Legal first and last name of person being assessed today: Marital Status: Social Security #: State: Zip: Employer:

Size: px
Start display at page:

Download "Legal first and last name of person being assessed today: Marital Status: Social Security #: State: Zip: Employer:"

Transcription

1 Admissions Staff Place Patient ID Sticker Here Patient Registration Please read and complete both sides of this form Date: Time: Legal first and last name of person being assessed today: Date of Birth: Age: Sex: Race: Marital Status: Social Security #: County: Phone #: Address: City: State: Zip: Employer: Emergency Contact Relationship: Phone # _ Address: How did you hear about Holly Hill Hospital? What type of treatment are you seeking today? Have you been a patient at Holly Hill in the past? How long ago? Guarantor/Guardian Name: Relationship: Check if information is the same as patient Guarantor/Guardian Phone Number: Guarantor/Guardian Address: Insurance Information Primary Insurance: Name of policyholder: Policy #: Group#: Date of Birth: SS# of policyholder: Employer: Secondary Insurance: Name of policyholder: Policy #: Continued on Back

2 Please Provide us with Information on Your Network of Support: Please list your treatment providers below. (Circle the appropriate credentials for each provider.) PROVIDER 1: Psychiatrist/Psychologist/Therapist/SW: City State Phone#: When was the last time you saw this provider? (circle one) 1-3 months 3-6 months 6+ months PROVIDER 2: Psychiatrist/Psychologist/Therapist/SW City State Phone#: When was the last time you saw this provider? (circle one) 1-3 months 3-6 months 6+ months PROVIDER 3: Psychiatrist/Psychologist/Therapist/SW: City State Phone#: When was the last time you saw this provider? (circle one) 1-3 months 3-6 months 6+ months If Child/Adolescent List School Name Would you like information provided to your provider network? Yes No STAFF USE ONLY Release of Information Signed during admission for ALL providers: Yes No, patient declined No providers Outpatient Providers contacted by Intake staff during admission process via: Direct call Voice mail Unable to reach or leave voic Patient declined No providers Staff Signature: Date/Time: Notes:

3

4

5 Signing below only acknowledges receipt of Holly Hill Hospital s Notice of Privacy Practices. Name of Patient (Print or Type) Signature of Patient Date Time Signature of Authorized Personal Representative Date Relationship Signature of Witness HHH Employee Date /Time

6 Holly Hill Hospital Consent to Use and Disclose Protected Health Information Use and Disclosure of Your Protected Health Information Your protected health information will be used by Holly Hill Hospital or disclosed to others for the purposes of treatment, obtaining payment, or supporting the day-to-day health care operations of the hospital. Notice of Privacy Practices You should review the Notice of Privacy Practices for more complete description of how your protected health information may be used or disclosed. You may review the notice prior to signing this consent. Requesting a Restriction on the Use or Disclosure of Your Information You may request a restriction on the use or disclosure of your protected health information. Holly Hill Hospital may or may not agree to restrict the use or disclosure of your protected health information. If Holly Hill Hospital agrees to your request, the restriction will be binding on the facility. Use or disclosure of protected information in violation of an agreed upon restriction will be a violation of the federal privacy standards. Revocation of Consent You may revoke this consent to the use and disclosure of your protected health information. You must revoke this consent in writing. Any use or disclosure that has already occurred prior to the date on which your revocation of consent is received will not be affected. Reservation of Right to Change Privacy Practices Holly Hill Hospital reserves the right to modify the privacy practices outlined in the notice. Signature of Patient or Authorized Personal Representative I have reviewed this consent form and give my permission to Holly Hill Hospital to use and disclose my health information in accordance with it. Name of Patient (Print or Type) Signature of Patient Date Signature of Authorized Personal Relationship of Authorized Personal Representative/Parent/Legal Guardian Representative to Patient Signature of Witness HHH Employee Date /Time Form # Rev. 9/15

