Patient Information First: Last: Birth Date: Age: Male/Female Social Security Number: Marital Status: S / M / D / W Address: City: State: Zip Code: Home Phone: Cell Phone: Driver's License Number: **IS IT OK TO CONFIRM APPOINTMENTS/PROCEDURES BY TXT MESSAGE Yes No Email Address: Patient Employer Information Employers Name: Occupation: Address: City: State: Zip Code: Responsible Party Information * Responsible Party is the Same as Above If Yes, Proceed to Insurance Information Yes No First: Last: Birth Date: Age: Male/Female Social Security Number: Address: City: State: Zip Code: Home Phone: Cell Phone: Driver's License Number:
Insurance Information * Policy Holder is the Same as Above If Yes, Then only answer Section B Yes No Section A Name of Insurance: Social Security Number: Home Number: Policy Holder's Name: Birth Date: Cell Section B Deductible $ Met $ Co-Pay $ Secondary Insurance Information Name of Insurance: Social Security Number: Home Number: Policy Holder's Name: Birth Date: Cell Deductible $ Met $ Co-Pay $ Please, Let Us know HOW DID YOU HEAR ABOUT US? Referring Doctor's Name: Internet Yes/No Patient's Name: Other: In case of an Emergency Name: Relationship: Male/Female Address: City: State: Zip Code: Financial Agreement Read before Signing I understand that fees are payable when service is rendered unless prior arrangements have been made. I understand that I am financially responsible for all charges whether or not covered by insurance. Payment for services rendered to me and/or my dependents will not be delayed or withheld because of pending insurance claims. I understand that I am financially responsible for any collection agency cost or legal costs resulting from any delays. I authorize payment of medical benefits to Coastal View Gastroenterology provider of services. I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS MY CLAIM
Signature: Date: Relationship: Patient Authorization for Use and Disclosure Of Protected Health Information By signing, I authorize Coastal View Gastroenterology to use and/or disclose certain protected health information (PHI) about me to and/or. I also wish to be contacted at this Number: Please leave a Detailed/No Message and/or a call back Number. This authorization permits Coastal View gastroenterology to use and/or disclose the following individually identifiable health information about me (specifically describe the information to be used or disclosed, such as date(s) of services, type of services, level of detail to be released, origin of information, etc.): The information will be used or disclosed for the following purpose: (If disclosure is requested by the patient, purpose may be listed as at the request of the individual. ) The purpose(s) is/are provided so that I can make an informed decision whether to allow release of the information. Coastal View Gastroenterology will not receive payment or other remuneration from a third party in exchange for using or disclosing the PHI. Coastal View Gastroenterology 2573 Pacific Coast Highway Suite B Torrance, CA 90505 Signed by: Signature of Patient or Legal Guardian Print Patient s Name Relationship to Patient Date Print Name of Patient or Legal Guardian, if applicable Patient/guardian must be provided with a signed copy of this authorization form.
Pharmacy Information Name of the Pharmacy: Address or Cross Streets: City& State: Patient s Name: I give authorization for Coastal View Gastroenterology to withdraw information from the pharmacy regarding any medication I have taken in the past, present or future. Patient Signature: Date: