7541 US HWY 87 E, Suite #1 San Antonio, Texas (210) PATIENT S EMPLOYER PLEASE CIRCLE ONE :
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1 7541 US HWY 87 E, Suite #1 San Antonio, Texas (210) PATIENT S EMPLOYER PLEASE CIRCLE ONE : PPO POS HMO HRA HSA CHOICE PLUSE HEALTH SELECT OTHER
2
3 NOTICE OF PRIVACY I have reviewed Beaver Medical Group s Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document at no cost to me. Patient requested copy: Yes No FINANCIAL POLICY I have review Beaver Medical Group s Financial Policy, and I understand that the services I have elected to participate in implies a financial responsibility on my part. I understand that as a courtesy, Beaver Medical Group will verify my coverage and bill my insurance on my behalf but I am ultimately responsible for payment of my bill and any fees not covered by insurance. I also understand that payment is due at the time of service. I certify that the information I have provided is, to the best of my knowledge, true and accurate. I authorize my insurer to pay any benefits directly to Beaver Medical Group, the full and entire amount of the bill incurred by me or the below named patient; or, if applicable any amount due after payment had been made by my insurance carrier. Patient requested copy: Yes No AUTHORIZATION FOR RELEASE OF PRIVATE HEALTH INFORMATION (PHI) *This gives the (representatives of Beaver Medical Group) the authorization to speak to your spouse, parent or significant other about your medical and/or financial information. Please DO NOT put N/A if you would like for us to be able to talk with someone other than yourself. This includes medication refills. I, date of birth, hereby authorization Beaver Medical Group to release my PHI to the following individual. This consent will remain in effect until Beaver Medical Group is otherwise notified by me in writing. Appointment Times Medical & Health Information Billing & Demographic Information All Information Name of individual information may be released to Relationship to patient ADVANCED DIRECTIVES Advance directives are legal documents that allow you to convey your decisions about end of life care ahead of time. They provide a way for you to communicate your wishes to family, friends and health care professionals. An Advance Directive tells how you feel about care intended to sustain life. I would like information regarding Advance Directives. I do not wish to have information provided to me at this time. I already have an Advance Directive. I do not have an Advance Directive
4 Beaver Medical Group, PLLC would like to welcome you to our office. We appreciate the opportunity to serve you. The following information is provided for your benefit so that we may better serve you. Please read, initial and sign at the bottom. Initials 1. PAYMENTS: All applicable fees, deductibles, coinsurance, or co-pays must be paid at the time of your appointment. We accept cash, checks, Visa, Mastercard, Discover or American Express. There will be a charge For all non-sufficient fund/returned checks billed directly to you by our recovery agency. 2. APPOINTMENT TIME: We ask that our patients arrive for their appointment on time; this will facilitate our ability to see you as scheduled. Patients arriving past their appointment time may need to be rescheduled. Please note that we strictly enforce a ($25.00/ $50.00 No Show Fee); depending on the type of appointment that is scheduled. This is enforced if you do not show up for your appointment or you do not cancel 24 hours prior to you appointment numbers or WEIGHT LOSS POLICY: All weight loss services (Phentermine refill/ Lipo-b injections) are considered cosmetic and (non billable to insurance). These appointments are separate from a sick visit appointment. For your convenience you may be seen by the provider for a weight loss visit at the same time as a sick visit (congestion, sinusitis, lab follow-up) but it will still be considered a separate (non billable to insurance) visit and you will be charged at the rate of ($85.00 for a New Weight Loss and $55.00 for an established Weight Loss patient). If you have been a previous weight loss patient but have not been seen for weight loss program for more 1 year you will be considered a New Weight Loss Patient. It is suggested to do your Lipo-B injections weekly; there is no appointment needed for this and the charge for the injection is $ CHANGE OF INFORMATION: Please provide us with any change regarding your address, phone Insurance information as soon as possible. 5. MEDICATION REFILL REQUESTS: We request that you contact your pharmacy first. They will call our office with the necessary information to refill your medication. No refills will be done after hours. Please request refills 1 week prior to your running out. Please allow 24 to 48 hours for your refill request to be processed. 6. LAB AND X-RAY RESULTS: Please allow 7 10 days for results. A member of our staff will contact you as soon as we receive and review your results. 7. INSURANCE VERIFICATION: This office will verify your benefits to the best of our ability once you supply your correct insurance information. Verification of coverage DOES NOT mean that all services rendered will be covered during your visit; however, any uncovered services, supplies and/or treatments will be your responsibility to pay. Please Note: If the services performed at Beaver Medical Group are not paid by your insurance due to information that has not been provided to our office by you (the patient) the balance