7 HOLLY HILL HOSPITAL FINANCIAL AGREEMENT The undersigned hereby agree as follows: 1) GUARANTEE OF PAYMENT: Holly Hill Hospital (HHH) and the Physician/Healthcare Professional identified above has been or will be providing care to the patient whose name appears above. I hereby agree to guarantee the payment of the bill for services rendered by HHH and the Physician/Healthcare Professional. I agree whether signing as guarantor or as patient, that in consideration of the services to be rendered to the patient, to be hereby jointly and individually obligated to pay the account of HHH and the Physician/Healthcare Professional in accordance with the regular rates and terms of HHH and the Physician/Healthcare Professional. Should the account be referred for collection by an attorney or collection agency, I agree to pay all attorney fees and other reasonable collection costs and charges that are necessary for the collection of any amount(s) not paid when due. 2) ASSIGNMENT OF INSURANCE BENEFITS: In consideration of medical services rendered or to be rendered by HHH and the Physician/Healthcare Professional, to the extent permitted by law, I hereby (I) irrevocably assign, transfer, and set over to HHH and the Physician/Healthcare Professional (II) all of my rights, title and interest to medical reimbursement, including, but not limited to, (III) the right to designate a beneficiary, add dependent eligibility and (IV) to have an individual policy continued or issued in accordance with the terms and benefits under any insurance policy, subscription certificate or other health indemnification agreement otherwise payable to me for those services rendered by HHH and the Physician/Healthcare Professional during the pendency of the claim for this admission. Such irrevocable assignment and transfer shall be for the recovery on said policy(ies) of insurance, but shall not be construed to be an obligation of HHH and the Physician/Healthcare Professional to pursue any such right of recovery. I hereby authorize the insurance company(ies) or third party payer(s) providing coverage for services to pay directly to HHH and the Physician/Healthcare Professional all benefits due for service rendered. 3) Authorization to Use and Disclose Protected Health Information for Payment Purposes: I hereby authorize the use or disclosure of the information identified herein, which may include information regarding drug/alcohol abuse, treatment and rehabilitation, psychological or psychiatric impairments, physical conditions, HIV, and/or AIDS, and other communicable diseases by HHH for payment purposes. The information to be used or disclosed includes those records which are necessary to support claims for payment or reimbursement for services provided to Patient. I understand that I may revoke or terminate this authorization at any time by submitting a written revocation to the HHH Privacy Official, except to the extent that action has already been taken in reliance thereon. If not previously revoked, this authorization will automatically expire six months following discharge. I hereby acknowledge that this consent is voluntary and that there are statutes and regulations protecting the confidentiality of authorized information. 4) INSUFFICIENT INSURANCE COVERAGE: If any insurance or other third party coverage which the patient may have rejects the patient s claim or pays only part of the claim, the undersigned shall be responsible for payment of the balance due, as determined by HHH and the Physician/Healthcare Professional. 5) I acknowledge that this agreement has been read and is understood. I further acknowledge an understanding that the physician s charges will be billed separately from or in addition to charges that may be billed by HHH or other licensed Healthcare professionals who may provide services to the patient. FOR MINORS OR OTHER DEPENDENTS COVERED UNDER PARENTAL GROUP HEALTH PLANS For married parents of patient, please supply the following information: Mothers DOB Fathers DOB For separated or divorced parents of patient, the separation agreement or divorce decree places legal custody with: I CERTIFY THAT THE INFORMATION SUBMITTED ON THIS FORM IS CORRECT TO THE BEST OF MY KNOWLEDGE AND I AGREE TO ALL OF THE PROVISIONS SET FORTH IN THIS FINANCIAL AGREEMENT. Patient Name Please Print Date Signature of Patient (Over 18 years old) Parent/ Legal Representative/Guarantor Please Print Date Signature of Parent/Legal Representative/Guarantor Signature of Witness HHH Employee Date/Time Form # HH9061 9/2015REV

Center for Psychology and Counseling Chart # 118 E. Sunbridge Drive, Fayetteville, AR (479)

Center for Psychology and Counseling Chart # 118 E. Sunbridge Drive, Fayetteville, AR (479) Center for Psychology and Counseling Chart # 118 E. Sunbridge Drive, Fayetteville, AR 72703 (479) 444-1400 Patient Name DOB Sex Today s SS# Marital Status: Allergies Responsible Party Address City _ State

More information

Trinity Family Physicians

Trinity Family Physicians Trinity Family Physicians Consent and Authorization for Minors By law, a healthcare provider must attempt to contact a birth / custodial parent or legal guardian prior to rendering treatment to a minor

More information

Oliver Winston Behavioral Urgent Care, LLC

Oliver Winston Behavioral Urgent Care, LLC Presenting Symptoms: What physical or emotional symptoms brought you here today? Current Stressors: Are there significant changes in your life which may have contributed to the symptoms which brought you

More information

Patient Information PATIENT NAME: DOB: AGE: ADDRESS: ZIP CODE: EMPLOYER NAME: WORK PHONE: RACE: SEX: Male Female PRIMARY DOCTOR: NAME: TELEPHONE#

Patient Information PATIENT NAME: DOB: AGE: ADDRESS: ZIP CODE: EMPLOYER NAME: WORK PHONE: RACE: SEX: Male Female PRIMARY DOCTOR: NAME: TELEPHONE# Patient Information Welcome to our office. We appreciate the confidence that you have placed with us regarding your healthcare needs. To assist us in serving you, please complete the following forms as

More information

Name: DOB: SS: Mailing Address: City: State: Zip: Home #: Cell phone #: Martital Status: Address:

Name: DOB: SS: Mailing Address: City: State: Zip: Home #: Cell phone #: Martital Status:  Address: Patient Information: Name: DOB: SS: Mailing Address: City: State: Zip: Home #: Cell phone #: Martital Status: Email Address: Race: Ethnicity: Gender: Primary Language: Preferred Spoken Language: Would

More information

PATIENT INFORMATION ***All Requested MUST be filled out ****

PATIENT INFORMATION ***All Requested MUST be filled out **** Child, Adolescent, Adult And Family Psychology Alexander T. Gimon, PhD, PA. 10225 Ulmerton Rd Ste 12B Largo, FL 33771 Phone: 727-584-1551 3115 Citrus Tower Blvd., Clermont FL 34711 Phone: 352-241-8540

More information

PATIENT REGISTRATION FORM

PATIENT REGISTRATION FORM Today s Date / / PATIENT REGISTRATION FORM PATIENT INFORMATION Patient Name Last First Middle Is this your legal name? If not, what is your legal name? Birthdate Age Sex q YES q NO / / q M q F q T Street

More information

LAS VEGAS ENDOCRINOLOGY

LAS VEGAS ENDOCRINOLOGY Today s Date: Primary Care Provider: Patient Information Last Name: First Name: Date of Birth: Sex: M F Social Security #: Street Address: City: State: Zip: Occupation: Employer: Home Phone: Cell Phone:

More information

Accessible, Affordable, Quality Patient Centered Medical Home

Accessible, Affordable, Quality Patient Centered Medical Home PATIENT REGISTRATION Child :Last Name: First Name: MI: D.O.B.: / / Sex: Primary Language: Ethnicity: Hispanic / Non-Hispanic / Unknown Race: Asian / Black / Hawaiian / White Primary Policy: Policy Holder

More information

Therapy & Life Counseling Associates Delma Z. Garza, LPC J. Michael Murray JD, MS, LMFT, LPC

Therapy & Life Counseling Associates Delma Z. Garza, LPC J. Michael Murray JD, MS, LMFT, LPC Client Information - Adult Insurance# Name: Last Name First Name Address: City: State: Zip: Home phone Cell Phone Email: Sex: (Circle One) M F Birthday: Soc Sec #: Marital Status: (Circle One) Single Married

More information

Green Valley Ranch Medical Clinic & Urgent Care. Patient Information Form

Green Valley Ranch Medical Clinic & Urgent Care. Patient Information Form Green Valley Ranch Medical Clinic & Urgent Care Patient Information Form Patient Name (Last) (First) (M.I) of Birth// Age Sex_ Marital Status Social Security Number Employment Status (Full Time) (Part

More information

PATIENT INFORMATION INSURANCE INFORMATION

PATIENT INFORMATION INSURANCE INFORMATION PATIENT INFORMATION RECORD (Please Print or Write Legibly) DATE ACCT # PATIENT INFORMATION NAME First Middle Init. Last MAILING ADDRESS CITY STATE ZIP SEX RACE Ethnicity: q hispanic/latino q Not Hispanic/Latino

More information

California Cardiovascular and Thoracic Surgeons

California Cardiovascular and Thoracic Surgeons California Cardiovascular and Thoracic Surgeons 168 North Brent Street, Suite 508 Ventura, CA 93003 Telephone (805) 643-2375 Fax (805) 643-3511 Your assistance in completing the following information thoroughly

More information

Jeffrey L. Brooks, M.D. (707)

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

More information

MILLE LACS BAND OF OJIBWE

MILLE LACS BAND OF OJIBWE Name: Suffix: SS#: - - Last Name First Name Middle Initial DOB: Sex: M F Marital Status: Address: Single Married Divorced Never Married Separated Unknown Widow/Widower Street City State Zip County Home

More information

K A R A N J O HA R, M.D.

K A R A N J O HA R, M.D. P: : REGISTRATION FORM - MAJOR MEDICAL Last Name: First and Middle Name: Social Security #: Birthdate: Age: Sex: F M Marital Status: M S D W Home Address: City: State: Zip: *Does the above address, match

More information

BILL L. JOU, M.D., INC.

BILL L. JOU, M.D., INC. BILL L. JOU, M.D., INC. AUTHORIZATION TO TREAT I (and/or the undersigned on behalf of the patient) voluntarily consent to allow Dr. Bill L. Jou and staff to provide such evaluation and/or care and treatments

More information

PATIENT REGISTRATION FORMS PLEASE PROVIDE INSURANCE CARD(S) & DRIVERS LICENCE TO RECEPTIONIST FOR COPYING

PATIENT REGISTRATION FORMS PLEASE PROVIDE INSURANCE CARD(S) & DRIVERS LICENCE TO RECEPTIONIST FOR COPYING PATIENT REGISTRATION FORMS PLEASE PROVIDE INSURANCE CARD(S) & DRIVERS LICENCE TO RECEPTIONIST FOR COPYING Registered PATIENT INFORMATION Updated Name: DOB: Age First MI last Home Address City: State: ZIP

More information

70 Hatfield Lane Goshen, New York SSN: First Name: MI: Last Name: Employment: Employed Unemployed Retired Employer: Employer Address:

70 Hatfield Lane Goshen, New York SSN: First Name: MI: Last Name: Employment: Employed Unemployed Retired Employer: Employer Address: 70 Hatfield Lane Goshen, New York 10924 SSN: First Name: MI: Last Name: Prefix (Ms., Mr.,) Sex: M F DOB: Marital Status: Single Married Divorced Widowed Spouse Name: Employment: Employed Unemployed Retired

More information

AUTHORIZATION TO USE, DISCLOSE, & RELEASE PROTECTED HEALTH INFORMATION

AUTHORIZATION TO USE, DISCLOSE, & RELEASE PROTECTED HEALTH INFORMATION AUTHORIZATION TO USE, DISCLOSE, & RELEASE PROTECTED HEALTH INFORMATION I understand the following: I have the right to refuse to sign this form for authorization to disclose or release my protected health

More information

Pediatric & Adolescent Center of NW Houston, PA & Northwest Houston Neurology, PA

Pediatric & Adolescent Center of NW Houston, PA & Northwest Houston Neurology, PA Pediatric & Adolescent Center of NW Houston, PA & Northwest Houston Neurology, PA Poonam Singh, M.D. * Elizabeth Sanchez Fowler, M.D. * Tonya Suffridge, M.D. * Anuradha Venkatachalam, M.D. Balbir Singh,

More information

PATIENT REGISTRATION INFORMATION FOR MINORS

PATIENT REGISTRATION INFORMATION FOR MINORS Today s Date: / / 620 Dr. Calvin Jones Highway, Suite 212 Please fill out and sign all registration paperwork attached. This will help us better serve you during your time at our clinic. PATIENT REGISTRATION

More information

Patient Registration

Patient Registration Patient Registration Please check Primary Home Work Cell phone Gender SSN E-mail Address Driver s License M F Marital Status Preferred Contact Ethnicity Race Married Single Divorced Separated Widowed Life

More information

My Doctor at WIM is: Dr. Azam Dr. Cohen Dr. Huynh Dr. Jacobellis Dr. McCarthy Dr. Taylor (CIRCLE ONE)

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.

