Amarillo Endoscopy Center Srinivas Pathapati, MD., PA 6833 Plum Creek Drive Amarillo, TX (806)
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- Peregrine Oliver
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1 Today s Date: / / PATIENT INFORMATION Patient s Last Name First Middle Mr. Miss Mrs. Ms. Marital Status (Circle one) Single / Mar / Div / Sep / Widow Legal Name (If applicable) Maiden Name Birth Date Age Sex Social Security Home Phone Cell Phone Street Address/P.O. Box City State Zip Code Employer Employer Phone No. IN CASE OF EMERGENCY Name of Local Friend or Relative (not living at same address) Relationship to Patient Home Phone No. Work Phone No. INSURANCE Primary Insurance Company A copy of your insurance cards will be obtained. If unavailable, you will be asked to provide more information. Subscriber s Name Subscriber s S.S.# Birthdate Name of Secondary Insurance PHARMACY Please lit below the Pharmacy you would like us to use: Mail In Pharmacy Phone#( ) Phone#( ) PATIENT PORTAL ADDRESS:
2 PERMISSION TO LEAVE RESULTS In the event there is lab, pathology results, or post procedure follow-up calls from the physicians, or his staff, please specify how this office may leave messages. (example: Machine or designated relative). I give my permission for this office/clinic to leave lab, pathology results, or post procedure follow-up calls as follows: Please circle MYSELF ONLY SPOUSE ANYONE WHO ANSWERS THE TELEPHONE ANSWERING MACHINE OTHER CONSENT TO TREATMENT I hereby voluntarily consent to outpatient care by Amit K. Trehan, M.D./Srinivas Pathapati, M.D. encompassing routine diagnostic procedures, examinations and medical treatment including (but not limited to routine laboratory work (such as blood, urine, and other studies), taking x-rays, heart tracings, and administration of medications). ASSIGNMENT OF BENEFITS AUTHORIZATION. RELEASE OF LIABILITY I hereby authorize the release of any medical information including the diagnosis and the treatment or examination rendered to me during the period of such care to third (3 rd ) party payer to process this claim and / or other health practitioners. Moreover, I authorize the holder of my medical records to release a CMS/Centers for Medicare & Medicaid Services and its agents any information to determine these benefits payable for related services. I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize and request Medicare or other insurance company benefits by made on my behalf directly to the doctor or doctors group, otherwise payable to me for any services furnished by them. I further understand that my insurance carrier may pay less than the actual bill of services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. Moreover, I agree to pay for nay services that are rendered if my insurance denies them for any reason. ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES/PATIENT BILL OF RIGHTS I acknowledge that I understand the Notice of Privacy Practices/Patient Bill of Rights from the offices of Amit,K. Trehan, M.D., And Srinivas Pathapati, M.D., or the Amarillo Endoscopy Center. PATIENT SIGNATURE Patient Signature Date Name of Office Representative Date Placed in Patient Chart
3 DATE: REFERRING PHYSICIAN: REASON FOR CONULTATION:1. PAST MEDICAL HISTORY: (check all that apply) Hypertension Heart Disease High Cholesterol Stroke Seizures Depression Diabetes Thyroid Disease Asthma/Emphysema/Bronchitis Cancer: a. Colon b. Lung c. Prostate d. Breast e. Others PAST SURGERIES: CURRENT MEDICATIONS: DRUG ALLERGIES SOCIAL HISTORY: Tobacco use Yes number packs per week? No. of years? No Alcohol use Yes What type? How much? No FAMILY HISTORY: Colon Cancer Colitis Peptic Ulcer Disease Liver Disease Other GI Problems
4 FINANCIAL POLICY We are doing everything possible to hold down the cost of medical care. You can help a great deal by reducing the number of bills we send to you. The following is a summary of our payment policy. ALL Co-Pays are EXPECTED AT THE TIME OF SERVICE. If you do not have your copay we will reschedule your appointment. Payment is required at the time services are rendered unless other arrangements have been made in advance. This includes applicable coinsurance and copayments for participating insurance companies. We accept cash, personal checks (in-state only), VISA, MasterCard, Discover, American Express and Care Credit. There is a $35 service charge for returned checks. Patients with an outstanding balance 60 days or more overdue must make arrangements for payment prior to scheduling appointments. We realize that financial difficulty is a reality. INSURANCE: We bill insurance companies as a courtesy to you. You are expected to pay your deductible and copayments at the time of service. If