Date of Birth: Age: Social Security #: Address: City: State: Zip Code: Home #: Cell#: Work#: Sex: F or M Marital Status: S M Wid Sep Div

Similar documents
Your Name: Today s Date: Doctor: Your Address: Date of Birth: Age: Social Security #: Address: City: State: Zip Code: Home #: Cell#: Work#:

PATIENT INFORMATION NOTICE OF PRIVACY POLICY PATIENT ACKNOWLEDGEMENT

Chong S Kim, MD ENT and Facial Plastic Surgeon

If you are employed, please provide the follow information regarding your employer; Employer Name: Work Address:

PATIENT REGISTRATION

PATIENT INFORMATION. Last Name: First Name: Middle Initial: Address:

Today s Date: Street Address: City: State: Zip: Mailing Address (only if different): Circle: MALE or FEMALE Married Status: Social Security: - -

VASCULAR HEART & LUNG ASSOCIATES

PRIMARY INSURANCE TO FILE SECONDARY INSURANCE TO FILE

Wayne Foot & Ankle Center, P.A.

LAST NAME: FIRST: MIDDLE: SOCIAL SECURITY NO: DATE OF BIRTH: ADDRESS: CITY, STATE, ZIP: HOME PHONE# CELL PHONE# WORK PHONE# ADDRESS:

PATIENT REGISTRATION FORM CAROLINA EAR, NOSE & THROAT

PATIENT REGISTRATION FORM Account #:

New Patient Packet Please print and complete the following 6 pages. Bring the completed forms to your scheduled appointment. Thank you!

Patient Information Last Name First Name Middle Initial

Patient Registration Form

KNIGHTSBRIDGE INTERNAL MEDICINE & CARDIOLOGY, INC. New and Current Patient Information Sheet

CROSSROADS HEALTH CLINIC Thank you for choosing us as your Health Care Provider.

What to bring to the appointment

West Houston Infectious Disease Associates. Address: Number Street Apt. No. City State Zip. Home Phone: Cell: Work:

PATIENT INFORMATION SHEET

ALBANY PLASTIC SURGEONS, PLLC 4 Executive Park Drive Albany NY (518) PATIENT INFORMATION FORM

Date: Patient Health Information. Patient Name: First Middle Last Nickname. Date of Birth: Age: Sex: Male Female. Referring Physician:

PATIENT HISTORY FORM. DOB: Age: Male Female Marital Status. Address: Preferred Method of Contact: Home Cell Work Text

ADDRESS CITY / STATE / ZIP CODE RACE/ETHNICITY WORK PHONE # ( ) ADDRESS MAY WE CONTACT YOU BY YES NO

Chief Complaint Form: Patient Name: Age: DOB: Occupation: Employer: Referring Physician: Town: Primary Care Physician: Town: Y N

SUMON NANDI, MD NEW ENGLAND BAPTIST HOSPITAL 125 PARKER HILL AVENUE FOGG BUILDING, SUITE 501 BOSTON, MA 02120

FOOT & ANKLE SPECIALISTS OF THE TWIN TIERS, PC 455 MAPLE STREET, SUITE 2 BIG FLATS, N.Y PATIENT INFORMATION FORM (PLEASE PRINT) DATE: / /

EAR, NOSE, AND THROAT ASSOCIATES, PC Financial Policy Effective September 1, 2014

Insurance Information:

Arizona State Urology, PLLC (Subsidiary of Glendale Urology, PC)

Social Security No: Home Phone: _. Employer: Work Phone: _. Employer Address: Occupation: _. Spouse/Parent Name: Phone No: _

How did you learn about our office? Patient s Last Name: First: MI: Address: City: State: Zip Code: Home Phone: ( ) Cell Phone: ( ) Work Phone: ( )

ADULT INFORMATION SHEET

Arizona Retina Associates

Louis Arno, MD, FACP, FCCP Nehal L. Mehta, MD, FCCP, D,ABSM Prashant B. Patel, MD, MS

Princeton and Rutgers Neurology, P.A. A Center Of Excellence

Welcome To Our Office Please Print

RESPONSIBLE PARTY DEMOGRAPHIC INFORMATION

We look forward to meeting you, and will be available for you at any time. Dr. Douglas Scott, M.D. Dr. Kirk Johnson, M.D.