More information

INSURANCE INFORMATION

INSURANCE INFORMATION PATIENT INFORMATION Last Name First Name M.I. Marital Status: Married Single Divorced Widowed Social Security No.: - - Birth Date: / / Sex: M F Place of Birth: Driver s License Number: Preferred Language:

More information

STUDENT STATUS: FULL TIME PART TIME NOT A STUDENT RESPONSIBLE PARTY: SELF GUARANTOR RELATIONSHIP

STUDENT STATUS: FULL TIME PART TIME NOT A STUDENT RESPONSIBLE PARTY: SELF GUARANTOR RELATIONSHIP / / Date Wellspring LAST NAME FIRST NAME MIDDLE INITIAL ADDRESS CITY STATE ZIP HOME PHONE CELL PHONE WORK PHONE (EXT) PRIMARY CARE DOCTOR REFERRING PHYSICIAN / / SEX: F M OF BIRTH SOCIAL SECURITY # MARITAL

More information

Name: Social Security# Address: City: State: Zip: Date of Birth: Phone: Cell: *Employer: Phone:

Name: Social Security# Address: City: State: Zip: Date of Birth: Phone: Cell: *Employer: Phone: Gallatin Family Practice Center Subir Guha, M.D. * Noridia Mauras, D.O * 608 Commons Drive Suite A * Gallatin, TN 37066 Telephone (615)452-5901 Fax (615)451-2006 Name: Social Security# Address: City: State:

More information

Patient Name: Last First Middle Address: Marital Status: (circle one) Single Married Divorced Widowed Other Gender: Female Male

Patient Name: Last First Middle Address: Marital Status: (circle one) Single Married Divorced Widowed Other Gender: Female Male Patient Information Patient Name: Last First Middle Address: City: State: Zip Code: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Email Address: of Birth: / / Social Security #: - - Marital Status:

More information

If it is not, call your insurance company and have them change the Children s Medical Center to one of Children s Medical Center physicians.

If it is not, call your insurance company and have them change the Children s Medical Center to one of Children s Medical Center physicians. **This form is for your personal use only and is a tool to help you understand your personal health benefits** Call your insurance company (phone number on the back of your insurance card) and ask them

More information

First Name: Middle Name: Last Name: Preferred Name: Address: City: State: Zip: Mother s First & Last Name: Mother s Home Phone: Mother s Work Phone:

First Name: Middle Name: Last Name: Preferred Name: Address: City: State: Zip: Mother s First & Last Name: Mother s Home Phone: Mother s Work Phone: Patient Information First Name: Middle Name: Last Name: Date of Birth: Gender: M F Preferred Name: Address: City: State: Zip: Contact Information Mother s First & Last Name: Mother s Address (If different

More information

Sinha Clinic Foxfield Road, Suite 240, St. Charles, IL Office: (630) Fax: (630)

Sinha Clinic Foxfield Road, Suite 240, St. Charles, IL Office: (630) Fax: (630) 2560 Foxfield Road, Suite 240, St. Charles, IL 60174 Office: (630) 762-9606 Fax: (630) 762-9605 www.sinhaclinic.com info@sinhaclinic.com Patient Name: Date: Home Phone: ( )- Cell Phone: ( )- Preferred

More information

Morris Medical Center, P.A.

Morris Medical Center, P.A. Thank you for choosing our practice to assist in your healthcare needs. We appreciate the confidence you and your personal physician have placed in us. Please read the following instructions and information

More information

PEDIATRIC PATIENT REGISTRATION GALEN MEDICAL GROUP, PC

PEDIATRIC PATIENT REGISTRATION GALEN MEDICAL GROUP, PC PEDIATRIC PATIENT REGISTRATION GALEN MEDICAL GROUP, PC Your Child: Name Your Child s Full Name: Child Goes By: Gender: Male Female DOB: Age: SS#: Child s Home Address: City: State: Zip: Phone: Primary

More information

Is this your child s first visit to the dentist? Yes No If no, date of: last exam dental x-rays fluoride treatment

Is this your child s first visit to the dentist? Yes No If no, date of: last exam dental x-rays fluoride treatment PATIENT HEALTH INFORMATION The following information is requested to enable us to give the most consideration to your time and feelings. It is our sincere desire to give personal attention to each of our

More information

Kinsler Psychology Help when life hurts

Kinsler Psychology Help when life hurts 1 ADULT INTAKE HISTORY Patient Name Date Age Birthdate Birthplace Gender Male/Female Address City State Zip Social Security# Home Phone Cell Phone Work Phone Occupation: Employer: Name and number of emergency

More information

Patient's Name: Date of Birth:

Patient's Name: Date of Birth: AUTHORIZATION TO USE AND/OR DISCLOSE HEALTH INFORMATION Fresno Children s Pediatrics 7720 N Fresno Street, Ste #104, Fresno, CA 93720 Phone: (559) 438-2300 Fax: (559) 438-1531 Patient's Name: Date of Birth:

More information

Family address preferred for patient portal access:

Family  address preferred for patient portal access: : Patient Relationship to Guarantor: of Birth: Sex: M F Social Security Number: Home Address: City: State: Zip Code: Pharmacy of Choice: Pharmacy Address: Pharmacy Phone Number: Siblings: Name Sex DOB

More information

(Please Print using Black or Blue Ink) SEX: GENDER IDENTITY: MARITAL STATUS: SINGLE MARRIED OTHER

(Please Print using Black or Blue Ink) SEX: GENDER IDENTITY: MARITAL STATUS: SINGLE MARRIED OTHER PATIENT INFORMATION (Please Print using Black or Blue Ink) LAST NAME: FIRST NAME: MIDDLE INITIAL: ADDRESS: CITY: STATE: ZIP: SEX: GENDER IDENTITY: MARITAL STATUS: SINGLE MARRIED OTHER RACE (OPTIONAL):

More information

Patient's Name: Date of Birth:

Patient's Name: Date of Birth: AUTHORIZATION TO USE AND/OR DISCLOSE HEALTH INFORMATION Magnolia Pediatrics 2497 Herndon Ave., suite #101, Clovis, CA 93611 Phone: (559) 538-3070 Fax: (559) 538-3071 Patient's Name: Date of Birth: Completion

More information

TILAK PEDIATRICS Patient Information Form For all Patients 18 years of Age and Older

TILAK PEDIATRICS Patient Information Form For all Patients 18 years of Age and Older Patient Information Form For all Patients 18 years of Age and Older Patient s Information Name: DOB: / / Male Female RACE African-American American Indian/Alaska Native Asian Caucasian Native Hawaiian/Pacific

More information

APPLICATION FOR ASSISTANCE (CHILDREN)

APPLICATION FOR ASSISTANCE (CHILDREN) WORLD CRANIOFACIAL FOUNDATION Medical City Dallas 7777 Forest Lane Suite C-621 Dallas, Texas 75230 Mailing Address: P.O. Box 515838 Dallas, Texas 75251-5838 Telephone (972) 566-6669 800-533-3315 APPLICATION

More information

PULMONARY AND CRITICAL CARE SPECIALISTS 160 Kingsley Lane, Suite 103 Norfolk, VA Phone: Fax:

PULMONARY AND CRITICAL CARE SPECIALISTS 160 Kingsley Lane, Suite 103 Norfolk, VA Phone: Fax: PATIENT INFORMATION Address: PULMONARY AND CRITICAL CARE SPECIALISTS 160 Kingsley Lane, Suite 103 Norfolk, VA 23505 Phone: 757-889-6677 Fax: 757-889-6652 PLEASE PRINT Today s Date: City: State: Zip: Age:

More information

HIPAA AUTHORIZATION FORM.docx LIEN MMC.docx LIEN MMIPP.docx MEDICAL RECORDS RELEASE INFO.doc PATIENT AND AUTO INFO.docx PATIENT HEALTH INFO.

HIPAA AUTHORIZATION FORM.docx LIEN MMC.docx LIEN MMIPP.docx MEDICAL RECORDS RELEASE INFO.doc PATIENT AND AUTO INFO.docx PATIENT HEALTH INFO. HIPAA AUTHORIZATION FORM.docx LIEN MMC.docx LIEN MMIPP.docx MEDICAL RECORDS RELEASE INFO.doc PATIENT AND AUTO INFO.docx PATIENT HEALTH INFO.docx HIPAA AUTHORIZATION FORM (Health Insurance Portability and

More information

Today s Date (mm/dd/yyyy):

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

More information

**** Does the above address, match the address on your State Identification Card? Yes No *****

**** Does the above address, match the address on your State Identification Card? Yes No ***** Kenneth B. Chapman, M.D. Kiran V. Patel, M.D. Keyvan Jahanbakhsh, M.D. Uel J. Alexis, M.D. Cameron Marshall, M.D. Brian Maloney, M.D. Last Name First Name: SS# Birth : / / Age Sex: F M Marital Status:

More information

VEIN CENTER OF VENTURA

VEIN CENTER OF VENTURA 168 N. Brent St., #508 Ventura, CA 93003 Tele: (805) 643-2855 Fax: (805) 643-3511 PATIENT INFORMATION Name of Birth SS # Marital Status: Sex: Home Address City State Zip Email Mailing Address (if different)

More information

JUST US KIDS PEDIATRICS NEWBORN HISTORY FORM

JUST US KIDS PEDIATRICS NEWBORN HISTORY FORM JUST US KIDS PEDIATRICS NEWBORN HISTORY FORM DATE: PATIENT NAME: D.O.B BIRTH HISTORY WAS YOUR BABY FULL TERM? PRE-TERM? ADOPTED? IF PRE-TERM, HOW MANY WEEKS? IF ADOPTED, AT WHAT AGE? TYPE OF DELIVERY:

More information

Consent for Purposes of Treatment, Payment and Healthcare Operations

Consent for Purposes of Treatment, Payment and Healthcare Operations Consent for Purposes of Treatment, Payment and Healthcare Operations I consent to the use or disclosure of my protected health information by Neuropsych Associates for the purpose of diagnosing or providing

More information

Representative Payee Application

Representative Payee Application Representative Payee Application I hereby authorize Greater Triangle Representative Payee Services, Inc. to manage by benefits and to serve as my organizational representative payee. I understand that

More information

PATIENT INFORMATION FORM

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

More information

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

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

More information

WELCOME TO OUR OFFICE. Patient s Name: Today s Date: First Middle Last. Home Address: City: State: Zip: Telephone: Home ( ) Cellular: ( ) Work: ( )

WELCOME TO OUR OFFICE. Patient s Name: Today s Date: First Middle Last. Home Address: City: State: Zip: Telephone: Home ( ) Cellular: ( ) Work: ( ) WELCOME TO OUR OFFICE Patient s Name: Today s Date: First Middle Last Home Address: City: State: Zip: Telephone: Home ( ) Cellular: ( ) Work: ( ) Email: Personal Work DOB: Age: SSN#: Ethnic Background:

More information

Carroll County Nephrology, PC

Carroll County Nephrology, PC Carroll County Nephrology, PC Phone: 770-832-0429 Fax: 770-838-9108 Maria J. Orig, M.D. FASN Bryan D. Quinn, M.D. WELCOME TO CARROLL COUNTY NEPHROLOGY **Please bring the completed enclosed paper work with

More information

CRG PATIENT REGISTRATION FORM

CRG PATIENT REGISTRATION FORM CRG PATIENT REGISTRATION FORM PATIENT INFORMATION Patient s Name: (Last) (First) (Middle) Birth : Social Security Number: Male: Female: Home Address: (Street / RR Box # / Apt. #) (City/State) (Zip) Preferred

More information

Quick Patient Registration Form Patient Information:

Quick Patient Registration Form Patient Information: Quick Patient Registration Form Patient Information: Legal First Name: MI: Legal Last Name: Sex: M F Date of Birth: Primary Language: Marital Status: Married Single Partner Divorced Widowed Race: Ethnicity:

