs. We will d ur best t ensure yur understanding f ur plicies s that we may cncentrate n yu and yur care. I acknwledge that I have read and understand the cntents f the financial and ffice plicies fr Skin Specialists PA. Signature Date ename: New Patient Packet EFF Page 4 f 9
5 Wh t Cntact: AUTHORIZATION TO COMMUNICATE HEALTH INFORMATION I hereby authrize and give permissin t Skin Specialists PA, the ffices f Tanya Reddick Rdgers, MD, FAAD, t disclse and discuss any infrmatin related t my medical cnditin(s) t/with the fllwing persns: Name Relatinship Name Relatinship CONTACT ME ONLY I Wish T Be Cntacted In The Fllwing Manner: Hme Phne: Cellular Phne: Check All That Apply _ Ok t leave message with detailed infrmatin _ Leave message with call-back number nly Wrk Phne: _ Ok t leave message with detailed infrmatin _ Leave message with call-back number nly Written Cmmunicatin: _ Ok t mail t my hme address _ Ok t mail t my wrk/ffice address _ Ok t fax t this number The duratin f this authrizatin is indefinite unless I revke it in writing. I understand that requests fr medical infrmatin frm persns nt listed abve will require a specific authrizatin prir t the disclsure f any medical infrmatin. Patient r Parent s Signature Date Office Staff Only Belw Line Signature f Witness Date ename: New Patient Packet EFF Page 5 f 9
6 PATIENT HISTORY FORM Name: Race: Marital Status: Number f children: Hw did yu hear abut ur ffice? Height: Weight: D yu drink alchl? Rarely Daily Scially Never D yu use any illegal drugs? N D yu use any tbacc prducts? Rarely Daily Scially Never Have yu ever had skin cancer? (if s, what type?) N Has anyne in yur immediate family ever had skin cancer? (if s, what type?) N D yu have any skin diseases? Ex: eczema, psriasis, rsacea etc. (if s, what type?) N Have yu ever been expsed t HIV/Aids? N D yu have any artificial jints? (if s, where?) N D yu require antibitics befre a surgical/dental prcedure? N D yu bleed easily? N Date: Are yu allergic t any medicatins? (please list) N (Wmen) Are yu currently pregnant and/r breastfeeding? N Please list surgeries that yu have had in the past. D yu Kelid (type f scar)? N D yu have any electrnic cardiac (heart) devices? (Pacemaker, Defibrillatr) N D yu have any anxiety, depressin, r are yu Bi-Plar? N D yu have a thyrid cnditin r diabetes? N Please list any family histry f any cancers in yur immediate family. D yu have any health prblems yu take medicatin fr? If s, what are the health cnditins? Ex: high bld pressure, chlesterl etc. (If yes, please explain) N What are yur chief cmplaints fr yur visit tday? **Please list any prescriptin, birth cntrl, and ver the cunter medicatins that yu are currently taking r take as needed.** ename: New Patient Packet EFF Page 6 f 9
7 Csmetic Interests Skin Specialists f Allen/Addisn wants t prvide yu with cmplete dermatlgic care. We ffer an array f Csmetic Services t serve a variety f needs. In rder t serve yu better, please place a check next t the Csmetic Service Issue(s) that yu wuld like t discuss with the dctr. Bdy Cnturing Aging Hands Unwanted Hair Facial Veins Facial Redness Wrinkle Fine Lines / Enlarged Pres Facial Scarring / Acne Scarring Parentheses-like creases arund the muth Under-eye Circles Sagging Facial and Neck Skin Leg Veins (Varicse Veins) Shrt Eyelashes Trn Earlbes Ear Piercing I have n csmetic cncerns that I d like t discuss tday PRINT - Patient Name Date ename: New Patient Packet EFF Page 7 f 9
