Phoenix Orthopaedic Surgeons Joseph S. Gimbel, M. D. PATIENT REGISTRATION

Transcription

1 Phoenix Orthopaedic Surgeons Joseph S. Gimbel, M. D. PATIENT REGISTRATION DATE Chart # PATIENT NAME AGE DATE OF BIRTH MALE FEMALE PREFFERED LANGUAGE RACE/ETHNICITY SINGLE, MARRIED, DIVORCED, SEPARATED,WIDOWED ADDRESS CITY, STATE, ZIP, HOME PHONE WORK CELL PATIENT SOCIAL SECURITY # OCCUPATION EMPLOYER RESPONSIBLE PARTY RESP. PARTY SS# DOB RELATIONSHIP TO PATIENT EMPLOYER NAME PRIMARY CARE PHYSICIAN PHONE FAX REFERRED BY PERSON TO CONTACT IN EMERGENCY PHONE ***************************** INSURANCE INFORMATION ********************************* PRIMARY INSURANCE SECONDARY INSURANCE INSURANCE COMPANY INSURANCE COMPANY ADDRESS ADDRESS POLICY HOLDER NAME POLICY HOLDER NAME POLICY HOLDER SEX F / M BIRTHDATE POLICYHOLDER SEX F/ M BIRTHDATE RELATIONSHIP TO PATIENT RELATIONSHIP TO PATIENT EMPLOYER EMPLOYER POLICY/ID # POLICY /ID# GROUP # GROUP # AUTHORIZATION TO PAY: I HEREBY AUTHORIZE PAYMENT DIRECTLY TO PHOENIX ORTHOPAEDIC SURGEONS FOR SURGICAL AND/OR MEDICAL BENEFITS, IF ANY, OTHERWISE PAYABLE TO ME FOR SERVICES RENDERED TO ME OR MY DEPENDENT. I ALSO AUTHORIZE P.O.S TO RELEASE OR OBTAIN INFORMATION REGARDING MY TREATMENT VIA FACSIMILIE OR U.S. MAIL. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES. SIGNED DATE AUTHORIZATION TO TREAT A MINOR: I HEREBY AUTHORIZE PHOENIX ORTHOPAEDIC TO TREAT THE ABOVE NAMED PATIENT. SIGNED (parent or legal guardian) DATE

2 Phoenix Orthopaedic Surgeons Joseph S. Gimbel, M. D. Diplomat American Board Fellow of American Academy of Orthopaedic Surgeons By signing below, I hereby acknowledge that I have received a copy of the Notice of Privacy Practices of Phoenix Orthopaedic Surgeons Ltd. I understand that occasionally Phoenix Orthopaedic Surgeons may need to contact me concerning health matters. On these occasions I give my permission to: Leave a message on my phone Yes No Speak to another authorized party Yes No Name of authorized party Printed name Signature Witness Date Minor Consent From I parent of Give permission to have my child treated at Phoenix Orthopaedic Surgeons, LTD for their orthopaedic condition. The following people are allowed to bring my child for care. Signature Date

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5 Patient Financial Policy To reduce confusion and misunderstanding between our patients and practice, we have adopted the following financial policies. If you have any questions regarding these policies, please discuss them with our office manager. We are dedicated to providing the best possible care and service to you and regard your complete understanding of your financial responsibilities as an essential element of your care and treatment. Full payment is due at the time of service unless your health insurance carrier has made prior arrangements. For your convenience we accept cash, checks or credit cards (i.e.; VISA, MasterCard, Discover and American Express) Your Insurance We have made prior arrangements with many insurers and health plans to accept an assignment of benefits. This means that we will bill those plans for which we have an agreement and will only require you to pay the authorized copayment at the time of service. This office s policy is to collect this copayment when you arrive for your appointment prior to being seen by the healthcare provider. If you have Medicare, PART B only you are responsible for your Medicare deductible and your 20% of the charges at the time of service. If you have insurance coverage with a plan for which we do not have a prior agreement, we will prepare and send the claim for you on an unassigned basis. This means that your insurer will send the payment directly to you. Consequently, the charges for your care and treatment are due at the time of the service. In the event that your health plan determines a service to be not covered, you will be responsible for the complete charge. Payment is due upon receipt of a statement from our office. Referrals If your insurance requires a referral it is your responsibility to provide the referral to our office prior to seeing the provider. If unable to provide the referral prior to the visit payment in full will be required at the time of the visit or the appointment will be rescheduled. Cancellation Policy Phoenix Orthopaedic Surgeons requires a 24 hour notice prior to the appointment schedule time for cancellations. A fee of $25.00 will be billed to the patient if the office does not receive notification of the cancellation. I have read the Patient Financial Policy and agree to abide by its terms Patient Name Patient/Guardian Signature Date: See other side and sign record release Thank you

6 Joseph S. Gimbel, M.D. Phoenix Orthopaedic Surgeons 2525 W. Greenway Road, Suite 114 Phoenix, Arizona Phone (602) Fax (602) MEDICAL RECORDS AND X-RAY RELEASE DATE: TO: TELEPHONE# FAX# I hereby authorize and request you to release the complete medical records and x-rays in your possession concerning Name: Date of Birth: SS# PLEASE MAIL OR FAX TO: TELEPHONE# FAX# Signed: Date: Relationship: Confidentiality Notice The documents in the facsimile transmission may contain confidential health information that is privileged and legally protected from the disclosure by federal law, the Health Insurance Portability and Accountability Act (HIPAA). This information is intended only for the use of the individual or entity named above. If you are not the intended recipient you are hereby notified that reading, disseminating, disclosing, distributing, copying, acting upon or otherwise using the information contained in the facsimile is strictly prohibited. If you have received this information in error, please notify the sender immediately at and destroy this facsimile.