More information

CRG PATIENT REGISTRATION FORM

CRG PATIENT REGISTRATION FORM CRG PATIENT REGISTRATION FORM PATIENT INFORMATION Patient s Name: Birth : (Last) (First) (Middle) Social Security Number: Male: Female: Home Address: _ (Street / RR Box # / Apt. #) (City/State) (Zip) Preferred

More information

PLEASE PRINT CLEARLY

PLEASE PRINT CLEARLY PATIENT INFORMATION FORM Rev. 02/2018 PLEASE PRINT CLEARLY New Patient Name Change Address Change Insurance Policy/Holder Change PATIENT INFORMATION Last Name: _ First Name: Middle Initial: DOB: Sex: Male

More information

PATIENT INFORMATION PATIENT INFORMATION. Middle Initial: Nickname: Date of Birth: Marital Status: Address: City: State: Zip Code:

PATIENT INFORMATION PATIENT INFORMATION. Middle Initial: Nickname: Date of Birth: Marital Status: Address: City: State: Zip Code: PATIENT INFORMATION PATIENT INFORMATION First Name: Last Name: Middle Initial: Nickname: Date of Birth: Sex: Marital Status: Address: City: State: Zip Code: Home Phone: Cell Phone: Email: How did you hear

More information

New Client Information Sheet

New Client Information Sheet New Client Information Sheet PSY Family Services Please complete ALL questions 301 W. Rosedale, Fort Worth, TX 76104 1. Client Demographics Patient Name: Last: First: Middle: Sex: ( )M ( )F DOB: Age: School

More information

Connecticut Asthma & Allergy Center LLC Registration Form

Connecticut Asthma & Allergy Center LLC Registration Form Name: Connecticut Asthma & Allergy Center LLC Registration Form Last First Middle Initial Date of Birth: / / Sex: Race: Ethnicity: Language: SS#: xxx-xx- Address: # Street Apt/PO Box Email: Town State

More information

Client Contract. Client Full Name: Social Security Number: POA/Guardian Name: Phone: Address:

Client Contract. Client Full Name: Social Security Number: POA/Guardian Name: Phone: Address: Client Contract Client Full DOB: Social Security Number: POA/Guardian Phone: _ I, or my advocate, have discussed my needs with my POA/Guardian. I agree to have Thrive serve has my representative payee

More information

Obstetrics and Gynecology 50 Medical Drive Suite 100 (806) Borger, TX

Obstetrics and Gynecology 50 Medical Drive Suite 100 (806) Borger, TX PATIENT INFORMATION First Name MI Last Name Date of Birth Age: Social Security # Race Ethnicity: Sex: Female / Male Marital Status: S M W D Email Address: Mailing Address City State Zip Physical Address

More information

PATIENT INFORMATION Date Patient last name Patient first name Patient middle name. Primary Address City State Zip. Alternate Address City State Zip

PATIENT INFORMATION Date Patient last name Patient first name Patient middle name. Primary Address City State Zip. Alternate Address City State Zip Clinic Name: The Mollen Clinic Physician/Provider being seen today: Arthur Mollen, DO, Martin Mollen, MD, Melvin Bottner, MD, Monika Sajecki, PA, Kaitlin Kramer, PA PATIENT INFORMATION Date Patient last

More information

Kalpana Thakur, M.D. PA Registration Form

Kalpana Thakur, M.D. PA Registration Form Registration Form (Please Print): : Patient Information Last Name: First: Middle: of Birth: Age: Sex: M F Marital Status: Single Married Other S.S. Number Home phone: Mobile: Street Address: City: State:

More information

VIATICAL SETTLEMENT APPLICATION

VIATICAL SETTLEMENT APPLICATION VIATICAL SETTLEMENT APPLICATION A. PERSONAL INFORMATION - (PRINT OR TYPE) Name of Insured: Male Female Date of Birth: SSN: Address: City: State: Zip: Telephone Number: Email Address: Marital Status: Single/Never

More information

Patient Registration Form

Patient Registration Form Patient Registration Form Patient Information Patient Name (Last, First, M.I.): Birth Date: / / Social Security Number: Sex (Circle One): Male / Female Race (Circle One): Asian/African American/American

More information

Stonebridge Adult Medicine, P.A. Registration Form (Please Print)

Stonebridge Adult Medicine, P.A. Registration Form (Please Print) Stonebridge Adult Medicine, P.A. Registration Form (Please Print) PATIENT INFORMATION Last Name: First Name: Is this your legal name? Yes No If not what is your legal name: Date of Birth: Sex: male female

More information

Patient Registration. All Inclusive Primary Care. PATIENT INFORMATION Name: (Last, First, MI) Address: City: State/Province: Zip: Country:

Patient Registration. All Inclusive Primary Care. PATIENT INFORMATION Name: (Last, First, MI) Address: City: State/Province: Zip: Country: Patient Registration PATIENT INFORMATION Name: (Last, First, MI) Address: City: State/Province: Zip: Country: Mailing Address (if different from above): Home Phone: Work: Mobile: Email: SSN: Birth Date:

More information

Advantage Physical Therapy Patient Registration

Advantage Physical Therapy Patient Registration Appointment Date/Time: Therapist: Advantage Physical Therapy Patient Registration ****Please note ALL patients are required to have a prescription for Physical Therapy from a referring Physician prior

More information

Conway Regional After Hours Clinic

Conway Regional After Hours Clinic Conway Regional After Hours Clinic Patient Information Patient Name: Date of Birth Sex (M) (F) SS# Marital Status M S W D Home Phone ( ) - Cell Phone ( ) - Work Phone ( ) - Mailing Address: Street City

More information

MACRI DENTAL LLC 4380 S. Syracuse St. Suite 502 Denver, CO Patient Registration Form

MACRI DENTAL LLC 4380 S. Syracuse St. Suite 502 Denver, CO Patient Registration Form Personal Information Patient Registration Form Responsible Party First Name Initial Last Name Patient First Name Initial Last Name Address City State Zip Home Phone Work Cell Birthday Social Security Email

More information

MORE MD Patient Information

MORE MD Patient Information MORE MD Patient Information Date: Patient Name: (Last) (First) (Middle) Mailing Address: City: State: Zip: SS# DOB: Age: Home Ph #: Cell Ph#: Work Ph#: Race: White Asian Africian-American American Indian

More information

MasterCare Physical Therapy, Inc.