8 Scheduling Depsits and Fees: FINANCIAL POLICY Amendment (Effective 03/01/2013) Depsits will be applied t charges fr services rendered. Charges fr Reschedules, Cancellatins, and N-Shws will be dealt with accrdingly (see table belw). See definitins belw unless therwise defined: N-Shw: N ntificatin and reschedule fr scheduled appintment, OR call t cancel r reschedule appintment within 24 hurs f appintment. Cancellatin: Call must be at least 24 hurs f appintment n a wrking day. Reschedule: Call t reschedule an appintment. Call must be at least 24 hurs f appintment n a wrking day. Wrking Day: Regularly scheduled ffice days. Weekends and ffice hlidays are nt cnsidered wrking days. ITEM DEPOSIT RESCHEDULE CANCELLATION NO-SHOW Standard ffice visit $0 OK OK Billed a $50 fee Surgery $0 OK OK Billed a $100 fee ClSculpting $250 up t 2 hur slt (additinal fr each 2hr slt) OK - Reschedule 3 wrking days earlier $100 charge per 2 hur slt fr reschedules within 3 wrking days $100 charge per 2 hur slt fr cancellatins within 3 wrking days Charged depsit amunt Fraxel / Sculptra $250 OK OK Charged depsit amunt Csmetic Evaluatins: ClSculpting = $0 evaluatin fee Other items = t be bked as a standard appintment. If evaluatin results in a nn-medical evaluatin then a $150 evaluatin fee will be billed. Nte that the $150 fee will be applied t the depsit/cst f any subsequently scheduled csmetic prcedure. ename: New Patient Packet EFF Page 8 f 9
9 ADDITIONAL DISCLOSURES TO PATIENTS RECEIVING TREATMENT FOR WARTS, ACTINIC KERATOSIS, BIOPSIES OR ANY OTHER PROCEDURE THAT MAY TAKE MULTIPLE VISITS. THERE MAY BE SEVERAL TREATMENTS REQUIRED FOR FULL RESOLUTION OF YOUR ISSUE. YOUR INSURANCE MAY CONSIDER THESE TO BE SURGICAL PROCEDURES AND APPLY THE CHARGES TO YOUR DEDUCTIBLE. PLEASE BE AWARE THAT EACH TREATMENT AND OFFICE VISIT SUBMITTED TO YOUR INSURANCE COMPANY MAY APPLY TO YOUR DEDUCTIBLE. IF YOU ARE CONCERNED ABOUT THE COST OF THE BILL, PLEASE NOTIFY THE NURSE AND OUR BILLING STAFF CAN PROVIDE YOU WITH A COST ESTIMATE. WE ARE BOUND BY OUR CONTRACTS WITH YOUR INSURANCE COMPANY AND ONLY CHARGE YOU FOR THE AMOUNTS WE ARE INSTRUCTED AS ALLOWED BY YOUR INSURANCE COMPANY. IF YOU HAVE QUESTIONS, PLEASE FEEL FREE TO CONTACT OUR OFFICE AT Patient Signature: Date ename: New Patient Packet EFF Page 9 f 9
CRG PATIENT REGISTRATION FORM
CRG PATIENT REGISTRATION FORM PATIENT INFORMATION Patient s Name: Birth : (Last) (First) (Middle) Scial Security Number: Male: Female: Hme Address: (Street / RR Bx # / Apt. #) (City/State) (Zip) Preferred
STOUGHTON DENTISTRY PATIENT INFORMATION INSURANCE INFORMATION ADDITIONAL INSURANCE INFORMATION
PATIENT INFORMATION Patient Last Name: First: MI Preferred Name: Sex: M F Birth Date: Marital Status: Scial Security N.: Street Address: City: State: Zip: Hme Phne: Wrk: Cell: Email: Preferred Cntact Methd:
Patient Registration Form
Patient Registratin Frm Tday s Date: PATIENT INFORMATION Date f Birth: Sex: M F Hme Address: City: State: Zip: Patient Lives With: MOTHER FATHER BOTH OTHER: We are required t cllect the fllwing infrmatin
Patient Information. Child s Name Birthdate Gender M F. Nickname SS# Responsible Party Name Relationship
Patient Infrmatin Date Child s Name Birthdate Gender M F Nickname SS# Respnsible Party Name Relatinship Address, Email address Hme Phne Cell Phne Wrk Phne Name f Schl Hbbies Whm may we thank fr referring