we have not received payment from your insurance company within 60 days of the date of service, you may be expected to pay the balance in full. You are responsible to ensure all charges are paid either by you or by your insurance carrier. If you need assistance or have questions, please contact The Billing Office between 8:30 a.m. and 5:00 p.m., Monday through Friday at REFUNDS: Patient/guarantor credits in amounts less than $20 will be retained on account to be credited toward future balances unless a written request for refund is received. Amounts of $20 and greater will automatically be refunded to the patient/guarantor. MANAGED CARE: If you are enrolled in a managed care insurance (i.e., HMO), you must have a referral from your primary physician in order to see us as we are a Specialist. MISSED APPOINTMENTS/LATE CANCELLATIONS: Broken appointments represent a cost to us, to you and to other patients who could have been seen in the time set aside for you. Cancellations are requested 24 hours prior to the appointment. We reserve the right to charge for missed or late-canceled appointments. Excessive abuse of scheduled appointments may result in discharge from the practice. If it becomes necessary to forward your account to a collection agency, in addition to the amount owed, you also will be responsible for the fee charged by the collection agency for costs of collections.
5 PATIENT BILL OF RIGHTS Dr. Amit Trehan and Dr. Srinivas Pathapati have established this Patient s Bill of Rights as a policy with the expectation that observance of these rights will contribute to more effective patient care and greater satisfaction for the patient, his physician, and the group organization. It is recognized that a personal relationship between the physician and the patient is essential for the provision of proper medical care. The traditional physician-patient relationship takes on a new dimension when care is rendered within an organizational structure. Legal precedence has established that the facility itself also has a responsibility to the patient. It is in recognition of these factors that these rights are affirmed. 1. The right of efficient and equal service, regardless of race, sex, religion, ethnic background, education, social class, physical or mental handicap, or economic status. 2. The right of considerate, courteous and respectful care from all staff of the facility. 3. The right of complete information in terms that the average patient can reasonably be expected to understand. 4. The right to informed consent and full discussion of risks and benefits prior to any invasive procedure, except in an emergency. Alternatives to the proposed procedure must be discussed with the patient. 5. The right to know the names, titles, and professions of the facility staff to whom the patient speaks and from whom services or information are received. 6. The right to refuse examination, discussion and procedures to the extent permitted by law and to be informed of the health and legal consequences of this refusal. 7. The right of access to patient s personal health records. 8. The right of respect for the patient s privacy. 9. The right of confidentiality of the patient s personal health record as provided by law. 10. The right to make a complaint and to have your complaints reviewed in a timely, confidential manner. 11. The right to examine and receive a full explanation of any charges made by the facility. 12. The patient has the right to know the facility rules and regulations and how they apply to his/her conduct as a patient. 13. The patient has the right to request information regarding the ownership of the facility. No catalog of rights can guarantee for the patient the kind of treatment he has a right to expect. This facility has many functions to perform, including the prevention and treatment of disease, the education of both health professionals and patients, and the conduct of clinical research. All these activities must be conducted with an overriding concern for the patient, and above the recognition of his dignity as a human being. Success in achieving this recognition assures success in the defense of the rights of the patient. PATIENT RESPONSIBILITY 1. You need to give complete, accurate information about your health, including present condition, past illnesses, hospitalizations, medications, natural products and vitamins and any other matters or changes that pertain to your health. 2, Tell your healthcare team if you do not understand what they are telling you, or if you need more information. 3. You and your healthcare team should agree on a treatment plan. If you are unable to follow the plan, tell your doctor or nurse. 