DEMOGRAPHICS & BILLING INFORMATION
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- Holly Hutchinson
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1 Jeffrey B. Russell, MD, FACOG, Director Board Certified Reproductive Endocrinology & Infertility 4745 Ogletown-Stanton Road Suite 111 Newark, DE Tel: Fax: South DuPont Blvd. Suite H Milford, DE Tel: Fax: DEMOGRAPHICS & BILLING INFORMATION Patient Name: of Birth: SS#: Home Phone: Employer Name: Work Phone: Occupation: Cell Phone: Pharmacy Name: Pharmacy Phone: Referral Source: Web Search Social Media Word of Mouth Physician: If previous patient, please provide name so that we may send a Thank You Primary Insurance Carrier: Address/ Secondary Insurance Carrier: Address/ Partner Name: of Birth: SS #: Employer Name: Home Phone: Occupation: Work Phone: Primary Care Physician: Cell Phone: Primary Insurance Carrier: Address/ Secondary Insurance Carrier: Address/ I certify that the above is true and accurate to the best of my knowledge.
2 AUTHORIZATION FOR RELEASE OF INFORMATION Patient Name: SS#: of Birth: * I,, hereby authorize any hospital, physician, laboratory or medically related facility to disclose or furnish in writing a report of my diagnosis, treatment, prognosis and recommendations a well as any other data pertinent to my treatment to: Jeffrey B. Russell, M.D. and the Delaware Institute for Reproductive Medicine, PA. I also authorize the disclosure in writing of any or all information with respect to my present illness, medical history and treatment to any physician or medical facility at which I have been seen or that I am referred to for further opinion/treatment. RELEASE OF INFORMATION TO PATIENT Voic A detailed voice mail message may be left at the following number: Do not leave a detailed voice mail message, I will call back for the details. * I acknowledge that I have read and fully understand the Patient Consent for Electronic Mail document provided to me. I understand the risks associated with the communication of between Provider and me, and consent to the conditions outlined therein. In addition, I agree to the instructions outlined therein, as well as any other instructions that Provider may impose to communicate with patients by . I understand that I may withdraw my consent for communication at any time by notifying my DIRM Provider in writing. Any questions I may have had were answered. I do not consent to electronic mail communication. FOR FAMILY, FRIENDS OR SIGNIFICANT OTHERS I,, authorize the following person(s) to share my medical information, including diagnosis, treatment plan, prognosis and care: Name: Relationship: Phone: Name: Relationship: Phone: Or: I do not wish any of my information to be shared with anyone at this time. EXPIRATION DATE OF AUTHORIZATION This authorization is valid for 12 months from original signature date and may be changed or revoked at any time by the patient or the patient s personal representative by completing, signing and dating a new form.
3 FINANCIAL POLICY Full payment for services is due at the time services are rendered, unless you are a member of an insurance carrier in which we participate. If you are a member of an insurance company in which we participate (Aetna, Blue Cross Blue Shield, Cigna, Coventry, Geisinger, Tricare, United Healthcare), full copayment, coinsurance and deductible is due at the time services are rendered. All medications dispensed from our offices must be paid for in full upon receipt of said medication. We accept cash, checks, MasterCard, VISA, Discover, and American Express. We will be happy to help you process your insurance claim form for reimbursement by your insurance carrier. It is our policy to obtain social security numbers and credit card information from all patients. By asking us to file an insurance claim on your behalf and wait for payment, we are extending credit to you, and as such, a social security number is required. If you decline to provide us with a social security number and credit card, we require payment of patient and partner service(s), in full, prior to each visit. We will provide you with a receipt so that you may seek reimbursement from your insurance company. Patients who begin a new cycle must have financial clearance from Patient Accounts at their baseline visit. Patients will be required to pay, in full, all patient and partner balances outstanding before they begin a new cycle. We will gladly discuss your proposed treatment and answer any questions to the best of our ability. However, responsibility for knowing your benefits falls solely upon you and your insurance company. It is your responsibility to contact your insurance carrier directly prior to your appointment to become familiar with your benefits. We must emphasize that as medical care providers, our relationship is with you and not your insurance carrier. While the filing of insurance claims is a courtesy that we extend our patients, all charges are your responsibility. We realize that temporary financial problems do arise, and we encourage you to contact us promptly for assistance in the management of your account. Overdue (>30 days) account balances will be assessed finance charges, currently at a rate of 25%. Accounts sent to collections will be assessed an additional finance charge of 25%. As your insurance policy is a contract between you, your employer, and the insurance carrier, we are not party to this contract in any way. Therefore, it is your responsibility to follow up with the insurance carrier on all unpaid claims. If we have not received confirmation from the insurance