Raleigh Pediatric Associates Financial Policy
Welcme t Raleigh Pediatrics Assciates! We re glad yu ve chsen us as yur child s pediatrician and strive t give yur children the best in medical care. We understand that in additin t feeling cmfrtable with
PATIENT LIABILITY STATEMENT
PATIENT LIABILITY STATEMENT (Updated 6/17) We will nt initiate therapeutic services until signed authrizatin is prvided. I understand that I am persnally respnsible fr charges incurred fr services rendered
Name: Patient relation to Guarantor:
Patient Infrmatin (Please print) Full Legal Name: Last First Middle Date f Birth: SS#: Mnth/Day/Cmplete Year Primary Care Physician: Preferred Name: Sex: Male Female Ethnicity: Hispanic/Latin Nn-Hispanic/Nn-Latin
Main Phone #: ( ) - Secondary Phone # :( ) -
Patient Infrmatin Email: Male r Female: SS# - - DOB: / / Address: Main Phne #: ( ) - Secndary Phne # :( ) - (Circle One): Married Single Divrced Widwed Name f Spuse r Guardian: In Case f Emergency: Whm
PATIENT MEDICAL QUESTIONAIRE
PATIENT FORM William I. Kuhel, MD PATIENT MEDICAL QUESTIONAIRE Name: Ht: Wt: Date: Occupatin: 1. Majr Cmplaint (describe in yur wn wrds why yu are cming in t the see the dctr) 2. Referred by: Name and
17183 I-45 S, Suite 410 The Woodlands, TX (281) / (281) Fax PATIENT INFORMATION
17183 I-45 S, Suite 410 The Wdlands, TX 77385 (281) 602-7380 / (281) 602-7386 Fax PATIENT INFORMATION Date: Name: DOB: Scial Security #: Address: City/State/Zip: Hm # Wrk # Cell # Emplyer: Email: Hw did
PATIENT FORM. Abtin Tabaee, MD. Reviewed By: Referring MD Primary Care MD Same Pharmacy Preference Name: Name: Name: Phone: Phone: Phone:
PATIENT FORM Patient Name: Date f Birth: High bld pressure Diabetes Heart disease Strke Asthma Other: Past Medical Histry COPD Thyrid disease Seizures Anxiety Depressin Medicatins (Name, dsage) Referring
SCARLET DENTAL, KATIE VINCER SEARS DDS, INC. Tel:
PATIENT INFORMATION Date: NEW PATIENT UPDATE Patient: LAST FIRST MI PREFERRED TITLE MALE FEMALE CHILD* STUDENT** SINGLE MARRIED DIVORCED WIDOWED *IF CHILD, PROVIDE PARENT/GUARDIAN NAME(S) BELOW: **IF STUDENT,
CONSENT FOR TREATMENT
Thank yu fr chsing 2 nd Street Dental, LLC as yur dental prvider. We are cmmitted t yur treatment being successful. Please understand that payment f yur fees is cnsidered part f yur treatments. The fllwing
NEW PATIENT COMPLETE EYE EXAM WILL TAKE 1-2 HOURS - YOUR EYES WILL BE DILATED
PLEASE COMPLETE ALL OF THE ENCLOSED FORMS AND BRING THEM WITH YOU AT THE TIME OF YOUR APPOINTMENT. FAILURE TO DO SO WILL DELAY YOUR APPOINTMENT. Cancellatins require 24 business hurs ntice. Appintments
Privacy & Data Protection Policy
Privacy & Data Prtectin Plicy Whitby & District Fishing Industry Training Schl Limited and 54 Nrth Maritime Training ("Whitby Fishing Schl", WDFITS, 54 Nrth Maritime "we" r "us") are cmmitted t prmting
The Safety Net Foundation
The Safety Net Fundatin Instructins fr Kineret (anakinra) and Sensipar (cinacalcet HCl) Instructins The Safety Net Fundatin prvides temprary prduct assistance t financially needy patients wh meet predetermined
PLAN DOCUMENT TEMPORARY DISABILITY INSURANCE PROGRAM FOR LAY EMPLOYEES DIOCESE OF METUCHEN OFFICE OF HUMAN RESOURCES. Effective January 1, 2014
DIOCESE OF METUCHEN OFFICE OF HUMAN RESOURCES TEMPORARY DISABILITY INSURANCE PROGRAM FOR LAY EMPLOYEES PLAN DOCUMENT Effective January 1, 2014 (Replaces January 1, 2013 Plan Dcument) 1 CONTENTS OVERVIEW...
Subject Access Requests
Subject Access Requests The Data Prtectin Act 1998 gives rights t individuals in respect f the persnal data that rganisatins hld abut them. One f thse rights is the right t get a cpy f the infrmatin that
Welcome to The Kids Dentist NEW PATIENT FORMS
TODAY S DATE Welcme t The Kids Dentist NEW PATIENT FORMS CHILD S FIRST NAME MI LAST NAME PREFERRED NAME: MALE FEMALE DATE OF BIRTH - - AGE ADDRESS CITY STATE ZIP PLEASE LIST IN ORDER THE BEST NUMBERS TO
A Step-by-Step Guide to Staying in Compliance Updated November 2016
A Step-by-Step Guide t Staying in Cmpliance Updated Nvember 2016 As f September 1, 1994, every persn in J-1 r J-2 status is required t maintain a gvernment-mandated minimum level f health insurance fr
VOLUNTEER REGISTRATION FORM
VOLUNTEER REGISTRATION FORM Office Use Only Prgram: Site: Day(s): Time: Name Email: Phne Number (cell) (hme) (Wrk) Address Birth date What is yur current ccupatin? Are yu r have yu ever been a member f
Steps toward Retirement
Steps tward Retirement Eligibility, Actin Steps, and Benefit Optins fr Faculty and Staff Nearing Retirement Eligibility fr Official University Retiree Status The fllwing jb types f the University are eligible
Best Execution & Client Order Execution Policy. October P age 1 6. BE31/10/17 v1
Best Executin & Client Order Executin Plicy Octber 2017 BE31/10/17 v1 P age 1 6 Cntents 1. Backgrund... 3 2. Order placement... 3 3. Order executin factrs... 3 4. Order executin plicy... 3 5. Order executin
Information Package CAFETERIA 125 PLANS
Infrmatin Package CAFETERIA 125 PLANS Shaffer Insurance Services, Inc. Benefits Divisin 902 E. Ave Q-9 Palmdale Ca. 93550 Tll Free (866) 412-5872 Office Tel (661) 575 9331 Fax (661) 280 2016 Sectin 125
REFERENCE NUMBER: PFS.PDS.115. TITLE: Patient Billing and Collections CURRENT EFFECTIVE DATE: 01/01/2018. PAGE 1 of 8 SCOPE:
PAGE 1 f 8 SCOPE: This Patient Billing and Cllectins Plicy applies t all Presbyterian Healthcare Services (Presbyterian) hspital facilities, including inpatient, utpatient, hme health care services and
PERSONAL. Guarantor Name Last First MI (Preferred)
PATIENT INFORMATION We are pleased t welcme yu t ur ffice. Please take a few minutes t fill ut this frm as cmpletely as yu can. If yu have any questins we ll be glad t help yu. PERSONAL Patient Name Last
What do you need? Copy of the HIPAA Policy on Amendment of Protected Health Information
HIPAA Privacy Prcedure #4 Effective Date: April 14, 2003 Reviewed Date: February, 2011 Amendment f Prtected Health Revised Date: February, 2011 Infrmatin Scpe: Radiatin Onclgy ************************************************************************************
JOHN L. LITTLE, D.D.S, P.A ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES. May Refuse to Sign This Acknowledgement-
JOHN L. LITTLE, D.D.S, P.A ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES -Yu I, Privacy Practices. May Refuse t Sign This Acknwledgement- ---, have received a cpy f this ffice's Ntice f {Please
You can get help from government organizations that are not connected with us
2011 Evidence f Cverage fr Medi-Pak Advantage MA (PFFS) Chapter 9: What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) BACKGROUND SECTION 1 Intrductin Sectin 1.1 What t d if
DATA PROTECTION POLICY FOR PUPILS AND PARENTS
DATA PROTECTION POLICY FOR PUPILS AND PARENTS This Plicy is relevant t the whle schl including EYFS Cntents 1.0 Intrductin 2.0 Respnsibility fr data prtectin 3.0 Types f persnal data prcessed by the schl
PATIENT REGISTRATION. Middle Initial: Last Name: Address: City, State, Zip: Home Phone ( ) Work Phone: ( ) Cell Phone: (_)
PATIENT REGISTRATION First Name: Middle Initial: Last Name: Address: City, State, Zip: Hme Phne ( ) Wrk Phne: ( ) Cell Phne: (_) Birth Date: Age: Sex: Male r Female Scial Security Number: Occupatin: Emplyer:
Tenancy Application Form
Tenancy Applicatin Frm Applicatins will nly be prcessed nce this applicatin is fully cmpleted. Shuld the applicant fail t prvide the fllwing details the applicatin will nt be prcessed. If yur applicatin
Bernard W Lynch, DMD, FAGD
Bernard W Lynch, DMD, FAGD Dental Care Burke 703.596.1555 9239 Old Keene Mill Rad Burke VA 22015 NEW PATIENT INFORMATION Patient Name: Date: Please answer the fllwing cmpletely and thrughly: 1. What specifically
REPRESENTATIVE PAYEE PROGRAM T. O. D., Inc.
P.O. Bx 99243 Referral Checklist Client Infrmatin: Please cmplete t the best f yur ability adding as many details as available. Budget: The budget shuld be filled ut as cmpletely as pssible. If yu are
CAREVEST MORTGAGE INVESTMENT CORPORATION Directions for Completing Retraction Requests
This package is ONLY fr Class A sharehlders f. Cntents f this package (5 pages): - Instructins fr cmpleting yur retractin request - Retractin Request frm fr CareVest Mrtgage Investment Crpratin The February
Workers' Compensation Employee's Guide
Wrkers' Cmpensatin Emplyee's Guide Intrductin What is Wrkers' Cmpensatin? What is a Wrk-Related Injury? Wh Is Cvered by the UCSD Wrkers' Cmpensatin Prgram and When? Where D Yu Receive Initial Medical Treatment?