5 will become that patients responsibility. It is the patients responsibility to keep our office informed of any changes in your insurance. 8. REFERRALS TO SPECIALISTS: Please allow our staff 7 10 days to process your referral. If you are unable to make a scheduled appointment with your specialist, it is your responsibility to reschedule. Please be advised that some insurance companies extend referrals for a certain period of time. If you cannot make it within your appointed time frame, there may be a charge for a repeat authorization. 9. MEDICATION MANAGEMENT: All patients on a medication management protocol must be seen by provider once Every 6 months; (ie, diabetes, cholesterol, testosterone, hormones, COPD etc. 10.NARCOTIC PAIN MEDICATION: Our office will prescribe pain medication as needed for acute pain and only for a short duration of time. If the patient suffers from chronic pain and needs further observation for possible long term use of prescription narcotics, we will refer the patient to a pain management center. We will not prescribe narcotic pain medication and controlled substances if they are obtained from multiple physicians and/or pharmacies. (Every patient that we prescribe narcotic medication to must be seen by the provider every 3 months for follow-up and refills and is subject to a drug test at the provider s discretion). 11.FORMS: We will be happy to fill out any forms and/or letters that the patient may require. However, there will be a charge per document up to $25. "I, the Guarantor of Payment and Responsible Party; agree to the above policies and agree to the terms regarding payment and payment responsibilities. Patient Name Signature Date
Today s Date (mm/dd/yyyy):
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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
Reminders. *Please arrive 30 minutes prior to your scheduled appointment time.*
Welcome to Southwest Spine & Sports. We kindly ask that you have this paperwork with you and completed, including signatures where indicated, when you arrive for your appointment. Please arrive 30 minutes
PLEASE PRINT AND COMPLETE ALL ENTRIES
Patient Name: (Last, First, MI) E mail Address: PLEASE PRINT AND COMPLETE ALL ENTRIES Your Date of Birth: / / Male Female Marital Status: S M Minor D W Your Social Security No: Address: Street Home Phone:
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THANK YOU FOR CHOOSING EAR, NOSE & THROAT PLASTIC SURGERY CENTER. IN ORDER TO SERVE YOU PROPERLY WE REQUIRE THE FOLLOWING INFORMATION. ALL INFORMATION RECEIVED IS STRICTLY CONFIDENTAL. PLEASE PRINT. ***************************************************************************************************
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Providence Medical Park / 3841 Piper Street, Suite T300 / Anchorage, AK 99508 Alaska Regional Campus / 2925 DeBarr Road, Suite 250 / Anchorage, AK 99508 Ph: (907)-563-3103 F: (907)-561-1862 Mat-Su Regional
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
Whom May We Thank for Referring You? Primary Care Physician. Insured/Responsible Party. Patient Information. Patient s Spouse/Guardian
Whom May We Thank for Referring You? Name: Other: Newspaper Radio TV Seminar Staff Yellow Pages Other Primary Care Physician Name: Address:_ City: State: Zip: Phone: Insured/Responsible Party Patient Information
SUBURBAN GASTROENTEROLOGY
SUBURBAN GASTROENTEROLOGY DARREN KASTIN, MD 1243 Rickert Dr. Telephone 630-527-6450 Naperville, IL 60540 Fax 630-527-6456 Suburban Gastroenterology, Ltd. would like to welcome you and confirm your appointment.
PATIENT INFORMATION (please print)
PATIENT INFORMATION (please print) Name: D.O.B. Email: Soc. Sec # Male: Female: Marital Status: Age: Home Phone ( ) Cell Ph ( ) Work Ph ( ) Address: City: State: Zip: Emergency Contact: Relation: Phone
Patient Health Questionnaire
Patient Health Questionnaire Patient s Name: Date of Birth: Drug / Food Allergies: Please list any and all allergies you have pertaining to medications and food, along with the reaction. Current Medical
LAWRENCE J. FINKEL, M.D., P.C. 360 CHURCH STREET WARRENTON, VA (540) PHONE (540) FAX
LAWRENCE J. FINKEL, M.D., P.C. 360 CHURCH STREET WARRENTON, VA 20186 (540) 347-2020 PHONE (540) 341-7980 FAX www.finkelderm.net Dear Patient: Welcome to our Practice. We have you scheduled for your first
PATIENT REGISTRATION
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
Lake County Neuromonitoring, LLC Libertyville, Illinois Lake County Imaging, LLC P: Lakeshore Physical Therapy, LLC F:
Section A: Patient Information Name: Today s Date: Telephone #: (H) (C) (W) Preferred method of contact: Home Cell Work Marital Status: Single Married Other Home Address: City/State/ZIP Date of Birth: