Welcome to Rosenman & Leventhal, P.C.
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- Violet York
- 5 years ago
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1 Welcome to Rosenman & Leventhal, P.C. Thank you for choosing our practice for all of your dermatological needs. Please have ALL of the attached paperwork filled out completely before arriving to our office. Please arrive 15 minutes before your scheduled appointment time. Present your insurance card/cards, credit card if you choose to take advantage of our Credit- Card-On-File program, along with your photo ID and finished paperwork to our front desk Greeters. If your insurance requires a referral for a Specialist visit, be sure to call your Primary Care Physician at least 48 hours ahead of your appointment day. This will give them the time needed to process your referral. If a valid referral is not received prior to your visit, you will be asked to reschedule your appointment. Any questions regarding our participation with your insurance, please call your insurance company prior to your appointment day. We look forward to meeting you!
2 Last Name: First Name: MI: Date of Birth: Address: Social Security Number: Gender Address: City: State: Zip: Primary Phone Number: Alternate Number: Primary Care Physician Information Did a physician recommend you come to our office? YES or NO Primary Care Physician Name: Address: City: State: Zip: Pharmacy Pharmacy Name: Phone Number: Insurance Information Primary Insurance Company: ID #: Group #: Relationship to Patient: Policy Holder s Name: Date of birth: Secondary Insurance Company: ID #: Group #: Relationship to Patient: Policy Holder s Name: Date of birth: Person/persons responsible for billing if different than the patient or policy holder: Name: Relationship to Patient: Address: City: State: Zip: Date of Birth of responsible person: Phone Number:
3 List all Medications you are currently taking: The reason for your visit today: Are you allergic to any medication? If so, please list below Have you ever had an allergic reaction to: (please circle) Jewelry Skin Cream Antibiotic Cream Hair Products Cosmetics Adhesive Tape Latex Do you smoke? NO YES How much? Do you drink alcohol? NO YES How much? Are you pregnant? NO YES Due date: Health History Please circle any of the following diseases or conditions you have had or have currently Bronchitis Diabetes Sun Burns Emphysema Thyroid Sensitive Skin Asthma Kidney or Bladder Psoriasis Pneumonia Stomach or Ulcers Eczema Chronic Cough Bowel Unusual Moles Tuberculosis Hepatitis Skin Cancer High Blood Pressure Gall Bladder Melanoma Chest Pain Cancer Blood Clots Heart Attack Seizures Varicose Veins Heart Murmur Glaucoma Bypass Surgery: Irregular Heartbeat AIDS Cardiac/Gastric Pacemaker Arthritis Lupus Family History Mother Father Brother Sister Alive Above Conditions/Diseases Deceased Cause of death Consent for Treatment I hereby consent to and authorize medical and/or surgical care, including diagnosis and treatment, by Physicians and staff of Rosenman & Leventhal, P.C. I understand I have the option to refuse any treatment. X Patient or Legal Guardian Signature:
4 AUTHORIZATIONS I authorize the release of information necessary to process this claim and also authorize payment of medical benefits directly to Rosenman & Leventhal, P.C. I certify that the information I furnish is true and correct. In order to establish optimal relations with our patient and avoid misunderstanding regarding our payment policies, our staff is trained to inform you of the financial payment policies of this office. Payment in full is required for anyone who does not have medical insurance, has an insurance in which Rosenman & Leventhal, P.C.does not participate with and for all cosmetic services at the time they are rendered. Insurance co-payments are due when services are rendered. It is the patient s responsibility to know if Rosenman & Leventhal, P.C. is participating with their insurance. It will be the patient s responsibility for all charges that occur during the visit if Rosenman & Leventhal, P.C. does not participate with the insurance. It is the patient s responsibility to obtain a valid referral from their primary care physician if the insurance requires one. If a valid referral was not obtained by the patient and was seen by a provider at Rosenman & Leventhal, P.C. the patient will be responsible for all charges that occur during the visit. In the event that a medical service was provided by Rosenman & Leventhal, P.C. and is deemed non-covered, or the full contracted payment is not received or deductible has not been satisfied, full payment is expected within 30 days of notification to you. If unforeseen financial problems interfere with payment of your medical care, please speak with our billing representative to arrange suitable payment arrangements. All accounts and balances older than 90 days may be transferred over to a collection agency and will be reported to the National Credit Bureau. Any personal checks that are returned to Rosenman & Leventhal, P.C. will be charged a surcharge. We accept payment in the form of cash, check, Visa, MasterCard, Discover and American Express. Your signature below communicates your understanding and willingness to comply to the above policies. X Patient or Legal Guardian Signature: Date: PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION With my consent Rosenman & Leventhal, P.C. may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Please refer to Rosenman & Leventhal, P.C. Notice of Privacy Practices for a more complete description of such uses and disclosures. I have received and reviewed the Notice of Privacy Practices prior to signing this consent. Rosenman & Leventhal, P.C. reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Rosenman & Leventhal, P.C. Privacy Officer at 385 Oxford Valley Road, Suite 312, Yardley, PA With my consent Rosenman & Leventhal, P.C. may call my home or other designated location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO such as appointment reminders, insurance items, and any call pertaining to my clinical care including laboratory results among others. With my consent Rosenman & Leventhal, P.C. can mail my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminders and patient statements as long as they are marked Personal. I have the right to request that Rosenman & Leventhal, P.C. restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. By signing this form I am consenting to Rosenman & Leventhal, P.C. use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent Rosenman & Leventhal, P.C. may decline to provide treatment to me. X I give permission to give Protected Health Information to: (Name and Relationship to patient) X Patient or Legal Guardian Signature: Date: MEDICARE HEALTH INSURANCE FORM I request that payment of authorized Medicare benefits be made either to me or on my behalf to Rosenman & Leventhal, P.C. for any services furnished to me by Rosenman & Leventhal, P.C. I authorize any holder of medical information about me to release to the Center for Medicare and Medicaid Services and its agents any information needed to determine these benefits or the benefits payable for related service. X Patient or Legal Guardian Name: Patient DOB:
5 Credit-Card-on-File-Policy We have implemented a credit-card-on-file policy. Although it is optional, this policy was designed to benefit you, the patient, and us, the healthcare provider, to help keep the costs and fees of healthcare down in an environment where they continue to rise. The advantage and savings to you is that you no longer will be using a check, an envelope and a stamp. The advantage and savings to our practice is that we will no longer use additional paper to print statements, use envelopes or use additional postage. The process is simple and secure. You will be asked for your credit card information at the time you check in. This information is then entered into our banks secure site. Once entered the only numbers that are visible are the last 2 digits of your card along with the expiration date and name. Once your insurance processes your claim they will send you an Explanation of Benefits before they send payment to us. Once we receive the payment we will post any payments and apply any applicable co-insurance or deductible. At that time any remaining balance due as the patient s responsibility will be charged to your credit card. A paid receipt will be mailed to you. This in no way will compromise your ability to dispute a charge or question your insurance company s determination of payment. The credit card can only be kept on file if the designated card member signs this waiver. This authorization will remain in effect until rescinded by the cardholder. By signing this waiver, I authorize Rosenman & Leventhal, P.C. to charge any outstanding balances on my account and the accounts of any family members listed below to my credit card. X Date: Card member s signature Name of Patient: Medical Acct. #: Please list the names of any family members to be included. Office Use ONLY Visa MasterCard Discover American Express Expiration Date: Last 2 Digits of card:
6 Makefield Executive Quarters 385 Oxford Valley Road, Suite 312 Yardley, Pennsylvania Ph: (215) Fax: (215) Directions to Our Office ( If you are using a GPS use Morrisville instead of Yardley ) From 95 North or 95 South 1. Take Exit 46A onto Route 1 North 2. Proceed North on Route 1 to the Oxford Valley Exit 3. At the traffic light off of the ramp turn LEFT onto Oxford Valley Road 4. Proceed 1.1 miles on Oxford Valley Road a. Ahead Kohl s will be on your right, CVS on your left ( that intersection is Big Oak Road & Oxford Valley Road ) 5. After you cross that intersection ( Big Oak Road & Oxford Valley Road ) Go to the second traffic light and make a LEFT into 385 Makefield Executive Quarters a. Christine s Restaurant is located in our complex 6. Make the first right turn and proceed to STOP sign then make Left into the parking lot 7. Go into the big, main front, center doors a. Our Suite is 312 on the right From Route 1 South 1. Take the Oxford Valley Exit ( Sesame Place ) 2. At the traffic light off of the ramp turn RIGHT onto Oxford Valley Road 3. Proceed 1.1 miles on Oxford Valley Road a. Ahead Kohl s will be on your right, CVS on your left ( that intersection is Big Oak Road & Oxford Valley Road ) 4. After you cross that intersection ( Big Oak Road & Oxford Valley Road ) Go to the second traffic light and make a LEFT into 385 Makefield Executive Quarters a. Christine s Restaurant is located in our complex 5. Make the first right turn and proceed to STOP sign then make Left into the parking lot 6. Go into the big, main front, center doors a. Our Suite is 312 on the right From Route 1 North 1. Take the Oxford Valley Exit ( Sesame Place ) 2. At the traffic light off of the ramp turn LEFT onto Oxford Valley Road 3. Proceed 1.1 miles on Oxford Valley Road a. Ahead Kohl s will be on your right, CVS on your left ( that intersection is Big Oak Road & Oxford Valley Road ) 4. After you cross that intersection ( Big Oak Road & Oxford Valley Road ) Go to the second traffic light and make a LEFT into 385 Makefield Executive Quarters a. Christine s Restaurant is located in our complex 5. Make the first right turn and proceed to STOP sign then make Left into the parking lot 6. Go into the big, main front, center doors a. Our Suite is 312 on the right
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Insurance Information:
Name Address Social Security # Date of Birth City State Zip Sex Marital Status Home Phone # Work Phone # Cell# Employer Occupation Race: Employed: Full Time Part Time Retired Student: Full Time Part Time
Please be aware that payment of all office visits and services are due at the time of your visit.