HIPAA Privacy Rule LINKS AND RESOURCES AFFECTED ENTITIES IMPACT ON EMPLOYERS. Provided by Brown & Brown of Louisiana, LLC
Prvided by Brwn & Brwn f Luisiana, LLC HIPAA Privacy Rule The HIPAA Privacy Rule establishes natinal standards t prtect individuals medical recrds and ther persnal health infrmatin. The Privacy Rule applies
NEWPORT-MESA UNIFIED SCHOOL DISTRICT
NEWPORT-MESA UNIFIED SCHOOL DISTRICT BELIEVE IN YOURSELF. WE DO. Cigna FAQ Belw please find details and frequently asked questins regarding the Cigna Netwrk (HMO), St. Jseph Hag Health (SJHH) Select Netwrk
Manhattan Beach Dermatology Financial Policy
Manhattan Beach Dermatlgy Financial Plicy Payment is expected n the day services are rendered. We accept cash, checks, Visa, MasterCard, American Express and Discver. Fr thse patients wh are cvered by
Child Health and Dental History Form
3205 SE 192 nd Ave Suite 100, Vancuver WA 98683 Office 360-891-9283 Fax 360-891-9283 www.undertheseakidsdentist.cm Child Health and Dental Histry Frm Child s Name: DOB Address: Phne# Gender: Male Female
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
January 1, 2014: NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Centre
AAFMAA CAP FAQs. General Questions:
Overview: AAFMAA has prvided Career Assistance Prgram ( CAP ) lans as a benefit f membership fr many years. We have cmpiled this list f Frequently Asked Questins fr yur cnvenience and t prvide yu with
Checking and Savings Account Application
Checking and Savings Accunt Applicatin Please use the Checking and Savings Accunt Applicatin t: Open a FREE Checking r Dividend Checking and Opt-in r Out f DCU s Overdraft Payment Service including an
Western Management 1654 The Alameda Suite 100 San Jose, California
Fax COMMUNITY NAME PROPERTY MANAGER FROM FAX PAGES PHONE DATE REGARDING Rental Applicatin CC Urgent Fr Review Please Cmment Please Reply Please Recycle Cmments: Western Management 1654 The Alameda Suite
Name DOB / / Age Sex First Middle Last Address City State Zip. Driver s License State SSN
CHART NO. Welcme t DHC! :) Welcme t ur ffice. We appreciate the cnfidence yu have placed in us t prvide yu with ral health services. T assist us in serving yu, please cmplete the fllwing frm. The infrmatin
FINANCIAL SERVICES GUIDE
PART N: iinvest Securities Financial Services Guide (FSG) FINANCIAL SERVICES GUIDE DATED: Octber 2017 Cntents f this FSG This Financial Services Guide ( FSG ) is an imprtant dcument that iinvest Securities
address: Driver license number: Date of birth: Occupation:
MEMBERSHIP APPLICATION PRIMARY MEMBER INFORMATION Name: Scial security Member Number: Hme phne: Cell phne: Business phne: Mther s Maiden Name: Security passwrd: Mailing address: City: State: ZIP Cde: Street
Institute For Orthopaedic Surgery (IOS) Subject: Billing and Payments: General Guidelines
Institute Fr Orthpaedic Surgery (IOS) Plicy and Prcedure Manual Subject: Billing and Payment: General Statements Purpse: T prvide directin t staff members in their interactin with patients and guarantrs
2018 Healthy Boiler Wellness Incentive Program FAQs
2018 Healthy Biler Wellness Incentive Prgram FAQs As healthcare csts cntinue t rise acrss the cuntry, the university s best way t cmbat this is by helping t imprve the verall wellness f ur ppulatin. Therefre,
Welcome to Lowcountry Family Dentistry!
Welcme t Lwcuntry Family Dentistry! Patient Medical and Dental Histry Frm Please take a few minutes t carefully read ver and answer the fllwing questins t help us treat yu safely. If yu have any questins,
Guide to Young Adult Dependent Coverage
Guide t Yung Adult Dependent Cverage The New Yrk State Legislature passed a law in 2009 which extends the availability f health insurance cverage t yung adults thrugh the age f 29. As a result, Freelancers
April 20, 2017 IMPORTANT: THESE GUIDELINES START ON THE NEXT PAGE: Go to
April 20, 2017 Dear Returning Lyn Cllege Athlete: Prir t participating n a team frm Lyn Cllege, athletes must prvide the Athletic Training Department with current address, emergency cntact, insurance,
Employee Rights & Responsibilities Page 1 of 4 Traumatic Injury/Form CA-1
Emplyee Rights & Respnsibilities Page 1 f 4 Traumatic Injury/Frm CA-1 The Federal Emplyees Cmpensatin Act (FECA) utlines the benefits fr federal emplyees injured in the perfrmance f their duties. The Office
Joining SportsWareOnLine
Dear new MBU Student-Athletes, Prir t participating n an athletic team fr Missuri Baptist University (MBU), student-athletes must prvide the Athletic Training Department with lcal and permanent addresses,
Ramsey Million Partnership
Ramsey Millin Partnership General Pints GUIDANCE FOR APPLICATIONS FOR FUNDING GENERAL GRANTS POT 2019 (i) Opening Statement Yur grant applicatin must meet the criteria as established by the Big Lcal and
Employee Hardship Assistance Policy
Emplyee Hardship Assistance Plicy Functinal Area: Human Resurces Applies T: All Faculty and Staff Plicy Reference(s): N/A Number: TBD Date Issued: March 4, 2013 Page(s): 6 Respnsible Persn The Directr
AAFMAA CAP FAQs. Q: What are the requirements for a CAP loan? A: The following items are required to receive a CAP Loan: Eligible military status: o
Overview: AAFMAA has prvided Career Assistance Prgram ( CAP ) lans as a benefit f membership fr many years. We have cmpiled this list f Frequently Asked Questins fr yur cnvenience and t prvide yu with
RENEW DERMATOLOGY NOTICE OF PRIVACY PRACTICES
RENEW DERMATOLOGY NOTICE OF PRACTICES Effective Date: September 21, 2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
What Does Specialty Own Occupation Really Mean?
What Des Specialty Own Occupatin Really Mean? Plicy definitins are cnfusing, nt nly t dentists but als t many f the insurance prfessinals wh sell them. Belw we will try t prvide an understandable explanatin
Western Management PO Box San Jose, California
Fax COMMUNITY NAME PROPERTY MANAGER FROM FAX PAGES PHONE DATE REGARDING Rental Applicatin CC Urgent Fr Review Please Cmment Please Reply Please Recycle Cmments: Western Management PO Bx 26824 San Jse,
Purpose... 1 Definitions... 1 Policy... 2
Cntents Purpse... 1 Definitins... 1 Plicy... 2 1. Privacy Principles... 2 2. Cllectin f infrmatin... 2 3. Unique Student Identifiers (USI)... 3 4. Strage and use f infrmatin... 4 5. Disclsure f infrmatin...
Explanation of a U.S. Address and/or U.S. Phone Number (S3)
Explanatin f a U.S. Address and/r U.S. Phne Number (S3) Custmer Name Custmer Number By cmpleting yur IRS Frm W-8 yu are affirming that yu are nt a citizen r resident f the United States r ther U.S. persn
o Hepatitis o High Cholesterol o High Blood o HIV o IBS o Kidney Disease o Liver Disease
Histry and Physical Name: Height: Weight: She Size: OFFICE USE: BP= / PULSE= List f Current Medicatins: Allergies: Medical Histry: Allergies Anemia Anxiety Arthritis Asthma Back Pain Bld Clts Bleeding
Employment Application. Name: Last First Middle. Home ( ) Alternate( ) Type: i.e. cell phone, message, etc. Social Security No.
Tribal Lending Enterprise (TLE) a whlly wned Crpratin f the Habematlel Pm f Upper Lake 635 B E. Hwy 20 Upper Lake, CA 95485-0516 7300 Cllege Blvd., Ste. 650, Overland Park, KS 66210 D: (913) 717-4664 TF:
Pershing Financial Services Guide (FSG) including its Privacy Policy
Pershing Financial Services Guide (FSG) including its Privacy Plicy Issued by Pershing Securities Australia Pty Ltd ABN 60 136 184 962 Australian Financial Services License N. 338 264 Date FSG was prepared:
FINANCIAL SERVICES GUIDE (FSG)
FINANCIAL SERVICES GUIDE (FSG) Australian Financial Services Licensee: Grsvenr Pirie Management Limited ABN: 81 002 558 956 Australian Financial Services Licence Number: 238184. Effective Date: 1 st August
OSHA INSPECTION CHECKLIST
OSHA INSPECTION CHECKLIST HANDLING AN OSHA INSPECTION The Occupatinal Safety and Health Act (OSH Act) authrizes the Occupatinal Safety and Health Administratin (OSHA) t cnduct wrkplace inspectins and investigatins
Grant Application Guidelines
Grant Applicatin Guidelines The prgram staff f the Cmmunity Fundatin f Greater New Britain lks frward t wrking with yu. This frm is fr rganizatins that have submitted a Letter f Intent t us and were invited
Victoria Banuchi Crespo, MD
PATIENT FORM Victria Banuchi Cresp, MD Patient s Name: Date f Birth: Age: Weight: Height: Reasn fr Visit: Occupatin/Emplyer: Marital Status: Name f Spuse/Significant Other: Children s Names & Date f Birth
MICHIGAN MODERN PSYCHOLOGY Client Information Form **please print clearly**
MICHIGAN MODERN PSYCHOLOGY Client Infrmatin Frm **please print clearly** Client Name: Client DOB: Address: City: State: Zip: Cell Phne: Hme Phne: E-mail: Vicemail & Text Vicemail Text Gender: Male Female
Instructions Fee Schedule
City f Lndn Tree Prtectin By-Law C.P.-1515-228 Tree Prtectin Area Permit Applicatin Cemetery r Glf Curse Planning Services - Urban Frestry 267 Dundas Street, 3rd Flr Lndn, Ontari N6A 1H2 Telephne: 519-661-CITY
What credit related information do we collect and hold and how do we collect it?
In this Credit Reprting Plicy, ORIX, we, us and ur mean ORIX Australia Crpratin Limited and ur related cmpanies. Thse related cmpanies may als have their wn privacy r credit reprting plicies which set
Lake Internal Medicine Associates Phone: (352) Prevatt Street ~ Eustis, FL
Lake Internal Medicine Assciates Phne: (352) 589-4774 2101 Prevatt Street ~ Eustis, FL 32726 www.steventangmd.cm LAKE INTERNAL MEDICINE ASSOCIATES NOTICE OF PRIVACY PRACTICES Effective Date: 10/17/2016
CLOVER PARK TECHNICAL COLLEGE INTERNATIONAL ADMISSION APPLICATION PACKET
CLOVER PARK TECHNICAL COLLEGE INTERNATIONAL ADMISSION APPLICATION PACKET 2017-2018 T apply fr admissin, please cmplete the frms belw and submit with the dcuments indicated: FORMS Internatinal Educatin
FSB Press Release 20 August 2015
Retirement funds must take all reasnable steps t trace and pay millins f their members and beneficiaries wh remain untraced, the Deputy Registrar f Pensin Funds, Rsemary Hunter said n Wednesday. Addressing
Your Retirement Guide. Employees
Yur Retirement Guide Emplyees Retirement is a big step. Over the next few weeks and mnths yu ll be asked t make many imprtant decisins abut yur New Yrk Life benefits and yur financial security. This easy-t-use
High Deductible Health Plan/ Health Savings Account Presentation
High Deductible Health Plan/ Health Savings Accunt Presentatin WHY THE CHANGE? Current plan cannt be sustained inflatin and disease states cmpunding effect n cst fr emplyees and Bard HDHC plan structured
Europa Group Privacy Policy
Eurpa Grup Privacy Plicy The privacy and security f yur persnal infrmatin is very imprtant t us (Eurpa Grup). This plicy explains hw we cllect and use yur persnal infrmatin. Please read it carefully. This
Notice of Privacy Practices for the S.U. Theatre Corporation Health Benefits Plan
Ntice f Privacy Practices fr the S.U. Theatre Crpratin Health Benefits Plan Ntice THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THE INFORMATION.
Financial Services Guide
Financial Services Guide Licensee: Integrity Private Wealth Pty Ltd (AFSL 436298) Crprate Authrised Representative: Nucleus Wealth Management Pty Ltd trading as Nucleus Wealth (ACN# 614 386 266) (CAR#
We process personal data for some or all of the following purposes depending on our relationship with the individual data subject:
PRIVACY POLICY Our purpses fr prcessing yur persnal data We prcess persnal data fr sme r all f the fllwing purpses depending n ur relatinship with the individual data subject: T adhere with all statutry
Patient Information. Personal Information. Preferred name: ( ) Male ( ) Female ( ) Single ( ) Married
Patient Infrmatin Welcme t Art f Dentistry! We will always d ur best t earn the trust that yu have placed in us. Please fill ut these frms. Persnal Infrmatin Patient s Full Name: f Birth: Address: Preferred
Correctly identifying the correct FSC/Plan is one of the most important aspects of collecting information from the patient.