MasterCare Physical Therapy, Inc. Patient Financial Responsibility To all of our Patients: We will, as a courtesy, file your insurance claims for you. Please be advised that it is solely your responsibility to know and to understand your

More information

Patient Registration Forms

Patient Registration Forms Patient Registration Forms PATIENT INFORMATION First Name: Middle: Last: DOB: / / Sex: M/F Primary Language: Address: City: ST ZIP Ethnicity: Hispanic / Non-Hispanic / Unknown Race: Asian / White / African

More information

INTAKE FORM Please print and give complete information

INTAKE FORM Please print and give complete information P.O. Box 339 Ashton, MD 20861 800.491.5369 Fax: 301-774-3678 Office Use Only Counselors please complete before submitting new Intakes. Case Number Initial Interview Date Location Association Counselor

More information

Child s Name: Gender: M or F Last First MI. Date Of Birth: - - ADDRESS: CITY: STATE ZIP: REFERRING SOURCE. Physician Name Last First MI

Child s Name: Gender: M or F Last First MI. Date Of Birth: - - ADDRESS: CITY: STATE ZIP: REFERRING SOURCE. Physician Name Last First MI PATIENT INFORMATION PATIENT INTAKE FORM DATE: PT/OT/ST Child s Name: Gender: M or F Last First MI Date Of Birth: - - SS# - - ADDRESS: CITY: STATE ZIP: REFERRING SOURCE Physician Name Last First MI Phone:

More information

Insurance Information My Plan is a: PPO HMO POS (Point of Service) Other. Patient Name Address City State Zip

Insurance Information My Plan is a: PPO HMO POS (Point of Service) Other. Patient Name Address City State Zip Patient Information Form Patient Name Address City State Zip Phone#: Home Cell Work Ext Date of Birth Gender Employer Primary Care/Referring Physician Physician s Name Phone # How did you hear about our

More information

Center for Emotional Wellness & Healing, LLC 100 Heritage Valley Rd, Ste. 1, Sewell, NJ 08080

Center for Emotional Wellness & Healing, LLC 100 Heritage Valley Rd, Ste. 1, Sewell, NJ 08080 100 Heritage Valley Rd, Ste. 1, Sewell, NJ 08080 INTAKE FORM Name: DOB: Age: Street: City/Town: Zip Code: Home Phone: May We Leave a Message? Yes No Cell Phone: May We Leave a Voice Message? Yes No May

More information

Name: last First middle Address: street city state zip code Mailing Address: ( if different) street city state zip code

Name: last First middle Address: street city state zip code Mailing Address: ( if different) street city state zip code 0 Mental Health Resources, PC (540) 899-9826 Fax (540) 373-3913 Date (or effective date of change) Patient Information DO NOT COMPLETE THIS FORM UNTIL YOU HAVE A CONFIRMED APPOINTMENT. Patient Information

More information

WELCOME TO KAYAL ORTHOPAEDIC CENTER, P.C.

WELCOME TO KAYAL ORTHOPAEDIC CENTER, P.C. WELCOME TO KAYAL ORTHOPAEDIC CENTER, P.C. PATIENT S NAME: TODAY S DATE: E-MAIL ADDRESS: PATIENT S DATE OF BIRTH: BRIEFLY DESCRIBE THE REASON FOR TODAY S VISIT DATE OF ONSET OR INJURY: IS TODAY S VISIT

More information

Ra m sd ell P ed iatrics, I nc.

Ra m sd ell P ed iatrics, I nc. Please Print Patient Information: Last Name First MI Address City State Zip - Home Phone Alt. Phone SSN Sex DOB / / Policyholder Information: Policyholder s Name Policyholder s Address Policyholder s DOB

More information

Patient Registration Form

Patient Registration Form Patient Registration Form PATIENT INFORMATION Full legal name (First, Middle, Last, suffix) Nickname Sex: Male Female Date of birth Social security number Race Preferred language Ethnicity: Hispanic n-hispanic

More information

First Middle Last Nickname (if any) Present Age Date of Birth. City State Zip Code Primary Phone Number

First Middle Last Nickname (if any) Present Age Date of Birth. City State Zip Code Primary Phone Number EMERGENCY CONTACTS SIBLINGS INSURANCE PARENT/GUARDIAN PATIENT Gerald A. Stagg, MD, FAAP Joel D. Chapman, MD, FAAP J. Colton Bradshaw, MD, FAAP Marc E. Kimball, MD, FAAP First Middle Last Nickname (if any)

More information

Welcome to Pediatric Dentistry of Greenville!