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Patient Information *Please Complete All Sections*
Front Desk Check-In Initials Patient Information *Please Complete All Sections* Account # (Office Use Only) Name (First, MI, Last) Date of Birth / / Age: Sex: M F Mailing Address Apt # City State Zip Home
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PATIENT INFORMATION EMERGENCY CONTACT
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Patient Last Name: First MI. Responsible Party (if a minor) Address: (Street or PO Box) (City) (State) (Zip) Home Phone: Cell Phone: Work Phone:
Patient Last Name: First MI Responsible Party (if a minor) Address: (Street or PO Box) (City) (State) (Zip) Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security No.: Sex: Marital Status:
FLOYD CARDIOLOGY Demographic Information
FLOYD CARDIOLOGY Demographic Information Patient Information Last: First: MI: SS #: Sex: DOB: Street Address: City: State: Zip: Home Phone: Work Phone: Email Address: Employer: Occupation: Responsible
PATIENT INFORMATION & PREFERENCES (Please print or type) YOUR MAJOR HEALTH CONCERNS OR QUESTIONS
Dear Patient: The following questions are designed to collect important information about you and your health. Answering these questions before your office visit will allow more time for a detailed discussion
Insurance Form. Patient Name: Date Last First Middle
Insurance Form Patient Name: Last First Middle Social Security Number Primary Insurance Carrier Insured Name & of Birth Relationship Member Identification Number Group Number Do you have Medical Insurance?
Medicine and Surgery of the Foot PATIENT INFORMATION PERSON RESPONSIBLE FOR PAYING THE BILL FAMILY PHYSICIAN INFORMATION HEALTH INSURANCE INFORMATION
PATIENT REGISTRATION Thank you for choosing our office! Please complete all pages. Patient Name: PATIENT INFORMATION Home Address: City: State: Zip: Sex: S S#: Marital Status: S,M,O or minor E-mail: Home
If you have any questions about this payment method, do not hesitate to ask. Visa MasterCard American Express Discover Other:
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Medicare Patient Registration
Medicare Patient Registration Name: Jr Sr Dr First Middle Last SS#: - - DOB: / / Sex: M F Primary Language: Race: Hispanic Non-Hispanic Decline E-Mail address: Is it okay to email you about upcoming cosmetic
PATIENT INFORMATION SHEET
PATIENT INFORMATION SHEET Patient Name: DOB: Address: ADDRESS CITY, STATE, ZIP SSN: Mailing Address: ADDRESS CITY, STATE, ZIP Same as above Home phone: Cell phone: Work phone: Marital Status: Single /
Patient Health History Form
Patient Health History Form PATIENT INFORMATION Patients Legal Name: Name that child likes to be called (Nickname): DOB: Current Age: SOURCES OF INFORMATION Name of Person Providing Information: Relationship
PATIENT INTAKE FORM. UNDER 18 years old?: INSURANCE INFORMATION (Please give your insurance card to the receptionist.)
PATIENT INTAKE FORM Primary Care Physician: Specialist Physician: Referred? : Referred By: PATIENT INFORMATION (Please give your I.D. to the receptionist.) Patient s FIRST Name: LAST Name: MI: Preferred
GUARANTORS' SIGNATURE: DATE: (SIGNATURE REQUIRED) IF THERE IS ANY PROBLEM FILLING OUT THIS FORM, PLEASE ASK FOR ASSISTANCE
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. ***************************************************************************************************
List all medications you are currently taking (including prescriptions, over-the-counter, & vitamins)
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Patient Registration Form
Patient Registration Form Name: Jr Sr Dr First Middle Last SS#: - - DOB: / / Sex: M F Primary Language: Race: Hispanic Non-Hispanic Decline E-Mail address: Is it okay to email you about upcoming cosmetic
Signature: Print Name: Date:
~ PLEASE PRINT CLEARLY ~ LAST ADDRESS FIRST MI HOME PHONE SOCIAL SECURITY # EMPLOYER WORK PHONE DATE OF BIRTH JOB/ PROFESSION: CELL PHONE MARITAL STATUS SPOUSE S SPOUSE S SOCIAL SECURITY # (If under spouse
PEDIATRIC REGISTRATION FORM
PEDIATRIC REGISTRATION FORM **Today s Date: PATIENT INFORMATION: (Please use full legal name, no nicknames) *Last Name: *First Name: Middle Initial: *Address: City: State: Zip: *Sex: *Date of Birth: Age:
Registration Form. City: State: Zip: Birthdate: Marital Status: M S W D. Patient Employer: Occupation: Employer Address: Emp.
Registration Form Patient Information Name: Address: SS#: Phone: City: State: Zip: Sex: F M Birthdate: Marital Status: M S W D Patient Employer: Occupation: Employer Address: Emp. Phone: Whom may we thank
PATIENT INFORMATION. DATE OF VISIT: Date of Birth Gender: M F. Address [Apt. # ] City State. address: Employer Phone
![PATIENT INFORMATION. DATE OF VISIT: Date of Birth Gender: M F. Address [Apt. # ] City State. address: Employer Phone](/thumbs/78/78629552.jpg "PATIENT INFORMATION. DATE OF VISIT: Date of Birth Gender: M F. Address [Apt. # ] City State. address: Employer Phone")
PATIENT INFORMATION DATE OF VISIT: Date of Birth Gender: M F PATIENT FULL NAME: Address [Apt. # ] City State Zip Email address: Preferred Phone: Secondary Phone: Circle: Single Married Partnered Divorced
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
PATIENT INFORMATION. (Please complete all sections) NAME OF PARENT(S) OR GUARDIAN(S): PARENT, SPOUSE, OR RESPONSIBLE PARTY If Different from Patient
Date: PATIENT INFORMATION (Please complete all sections) Office Location: PATIENT NAME (Last, First M.I.): DATE OF BIRTH: / / NAME OF PARENT(S) OR GUARDIAN(S): SSN#: SEX: (_) Male (_) Female MARITAL STATUS:
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HIPAA Patient Consent Form
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Parent/Guardian Name: Social Security #: Male / Female: Date of Birth: / / Home Phone: Mobile Phone: Work Phone: Street Address: City: State: Zip:
PATIENT INFORMATION Today s : / / Patient Name (Last, Middle, First) Social Security #: Male / Female: of Birth: / / Street Address: Email Address: Home Phone: Mobile Phone: Work Phone: IF THE PATIENT
CONSULTANTS. Welcome Letter Dr. Peter Van Houten & Associates. Date: Patient:,
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PATIENT HISTORY FORM Name: SSN: (Last) (First) (MI) DOB: Age: Male Female Marital Status Address: (Street) (City) (State) (Zip) Home Phone: Cell: Work: Email Address: Preferred Method of Contact: Home
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Associated Podiatrists, P.C. 26750 Providence Parkway Suite 130 - Novi, MI 48374 Telephone: (248)348-5300 PLEASE FILL OUT COMPLETELY Today s date Name (First, Middle, Last): DOB: Home Address: City State
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
Dental Insurance Information
Dr. Talib Ali DMD Dr. Ali Mualla DDS Patient s Name Social Security # Gender Birthdate Email Address Home Address City State Zip Home Phone Cell Phone Most Recent Dental Visit Who may we thank for your
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2800 E Broad Street, Suite 124 Mansfield, TX 76063 P: 817-539-0959 F: 817-539-0480 723 N Fielder Road, Suite C Arlington, TX 76012 P: 817-539-0959 F: 817-261-1123 780-B NE Alsbury Blvd Burleson, TX 76028
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LUPTON DERMATOLOGY MR# Today s Date:
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GWINNETT DERMATOLOGY, P.C. PATIENT REGISTRATION
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Family Foot and Ankle Centers Patient Registration Form (Please present your insurance cards to the receptionist upon arrival)
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Endocrinology of the Rockies, PC. PATIENT REGISTRATION FORM E. 9th Ave. Ste. 245, Denver, CO 80220
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ELYSE S. RAFAL, F.A.A.D.
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VASCULAR HEART & LUNG ASSOCIATES
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PATIENT REGISTRATION FORM CAROLINA EAR, NOSE & THROAT
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One Stop Medical Center Tel:
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1600 N Coalter St, Ste 19 Staunton, VA 24401 Phone: 540-885-4500 Fax: 540-885-4600 PATIENT DEMOGRAPHIC INFORMATION PLEASE PRINT NAME: AGE: (LAST) (FIRST) (MIDDLE) SEX: M F (CIRCLE) DATE OF BIRTH: PERSON
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PARKVIEW PRIMARY CARE PHYSICIANS 20 Losson Road, Suite 105 Cheektowaga, NewYork (716) Fax (716)
Orville Hendricks, M.D. John Kavcic, M.D. Deirdre Bastible, M.D. PARKVIEW PRIMARY CARE PHYSICIANS 20 Losson Road, Suite 105 Cheektowaga, NewYork 14227 (716)558-7727 Fax (716)558-7720 Office Policy (revised