Selecting a FSC/Plan Overview Intrductin This lessn intrduces yu t assigning a FSC/Plan. Failure t crrectly assign the FSC/Plan can significantly impact revenues and can result in unnecessary prblems fr
PSNC Briefing on the NHS Complaints procedure (from 1 April 2009)
PSNC Briefing n the NHS Cmplaints prcedure (frm 1 April 2009) Under the prvisins f the Natinal Health Service (Pharmaceutical Services) Regulatins 2005 1 pharmacy cntractrs are required t make arrangements
Details of Rate, Fee and Other Cost Information
Details f Rate, Fee and Other Cst Infrmatin Accunt terms are nt guaranteed fr any perid f time. All terms, including fees and APRs fr new transactins, may change in accrdance with the Credit Card Agreement
EMPLOYMENT APPLICATION LEE COUNTY GOVERNMENT P.O. Box 398 ATT: Human Resources Fort Myers, Florida (239)
PERSONAL INFORMATION EMPLOYMENT APPLICATION LEE COUNTY GOVERNMENT P.O. Bx 398 ATT: Human Resurces Frt Myers, Flrida 33902 (239) 533-2245 http://www.lee-cunty.cm JOB NUMBER: JOB TITLE: EXAM ID#: Received:
NURSE PROFESSIONAL LIABILITY
8722 S. Harrisn St. Sandy, UT 84070 P.O. Bx 4439 Sandy, UT 84091 877-678-7342 Fax 800-498-9880 NURSE PROFESSIONAL LIABILITY 1. General Infrmatin Prpsed Effective Date: Applicant is (check all that apply):
Privacy Notice for Applicants and Tenants
Privacy Ntice fr Applicants and Tenants What we need Scttish Brders Husing Assciatin (SBHA) will be a "cntrller" f the persnal infrmatin that yu prvide t us thrugh yur cmpleted Husing Applicatin Frm, and
o Native Hawaiian / Pacific Islander o White
PATIENT INFORMATION Last Name: First Name: MI: DOB: / / Gender: M F Height: Weight: Address: City: State: ZIP: Hme Phne: ( ) Cell Phne: ( ) Wrk Phne: ( ) Preferred Cntact Methd: Hme Cell Wrk Scial Security#:
Preparing for Your Early Retirement
Preparing fr Yur Early Retirement Imprtant Infrmatin fr Railrad Emplyees Eligible fr GA-46000 Eligibility fr Railrad Annuity Railrad Retirement Bard https://secure.rrb.gv/ Call yur lcal Railrad Retirement
This policy outlines the Company s guidelines, expectations and requirements related to:
COMMUNICATION & RELEASE OF INFORMATION POLICY #77 Intrductin This plicy utlines the Cmpany s guidelines, expectatins and requirements related t: Use f devices t capture phtgraphs, vide and/r audi while
NYTD Survey- 19 year olds
1 The fllwing survey is being dne t recrd yur experience in the West Virginia Fster Care System. Yur respnses are imprtant and we really d want yur input as we try t find ways t imprve Fster Care and create
NTA LIFE CLAIM PACKET
PROTECTING THE HEART OF OUR COMMUNITY NTA LIFE CLAIM PACKET Included in this packet yu will find: 1. Instructins fr Cmpleting the Health, Accident, and Disability Claim Frm 2. Health, Accident, and Disability
Physical Therapists and Related Occupations Application
Physical Therapists and Related Occupatins Applicatin Darwin Natinal Assurance Cmpany Main Administrative Office: Crprate Office: 9 Farm Springs Rad 1807 Nrth Market Street Farmingtn, CT 06070 Wilmingtn,
Summary Plan Descriptions
Summary Plan Descriptins All grup health plans subject t the Emplyee Retirement Incme Security Act (ERISA) are required t prvide participants with a Summary Plan Descriptin (SPD). An SPD must be written
PAYMENT BY CARD TERMS & CONDITIONS
PAYMENT BY CARD TERMS & CONDITIONS Versin 2.0 - June 2013 Effective frm 1 st June 2013 Issued n 1 st June 2013 Terms & Cnditins fr use f Credit/Debit card fr Payments (POS) Intrductin This Service is ffered
Practice Management: Billing, Coding and Collections. Provided by Coverys Risk Management
Practice Management: Billing, Cding and Cllectins Prvided by Cverys Risk Management Practice Management: Billing, Cding and Cllectins What s the Risk? Overly aggressive cllectin techniques can alienate
Quality of Life Equipment Grants
Quality f Life Equipment Grants Abut the Quality f Life Equipment Grants Prgram The MS Sciety f Canada makes available t individuals living with multiple sclersis (MS) a Quality f Life Equipment Grants
Title II, Part A Private School Principal s Consultative Meeting
2017 2018 Title II, Part A Private Schl Principal s Cnsultative Meeting HOSTED BY DCPS FEDERAL PROGRAMS THURSDAY, AUGUST 3, 2017 LOCATION: MOSH TIME 1:00 3:00PM Thursday, August 3, 2017 Agenda Welcme Title
NHCAC North Hudson Community Action Corporation
NHCAC Nrth Hudsn Cmmunity Actin Crpratin RFP 340B Prgram Auditing Services INQUIRIES SHOULD BE DIRECTED TO: Name: Title: Entity: Address: Manny Diaz Directr f Cmmunity Develpment Nrth Hudsn Cmmunity Actin