Welcome to Pediatric Dentistry of Greenville! Welcome to Pediatric Dentistry of Greenville! Child's Information Child's Name(Last, First, Middle Initial) Child's DOB: / / Child's Age Nickname: ( ) Male ( ) Female School : Grade: Child's Home Phone

More information

WELCOME TO OUR OFFICE PLEASE PRINT THE FOLLOWING INFORMATION THANK YOU

WELCOME TO OUR OFFICE PLEASE PRINT THE FOLLOWING INFORMATION THANK YOU DATE: / / WELCOME TO OUR OFFICE PLEASE PRINT THE FOLLOWING INFORMATION THANK YOU Richard L. Corbin, DPM, FACFAS PATIENT NAME: LAST FIRST MIDDLE SOCIAL SECURITY NUMBER: / / D.O.B: / / STREET ADDRESS: CITY:

More information

West Cary Family Physicians 256 Towne Village Dr Cary, NC

West Cary Family Physicians 256 Towne Village Dr Cary, NC New Patient Registration Form - page 1 PATIENT INFORMATION Patient s first name: Patient s middle name: Patient s last name: Patient date of birth: Patient sex: Marital status: single married Patient s

More information

PATIENT REGISTRATION (Please Print) Social Security # Address City State Zip. Address

PATIENT REGISTRATION (Please Print) Social Security # Address City State Zip.  Address PATIENT REGISTRATION (Please Print) Date Name (Last) (First) (MI) Clinician Social Security # Address City State Zip Email Address Home Phone ( ) Mobile/Alt. Phone ( ) Work Phone ( ) PLEASE IDENTIFY WHICH

More information

Pharmaceutical Assistance Program

Pharmaceutical Assistance Program Thank you for choosing the Shannon Pharmaceutical Assistance Program to provide service for you. Our goal is to provide medications at a minimal cost for qualifying patients with chronic conditions so

More information

APPLICATION FOR ASSISTANCE (ADULTS)

APPLICATION FOR ASSISTANCE (ADULTS) WORLD CRANIOFACIAL FOUNDATION Medical City Dallas 7777 Forest Lane Suite C-621 Dallas, Texas 75230 Mailing Address: P.O. Box 515838 Dallas, Texas 75251-5838 Telephone (972) 566-6669 1-800-533-3315 APPLICATION

More information

First Name: Last Name: Initial:

First Name: Last Name: Initial: Patient Information Sheet Please complete the entire form First Name: Last Name: Initial: Address: City: State: Florida Zip Code: Home: ( ) Work: ( ) Cell: ( ) 420 South Dixie Hwy, Suite 4D Email: Gender:

More information

Patient Name: DOB: Sex: Male/Female. Primary Address: Home Phone: Mobile Phone: Address: Emergency Contact Name and Phone Number:

Patient Name: DOB: Sex: Male/Female. Primary Address: Home Phone: Mobile Phone:  Address: Emergency Contact Name and Phone Number: Patient Registration Patient Name: DOB: Sex: Male/Female Primary Address: Home Phone: Mobile Phone: Email Address: Emergency Contact Name and Phone Number: Primary Language: Race(s): (Circle all that applies)

More information

Patient/Guardian Signature: I hereby agree that the information above is true and accurate. Patient Medical History Form PATIENT MEDICAL HISTORY FORM

Patient/Guardian Signature: I hereby agree that the information above is true and accurate. Patient Medical History Form PATIENT MEDICAL HISTORY FORM PATIENT MEDICAL HISTORY FORM Patient Medical History Form DATE: Last Name: First Name: Chart#: Birth Date: Sex: Male / Female Height: Weight: PATIENT HISTORY AND SAFETY QUESTIONS Physician Name: Do you

More information

Bailey Behavioral Health, LLC Treatment Questionnaire

Bailey Behavioral Health, LLC Treatment Questionnaire Bailey Behavioral Health, LLC Treatment Questionnaire (Please Print) Patient Name Date Address: City: State: Zip Code: Age: Date of Birth: Social Security : Home Phone Number: Cell: Marital Status: (Circle)

More information

CREEKSIDE DENTAL REGISTRATION FORM. Please Print PATIENT INFORMATION. Patient s Last Name: First: Middle:

CREEKSIDE DENTAL REGISTRATION FORM. Please Print PATIENT INFORMATION. Patient s Last Name: First: Middle: Today s date CREEKSIDE DENTAL REGISTRATION FORM Please Print PATIENT INFORMATION Patient s Last Name: First: Middle: Home Phone #: Work #: Cell #: Email Address: Street Address: City: State: Zip Code:

More information

Policies and information:

Policies and information: Policies and information: Basic Policies: Please be on time for your appointments. If you are late for your scheduled appointment, there is a chance that you will be rescheduled. We require at least 24

More information

Today s Date: Street Address: City: State: Zip: Mailing Address (only if different): Circle: MALE or FEMALE Married Status: Social Security: - -

Today s Date: Street Address: City: State: Zip: Mailing Address (only if different): Circle: MALE or FEMALE Married Status: Social Security: - - New Patient Forms Today s Date: Name (Last, First, MI): Date of Birth: Today s Date: Street Address: City: State: Zip: Mailing Address (only if different): _ Home Phone: _ ( ) Cell Phone: _ ( ) Work Phone:

More information

New Patient Intake Paperwork

New Patient Intake Paperwork New Patient Intake Paperwork NAME: Last First Middle DATE OF BIRTH: SEX: M / F ADDRESS: Street City State Zip PHONE: MOBILE: EMAIL ADDRESS: EMPLOYER NAME: PHONE: EMPLOYER ADDRESS: EMERGENCY CONTACT: PHONE:

More information

MacInnis Dermatology New Patient Registration Form

MacInnis Dermatology New Patient Registration Form MacInnis Dermatology New Patient Registration Form Please print and answer all questions in full Date Patient Information (please complete using your name as listed on your insurance card) Patient First

More information

Past Medical History

Past Medical History Past Medical History Patient Name Age: Sex: M or F Allergies:_ of Birth Current Medicines: If Newborn: Was baby born in a Hospital: Y N If Yes what Hospital: Medical History BIRTH HISTORY (Please list

More information

Who to call for an emergency: Name: Relationship: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) -

Who to call for an emergency: Name: Relationship: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - 4425 Ponce de Leon Blvd., Suite 115 Email:info@ Dr. Mercedes Gonzalez, Pediatric Dermatologist Patient Information: Patient Name: Social Security Number: / / Date of Birth: / / Sex: M / F (Circle one)

More information