FOOTHILLS SPORTS MEDICINE PHYSICAL THERAPY. PATIENT REGISTRATION FORM Please Print
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1 FOOTHILLS SPORTS MEDICINE PHYSICAL THERAPY PATIENT REGISTRATION FORM Please Print Patient Name: Patient Social #: Gender: [ ] Male [ ] Female Birth Date: Age: Address: City, State, Zip: Home Phone: Cell Phone: Work Phone: Authorization to leave voice message, please initial Parent/Guardian: Relationship to Patient: Parent/Guardian Social #: Parent/Guardian Birth Date: Referring Physician: Primary Physician: Emergency Contact: Relationship/Phone: Employer/School/Team Name: How did you hear of Foothills Sports Medicine Physical Therapy? [ ] Referred by Doctor [ ] Friend or Family [ ] Social Media/Online [ ] Other: Insurance Information (To be completed even if insurance card on file) Primary Insurance Secondary Insurance Insurance Co Name: Insurance Co Name: Policy Holder: Policy Holder: Policy Holder Birth Date: Policy Holder Birth Date: Relationship to Patient: Relationship to Patient: AUTHORIZATION TO RELEASE PATIENT INFORMATION: I hereby authorize Foothills Sports Medicine Physical Therapy to release any personal health information (PHI) required in the course of my examination or treatment to the above stated insurance company, or their affiliates. Signed (Patient or guardian) Date AUTHORIZATION TO PAY: I hereby authorize insurance payment directly to Foothills Sports Medicine Physical Therapy, Billing Department, S. Mountain Pkwy. Suite 112, Phoenix, AZ for medical services rendered. I understand that I am financially responsible for the charges not covered by my insurance. In the event of default, I promise to pay collection costs and reasonable fees as may be required to obtain collection of this account. Signed (Patient or guardian) Date FOOTHILLS SPORTS MEDICINE PHYSICAL THERAPY BILLING DEPARTMENT S. MOUNTAIN PKWY. SUITE 112, PHOENIX, AZ 85044
2 FOOTHILLS SPORTS MEDICINE PHYSICAL THERAPY NOTICE OF PATIENT INFORMATION PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO INFORMATION, INCLUDING HOUSE BILL PLEASE REVIEW IT CAREFULLY. FOOTHILLS SPORTS MEDICINE PHYSICAL THERAPY S LEGAL DUTY Foothills Sports Medicine Physical Therapy is required by law to protect the privacy of your personal health information, provide this notice about our information practices and follow these practices that are described herein. USES AND DISCLOSURES OF HEALTH INFORMATION Foothills Sports Medicine Physical Therapy uses your personal health information primarily for treatment; obtaining payment of treatment; conducting internal administrative activities and evaluating the quality of care that we provide. For example, Foothills Sports Medicine Physical Therapy, may use your personal health information to contact you to provide appointment reminders, or information about treatment alternatives or other health related benefits that could be of interest to you. Foothills Sports Medicine Physical Therapy may also use or disclose your personal health information without prior authorization for public health purposes, for auditing purposes, for research studies and for emergencies. We also provide information when required by law. In any other situation, Foothills Sports Medicine Physical Therapy s policy is to obtain your written authorization before disclosing your personal health information. If you provide us with a written authorization to release your information for any reason, you may later revoke that authorization to stop future disclosures at any time. Foothills Sports Medicine Physical Therapy may change its policy at any time. When changes are made, a new Notice of Information Practices will be posted in the clinic and will be provided to you on your next visit. You may also request an updated copy of our Notice of Information Practices at any time. PATIENT S INDIVIDUAL RIGHTS You have the right to review or obtain a copy of your personal health information at any time. You have the right to request that we correct any inaccurate information or incomplete information in your records. You also have the right to request a list of instances where we have disclosed your personal health information for reasons other than treatment, payment or other related administrative purposes. You may also request in writing that we not use or disclose your personal health information for treatment, payment and administrative purposes except when specifically authorized by you, when required by law or in emergency circumstances. Foothills Sports Medicine Physical Therapy will consider all such requests on a case by case basis, but the practice is not legally required to accept them.
3 CONCERNS AND COMPLAINTS If you are concerned that Foothills Sports Medicine Physical Therapy may have violated your privacy rights or if you disagree with any decisions we have made regarding access or disclosure of your personal health information, please contact the following person: Cheri Anguis You may also file a complaint with the Department of Health and Human Services via mail, fax, , or the OCR Complaint Portal. Additional information can also be found on their website at You will not be retaliated against for filing a complaint. HOUSE BILL 2045 Effective December 31, 2013, in accordance with the Arizona House Bill 2045 which requires healthcare providers who are owners or employees of a legal entity with three or more licensed healthcare providers to post their direct pay prices for their 25 most commonly provided services online or make them available upon request. The bill specifies how services are to be identified, how often the list is to be updated and the timeframe from which the list is to be determined. HB 2045 also requires healthcare providers to obtain a person s signature on a notice before accepting direct payment from that person if the healthcare provider is contracted as a network provider for a healthcare system in which the person is an enrollee. For more information about House Bill 2045, please visit the website of the Arizona State Legislature, azleg.gov. You may search for the bill using their Bill Number Search. All patients or their guardians must read and acknowledge the following guidelines. MEMBER DIRECT PAYMENT NOTIFICATION PROVIDER Arizona state constitution permits you to pay a healthcare provider directly for health care services. Before you make any agreement to do so, please read the following important information. If you have active health insurance coverage and your healthcare provider is contracting with your health insurance provider, the following guidelines apply: 1. You may not be required to pay the healthcare provider directly for the services covered by your health insurance plan, except for the cost-share amounts that you are obligated to pay under your plan; such as co-payments, co-insurance, and deductible amounts. 2. Your healthcare provider s agreement with your health insurance plan may prevent the healthcare provider from billing you for the difference between the healthcare providers billed charges and the amount allowed by your health insurance plan for covered services. 3. If you pay directly for health care service(s), your healthcare provider is not responsible for submitting claim documentation to your health insurance plan. Before paying your claims, your health insurance plan may require you to provide information and submit documentation necessary to determine whether the services are covered under your health insurance plan. 4. If you do not pay directly for health care service(s), your healthcare provider may be responsible for submitting claim documentation to your health insurance plan for the health care service(s).
4 PATIENT INFORMATION ACKNOWLEDGEMENT FORM I have read and fully understand Foothills Sports Medicine Physical Therapy s Notice of Information Practices. I understand that Foothills Sports Medicine Physical Therapy may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment. I understand that I have the right to restrict how my personal health information is used and disclosed for treatment, payment, and administrative operations if I notify the practice. I also understand that Foothills Sports Medicine Physical Therapy will consider requests for restriction on a case by case basis, but does not have to agree to request for restrictions. I hereby consent to the use and disclosure of my personal health information for purposes as noted in Foothills Sports Medicine Physical Therapy s Notice of Information Practices. I understand that I retain the right to revoke this consent by notifying the practice in writing at any time. Your signature below acknowledges that you received House Bill 2045 notice before paying this provider for healthcare service(s). Patient Name: Signature of responsible party: Printed Name of signer: Date: DESIGNATED INDIVIDUALS AUTHORIZATION FORM I hereby authorize one or all of the designated parties listed below to request and receive the release of any protected health information regarding my treatment, payment or administrative operations related to treatment and payment. I understand that the identity of designated parties must be verified before the release of any information. Authorized Designees: Patient Name: Signature of responsible party: Printed Name of signer: Date:
5 ELECTRONIC COMMUNICATION CONSENT Patient Name: Cell Phone: Appointment Reminders Complete this form and sign below to give your permission for Foothills Sports Medicine to provide automatic appointment reminder service by OR by cell phone text message. OR OPTION: Foothills Sports Medicine may send messages to confirm my upcoming appointments. TEXT OPTION: Foothills Sports Medicine may send cell phone text messages* to confirm my upcoming appointments. *Normal text messaging rates may apply. Please circle your cell phone carrier ALLTel AT&T Boost Mobile Cingular Cricket Wireless Metrocell MetroPCS Nextel Quest Sprint PCS T-Mobile US Cellular Verizon Virgin Mobile Text Message Surveys In an effort to provide the highest possible quality of care, we will send text message surveys regarding your experience. You may opt-out at any time by replying STOP to any text you receive. Join our Mailing List Stay connected with all of the latest updates from Foothills Sports Medicine Physical Therapy. By providing your address, you agree to receive periodic updates from Foothills Sports Medicine Physical Therapy. You may opt-out at any time by unsubscribing via the link at the bottom of every . Signature: Date: Revised 1/2017
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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
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First Name Middle Name Last Name Preferred Name PATIENT REGISTRATION Patient Information Byron C. Cotton, M.D., FAAP Gayla Woodson, MSN, CPNP First choice for infants thru young adult! First Patient Second
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PATIENT DEMOGRAPHICS. Name Address. City State Zip Code DOB / / Sex SS# / / Home Phone # Work Phone # Cell Phone # PRIMARY INSURANCE
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New Patient Information Form
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New Patient Referral and Insurance Verification Form
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Tempe Dental Care 5801 S. McClintock Dr. Suite 101 Tempe, AZ 85283
Tempe Dental Care 5801 S. McClintock Dr. Suite 101 Tempe, AZ 85283 Thank you for visiting Tempe Dental Care. We want your visit to be pleasant and comfortable. Please help us by completing this form. Patient
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Germantown Smiles,PC Germantown Road Suite 225 Germantown, Maryland
Germantown Smiles,PC 19735 Germantown Road Suite 225 Germantown, Maryland 20874 240-654-3302 Patient Information Patient Name: Last First MI Gender: Male Female Family Status: Married Single Child Other
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Southwest National Bank Internet Banking Agreement
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SEP BADY, MD THOMMAN KURUVILLA, DPM EUGENE LIBBY, DO., F.A.C.O.S X. NICK LIU, DO MATTHEW HC OTTEN, DO TIMOTHY J. TRAINOR, MD MICHAEL A. TRAINOR, DO RANDALL E. YEE, DO Today s Date: Last Name: First Name:
Patient Information. Patient Name: Address . City State Zip. Birthdate Sex: Female Male Marital Status: Married Single Other
Patient Information Patient Name: Address Email City State Zip Birthdate Sex: Female Male Marital Status: Married Single Other Home Phone Work Phone Cell Phone Student Status: Full Time Part Time None
NOTICE OF $30 FEE FOR NEW EYEGLASS PRESCRIPTIONS
NOTICE OF $30 FEE FOR NEW EYEGLASS PRESCRIPTIONS If you would like a new prescription for eyeglasses, we must perform a REFRACTION. Refraction is the procedure that a trained ophthalmic professional performs
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Carolina Vein Center Patient Information Name: Date: Address: Home Phone: City: State: Zip: Work Phone: SS#: Marital Status: Occupation: Date of Birth: _ Cell Phone: Emergency Contact: E-Mail: Emergency
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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
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