New Patient Intake Form

PLEASE FILL OUT FORM BELOW AND THEN FAX BACK TO: ADDITIONALLY, PLEASE BRING FORM WITH YOU ON THE DAY OF YOUR SCHEDULED APPOINTMENT.

Surgical Group of Gainesville, PA

SILVERDALE EYE PHYSICIANS PATIENT REGISTRATION FORM

Stark County Surgeons, Inc Patient Information. Patient Name: Address: City: State: Zip: Date of Birth: / / Social Security Number: - -

PATIENT INFORMATION PRIMARY INSURANCE INFORMATION

PATIENT INFORMATION FULL NAME First M.I. Last CONTACT INFORMATION

AUBURN URGENT CARE. Patient Information. Name: Last First Middle. Permanent Address: Apt #: Zip: City: State: Employer: Phone: ( )

CENTRAL FLORIDA ORAL & MAXILLOFACIAL SURGERY, PA PATIENT REGISTRATION Date: PATIENT INFORMATION

PATIENT INFORMATION FORM - DIABETES

Ronald E. McFarland M.D. PATIENT REGISTRATION AND HISTORY

PRIMARY INSURANCE: Policy # Group # Name of Subscriber (if other than patient)

Name: Date of Birth: Sex: Office: Date:

Patient Information Form

Villa Medical Arts New Patient Forms

Patient Registration Form

Name (Last, First, MI): Date of Birth: / /

CENTER CITY DERMATOLOGY STEPHEN HESS, M.D., Ph.D. MEDICAL HISTORY

PATIENT INFORMATION. First:

PATIENT INFORMATION. Patient s Last Name First M.I. Home Phone Work Phone Cell Phone Home Address City State Zip Address

New Patient Medical Information Survey Revised 3/2013

GENERAL INFORMATION. Scott D. Kazdan, D.O., LLC 601 N. Flamingo Road, Suite 209 Pembroke Pines, FL Phone (954) Fax (954)

Patient Registration Form This form is posted on our website

Montville MedSpa & Pain Center

PATIENT REGISTRATION FORM

Endocrinology of the Rockies, PC. PATIENT REGISTRATION FORM E. 9th Ave. Ste. 245, Denver, CO 80220

Other Scan(s): List All Your Medical Diagnosis: Chemotherapy? YES NO If yes, please list treatment regimen:

Medicine and Surgery of the Foot PATIENT INFORMATION PERSON RESPONSIBLE FOR PAYING THE BILL FAMILY PHYSICIAN INFORMATION HEALTH INSURANCE INFORMATION

Winter Park Colon & Rectal Specialists, LLC JACQUELINE L. KAISER, MD 255 N. Lakemont Ave #100 Winter Park, FL 32792

X PRINT PATIENT S NAME DATE OF BIRTH SIGNATURE

2014 Patient Information

Natural Image Skin Center Registration Form

PATIENT REGISTRATION FORM (Complete All Pages)

Caritas Medical Center, LLC

PATIENT INFORMATION Patient Demographics and Insurance

ACKNOWLEDGMENT OF RECEIPT OF PRIVACY NOTICE

Personal Medical History Barth Wolf DPM and Daniel Reznick DPM

HIPAA PATIENT CONSENT FORM

Patient Name Sex: M F Today s Date. Social Security Number Date of Birth Age. Ethnicity: Hispanic Non-Hispanic Refuse to report

WELCOME TO OUR PRACTICE! We look forward to seeing you very soon.

PATIENT INFORMATION. PATIENT NAME Last First M.I. Social Security Number. ADDRESS Street DATE OF BIRTH SEX Female Male

1421 S. Potomac Street, Suite 120 Aurora, CO Please print and complete all parts.

Referring Physician: Primary Care Physician: Other Physician(s)/Specialty: EMERGENCY CONTACT INFORMATION INSURANCE INFORMATION

Main Phone: Fax: (973) Patient Information. Demographics. o English o Spanish. o Asian. o Non-hispanic. Employer Information

PATIENT INFORMATION PATIENT NAME Last First M.I. Social Security Number

BenchMark Rehab Partners Welcome to

Tri-Valley Internal Medicine Group New Patient Registration Form

Signature: Print Name: Date:

Secondary Insurance Carrier Name of Insured Member ID# Group # Birthdate of Insured / / Employer SS # of Insured / / Relation to Insured

SILVERDALE EYE PHYSICIANS PATIENT REGISTRATION FORM

Patient Registration Form

MICHAEL K. BLOCK, DPM, LLC PATIENT FINANCIAL POLICY

Last Name: First Name: MI: Address: Apt #: City: State: Zip: Home #: Work #: Emergency #: Birthdate: SSN: Sex: Marital Status: Employer: Occupation:

PATIENT REGISTRATION INFORMATION

If you are prescribed any medications, where would you like the script sent? Pharmacy Name: Pharmacy Phone:

Buckland Ear, Nose & Throat, LLC. Medical History

PATIENT & INSURANCE INFORMATION. INSURANCE INFORMATION: (please list the Policy Holder information if it is NOT the patient)

Ear, Nose & Throat Consultants Patient Medical Hx Form Name: Date: / / DOB: / / Age:

Patient Name Date of Birth Age Social Security Number Male Female Marital Status: Single / Married / Divorced / Widowed / Separated

Patient s Name: Age: Social Security: Height: Weight: Street Address: City: State: Zip: Mailing Address (if different): City: State: Zip:

Transcription:

Your Name: Email Address: Date of Birth: Age: Social Security #: Address: _ City: State: Zip Code: Home #: Cell#: Work#: Sex: F or M Marital Status: S M Wid Sep Div Spouse s Name: Emergency Contact: Telephone #_ Primary Doctor s Name: Referring Physician s Name: Insurance Name: ID#: Group#: Office Policies you should know: A. Please alert our office of any insurance or address changes B. We are not Medicaid providers; if your secondary insurance is Medicaid you will be responsible for your annual Medicare deductible. C. Tests done outside our office (Blood, X-ray, CT-Scan, MRI, etc) may take up to 2 weeks or longer for results. If you have not received a call back in two weeks, please call our office. D. Co-payments, co-insurances and deductibles are due at the time of service; otherwise your appointment will be rescheduled. E. Please be aware that we are not your insurance company; therefore, we have limited Insurance benefit information. If you have any questions about your insurance benefits, please contact the 1-800 numbers listed on your ID card. Thank you. F. If you are an HMO patient, you will need an authorization or referral from your primary care physician or referring physician for every visit. It is your responsibility to make sure the referral is faxed, mailed, and/or brought to our office by the date of your appointment. Without the referral you will be responsible for all services. New patient visits are $325 follow-up visits are $140. G. If you are here due to a car accident we will need the claim number from your car insurance, claim address, and the phone number to the claim representative. Your health insurance does not cover these charges until your car insurance has processed the charges. H. We welcome your suggestions or complaints about our office. You may submit any suggestions or complaints by mail at 9090 SW 87 CT. suite 200 Miami, FL 33176 Att: Practice Manager or by e-mail at Iclark@neuroscienceconsultants.com I. For any medication refill please have the pharmacy fax us the request to 305-596-0657 at least 72 hours in advance. J. If you would like a copy of these policies, please ask the clerks. K. The office also had a no show fee for $25 per visit. Page 1 of 6

Patient Signature: Date: Financial Agreement/ Assignment of Benefits: I hereby authorize payment to be made directly to Neuroscience Consultants LLP of benefits due to me from my insurance company. The responsible parties agree to pay for all fees, services and treatment incurred by the patient. If there is a fee that is not covered be the insurance, this is payable by the patient. The patient also agrees to pay for all deductibles, co-payments, co-insurances and non-covered services. After receipt of a statement, if payment is not received by the next billing cycle, it is subject to a monthly finance charge. If an account is referred to an outside agency for collection, the patient agrees to pay all costs related to such action. An account will be referred to a collection service if no payment has been received within 90 days of service. Patient or Guardian: Date: HMO and Workman compensation patient notice: You are responsible for obtaining a referral /authorization for your visits and or testing in our offices from your primary care physician or claims adjuster. Patient or Guardian: Date: Medical Records Release I, give full authorization to discuss my medical treatment, medications, diagnosis, and/or financial information with the following Physicians and or family members only. I understand that my medical care will not be discussed with anyone that is not on this list. Relation Relation Relation _ Patient Signature Date Page 2 of 6

Page 3 of 6

1. What is your neurological complaint today? 2. CURRENT MEDICATIONS (include dose and frequency): For follow up patients, please update list. 3. PHARMACY: Name: Address/ZIP: Phone Number: 4. List any other neurologist seen in the past 5. YOUR PAST MEDICAL HISTORY (Circle if appropriate. ADD OTHERS not listed.) Cancer or blood disease: (List type) Heart and Blood Vessels: Atrial fibrillation, Congestive heart failure, Coronary artery disease, Heart attack, Hypertension, Peripheral Vascular Disease, High cholesterol Lungs: Kidneys: Psychiatric/emotional: Gastrointestinal : Endocrine/Hormonal: Neurologic: Asthma, Emphysema, Bronchitis Kidney stones, Prostate enlargement, Renal failure Depression, Anxiety, Alcohol or drug addiction/treatment Ulcer, Liver disease, Reflux disease Diabetes (Type 1 or 2), Thyroid disease (hypo or hyper) Dementia, Parkinson s, Epilepsy, Migraine, Head trauma, Stroke, Neuropathy List date and reason for hospitalization or surgery: ARE YOU CURRENTLY PREGNANT or planning to become so shortly? 6. ALLERGIES: a. Name of medication Type of Reaction b. Non-medication allergies: Iodine Seafood (circle if present) Latex Other (specify) Page 4 of 6

Name: Date: ECW #: 7. FAMILY MEDICAL HISTORY: (Please indicate any neurologic/cardiologic or other pertinent diseases in your family.) Father Mother Siblings/Others 8. SOCIAL HISTORY: Single Married Widow Divorced Separated Number of Children: Your Occupation: Check if retired. Tobacco use : YES OR NO (please circle) If Yes, how many cigarettes a day Alcohol use (number of drinks most days): 9. REVIEW OF SYMPTOMS General: Fever Eyes: Blurred vision Weight loss Eye pain ENT: Decreased hearing Cardiovascular: Chest pain Ringing in ears Palpitations/Heart racing Respiratory: Shortness of breath Gastrointestinal: Abdominal pain Cough Change in bowel habits Wheezing Nausea Genitourinary: Frequent urination Muscular/Skeletal: Muscle pain Urinary incontinence Swollen joints Skin: Change in hair or nails Psychiatric: Anxiety Rash Depression Suicidal thoughts Endocrine: Temperature intolerance Hematologic: Easy bruising Excessive thirst Swollen glands How tall are you? How much do you weigh? 10. SLEEP COMPLAINTS Do you snore? Are you overly sleepy during the day? What time do you fall asleep? What time do you wake up in the morning? Page 5 of 6

How many times do you wake up at night and for what reason? _ Does the need to move your arms or legs prevent sleep? Name: Date: ECW #: Page 6 of 6

2024 © financedocbox.com Privacy Policy | Terms of Service | Feedback