carrier within 14 days of the billing date, we request your involvement in resolving these issues. Not all services are a covered benefit in all contracts. Some insurance companies select certain services that are excluded from coverage. When we do not participate with a carrier, we do not accept the usual and customary payment amount as payment in full for services rendered. You will be responsible for payment of any amounts not allowed by your plan. Payment in full is due immediately upon receipt of your statement. I have read and understand the above statements. I have been given an opportunity to ask questions and any questions I may have had have been answered to my satisfaction. I hereby authorize Delaware Institute for Reproductive Medicine, P.A. (DIRM) to charge the following credit card for any copay, coinsurance/deductible/denial of services remaining after my insurance carrier has paid my claim(s). This authorization is valid for 12 months/1 year from signed date. MasterCard Visa Discover American Express Last 4 Digits of Card Number Expiration CVV Code Cardholder s Signature & Signature of Patient Printed Name Patient Printed Name - Partner
4 ASSIGNMENT OF BENEFITS & RECEIPT OF NOTICE OF PRIVACY PRACTICES I (We),, hereby authorize the Delaware Institute for Reproductive Medicine, P.A. (DIRM) to release information concerning the care, treatment and cost of said care and treatment to my (our) insurance company(ies) and/or third party administrator(s) which may be responsible for payment of my (our) care and treatment. I (We) authorize payment directly to DIRM for healthcare benefits and agree that if the cost of the treatment is not reimbursed by my (our) insurance company(ies) and/or a third-party administrator(s) that it shall be my (our) personal responsibility to pay DIRM for the full cost of services rendered. I (We) agree that I (we) am (are) responsible for my (our) percentage of benefits that the insurance company(ies) and/or third-party administrator(s) deems my (our) responsibility. I (We) understand that the balance of my (our) account is due and payable in full upon receipt of my (our) statement. Regardless of my (our) health insurance benefit status, I (we) understand and agree that the cost of care and treatment remains my (our) personal financial responsibility. I (We) also agree to pay all costs incurred in collecting amounts due for services rendered under this agreement, including but not limited to attorney s fees and legal expenses. I (We) have received a copy of the Delaware Institute for Reproductive Medicine, P.A. Notice of Privacy Practices. WEBSITE AND SOCIAL MEDIA RELEASE I (We),, do do not hereby grant permission to Delaware Institute for Reproductive Medicine, PA (DIRM) to post my and/or my child s story, photo, or other item, hereinafter referred to as Materials, I submit to and for DIRM s website, Instagram account, and Facebook account. I hereby release you, your representative, employees, managers, members, officers, parent companies, subsidiaries, and directors, from all claims and demands arising out of or in connection with any use of said Materials, including, without limitation, all claims for invasion of privacy, infringement of my right of publicity, defamation and any other personal and/or property rights. I acknowledge and agree that no sums whatsoever will be due to me because of the use and/or exploitation of the Materials or any rights therein.
5 AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS I (We) hereby authorize release of my (our) medical records to Jeffrey B. Russell, M.D. and Delaware Institute for Reproductive Medicine, P.A Ogletown-Stanton Road, Suite 111, Newark, Delaware Please fax my medical records to (302) This authorization is valid for 12 months from original signature date. Physician/Practice Name: Patient Name (Print): Patient of Birth: Patient SS#: Physician/Practice Name: Partner Name (Print): Partner of Birth: Partner SS#: PATIENT PARTNER I (We) understand my (our) records may contain information regarding the diagnosis or treatment of HIV/AIDS, sexually transmitted diseases, drug and/or alcohol abuse, mental illness or psychiatric treatment. I give my authorization for these records to be released, except for the following: HIV/AIDS diagnosis/treatment/testing Sexually transmitted disease Drug/Alcohol abuse/treatment/diagnosis Mental illness or psychiatric diagnosis/treatment Jeffrey B. Russell, MD, FACOG, Director Board Certified Reproductive Endocrinology & Infertility 4745 Ogletown-Stanton Road Suite 111 Newark, DE Tel: Fax: South DuPont Blvd. Suite H Milford, DE Tel: Fax:
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TEXAS PEDIATRIC SPECIALTIES AND FAMILY SLEEP CENTER REGISTRATION FORM ADULT
Referring Physician: TEXAS PEDIATRIC SPECIALTIES AND FAMILY SLEEP CENTER REGISTRATION FORM ADULT Primary Care Physician: Patient s LEGAL Last name: First: Middle Initial: Patient Date of birth / / Marital
Financial Policy Guidelines
Financial Policy Guidelines Welcome to The Women s Group of Northwestern. We strive to provide you with excellent medical care and our goal is to make your visit as convenient as possible. Please read
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
CLINIC POLICIES and PROCEDURES
CLINIC POLICIES and PROCEDURES Thank you for choosing Dr. James E. Wilson and Dr. Jay Kiokemeister, Interventional Pain Specialists, and Dr. J. Preston Harley, Pain Management Psychologist. The Clinic
Dear Patient, Now that you are 18 years old we need a signed copy from you on file. Attached is a copy of the HIPAA form.
Dear Patient, We have a signed consent form on file that one of your parents has signed giving us consent to treat you and, if covered, to bill the Insurance Company. Now that you are 18 years old we need
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
Parkway Dental of Clinton Matthew K. Chow, D.D.S. 401 Clinton Parkway, Clinton, MS Patient Information:
Patient Information: Name: Date: Last, First MI (Preferred Name) Social Security #: Birth date: / / Gender: Family Status: Address: City/State/Zip: Phone (Home): (Cell): (Other): Employer Name: Work Phone:
Holistic Speech & Language Phone: (206) Fax: (206)
Client Intake Form Demographic Information Last Name: First Name: of Birth: Sex: Diagnosis (if known): Parent/Guardian Name(s): Home Address: Parent #1 Phone: Parent #2 Phone: Parent #1 Email: Parent #2
Gastroenterology Specialists of Delaware, LLC
Gastroenterology Specialists of Delaware, LLC George Benes, M.D. Michael J. Brooks, MD As a patient of GI Specialists of DE, I understand that there may be occasions where the office staff may need to
Welcome! Warren Parkway Suite 306 Frisco, TX PlastiksForKids.com. Please remember to bring: New Patient Paperwork
Welcome! Thank you for choosing Dr. Christine Stiles to care for your child s plastic surgery needs. All appointments are on Monday afternoons. Dr. Stiles operates at the Pediatric Surgery Center. Plastiks
Who to call for an emergency: Name: Address: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Relationship:
Patient Information: Patient Name: Social Security Number: / / Date of Birth: / / Sex: M / F (Circle one) Married/Single/Divorced/Widow Address: Zip Code: Home Phone: ( ) - E-mail Address: Cell Phone:
Has a family member been a patient in our office? Yes No
Patient Information *Please complete all pages First Name M.I. Last Address Sex M / F Age City State Zip Code Date of Birth Social Security Marital Status S M W D Primary Phone Alternate Phone E-mail Physician
Our portals are encrypted and password-protected, too, so health data remains secure.
Patient Portal Education Sheet We know you re busy. That s why Palmetto Health-USC Medical Group s physician practices are offering a way for you to manage your health care online. We offer convenient
Appointment Date: / / Appointment Time: Date: / / Account #:
Appointment: / / AppointmentTime: : / / Account#: PATIENTINFORMATION Name:(Last) (First) (MI) Suffix/nickname: Birth: Sex: MaritalStatus: Address: City: State: Zip: HomePhone:_MobilePhone: WorkPhone: Employer:
Please Present Insurance Card at Each Office Visit
PATIENT REGISTRATION FORM RONALD J ESCUDERO, MD, FACS Please print clearly and fill out completely Patient Legal Name Birthdate Age Address Social Security # City ST ZIP Email Phone Numbers ( ) Home (
Would you like to receive s with special offers from Carolina Vein Center? yes no
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
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:
Advanced Endocrinology and Weight Management Ritu Malik MD
PATIENT INFORMATION PERMANENT ADDRESS EMAIL: PHONE: Home Work Cell SEX M F AGE MARITAL STATUS M S D W SPOUSE NAME PATIENT SOCIAL SECURITY - - OCCUPATION EMPLOYER EMPLOYER ADDRESS EMERGENCY CONTACT NAME
Welcome to a Brighter Morgantown!
Welcome to a Brighter Morgantown! New Patient Information Payment Options E X C E L L E N C E I N D E N T I S T R Y S I N C E 1 9 2 7 Welcome to a Brighter Morgantown! Morgantown Dental Group would
Family Physicians of Johnson City 303 Med Tech Parkway, Suite 100 Johnson City, TN 37604
Family Physicians of Johnson City 303 Med Tech Parkway, Suite 100 Johnson City, TN 37604 Patient Registration Form Last Name First Name Middle Initial Sex: M F of Birth Address City State Zip Code Social
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
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
New Patient Information Form
PATIENT INFORMATION New Patient Information Form Patient s Patient s Preferred Name Middle Initial Date of Birth SSN# Primary Language YES NO Email Address Race/Ethnicity Is patient of Hispanic Origin?