4. If you are not able to keep an appointment, please call the office as soon as possible to change the appointment. 5. Treat other patients, visitors, and medical staff with courtesy, compassion, and respect. 6. We encourage you to leave your valuable at home. The doctor s office is not responsible for lost or stolen belongings. If you believe any of your rights have been violated or you have other concerns or complaints about your care facility, you may contact the following: Texas Department of State Health Service Health Facility Compliance Group Post Office Box Austin, Texas (888) Complaints may be registered with the department by phone or in writing. A complainant may provide his/her name, address, and phone number to the department. Anonymous complaints may be registered. All complaints are confidential
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James M. Wilson, M.D. - Medical Information Email to wilson@houstonmds.org (fax to 713-790-1605) PATIENT INFORMATION Last name: First: D.O.B: SSN: Age: Gender: M F Home Phone #: Cell Phone #: Work Phone
More informationX Name of Patient (Please Print) X Signature of Patient (or Parent/Legal Guardian) X Name of Parent/Legal Guardian (Please Print)
In Office Policies Identification - For the protection of our patients, and to reduce medical identity theft, all patients are required to present a valid insurance ID card and/or driver s license at the
More informationFriendswood Counseling Center, LLC Phone: (479) E. FM 528 Rd, Suite 200 Fax: (281) Client Registration
Friendswood Counseling Center, LLC Phone: (479) 200-6034 3526 E. FM 528 Rd, Suite 200 Fax: (281) 819-7845 Friendswood, TX 77546 Email: kristi@friendswoodcc.com Website: www.friendswoodcc.com Client Registration
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The Home Doctor Registration Checklist All enrollees: ( ) Enrollment Form ( ) Copy of Insurance card(s) ( ) Medication List ( ) POA/Guardianship documents NOTICE Please allow two weeks for processing this
More informationNORTH COUNTY PHYSICAL THERAPY, INC. DBA MISSION PHYSICAL THERAPY GROUP
NORTH COUNTY PHYSICAL THERAPY, INC. DBA MISSION PHYSICAL THERAPY GROUP Last Name First Name MI Mailing Address City State Zip Date of Birth Age SSN: - - Gender: M or F Home Phone Cell Phone Email: Patient
More informationPlease complete all pages of this form. Your physician will review the form with you during your appointment. Last Name: First Name: Middle Initial:
Please complete all pages of this form. Your physician will review the form with you during your appointment. Patient Information Last Name: First Name: Middle Initial: Date of Birth: / / Age: SSN: - -
More informationStatement of Financial Responsibility
Statement of Financial Responsibility Patient Name: Date: Acct : BIR JV, LLP including; Out-Patient, In-Patient and, Home Health Rehab appreciates the confidence you have shown in choosing us to provide
More informationLast Name First Middle. Mailing Address. City State Zip Phone. Date of Birth Age Soc. Sec# Cell. Employer Work Phone
Last Name First Middle Mailing Address City State Zip Phone Date of Birth Age Soc. Sec# Cell Employer Work Phone Email Address Emergency contact Phone # Relation: Name of Primary Insurance Policy # -----
More informationNAME (LAST, FIRST, M.I.) SOCIAL SECURITY NUMBER DATE OF BIRTH SEX M F MAILING ADDRESS CITY STATE ZIP CODE STREET ADDRESS CITY STATE ZIP CODE
1. PATIENT INFORMATION All patients complete this section. NAME (LAST, FIRST, M.I.) SOCIAL SECURITY NUMBER OF BIRTH SEX M F MAILING ADDRESS CITY STATE ZIP CODE STREET ADDRESS CITY STATE ZIP CODE EMAIL
More informationWelcome to Baptist Medical Group - Westside. Please read the below information carefully to prepare for your upcoming appointment.
BAPTISTMEDICALGROUP.ORG Westside Welcome to - Westside Please read the below information carefully to prepare for your upcoming appointment. Please arrive 15 minutes prior to your regularly scheduled appointment
More informationBeck & Blackley Chiropractic Clinic
Address City State Zip Code Home Phone Cell Phone Work Phone Email Address Sex: M F Marital Status: M S D W Date of Birth SS# Spouse Name How did you hear about our office? Employer Name/Occupation Emergency
More informationWelcome to the Southeastern Urology Associates meridianemr Patient Portal
New Patients: Please register for our Portal following the instructions below and send us a Message though the New Message Message for Office Section to let us know you received this packet and are confirming
More informationResponsible Party (Guarantor) Info. Insurance Information
Associates in Women s Health, P.C. 2801 YOUNGFIELD STREET, SUITE 200 GOLDEN, CO 80401 P: 303-940-1867 F: 303-940-1894 Please Circle Your Doctor: ELLIS GANTER PYTHON SCHOEN WESSELL, WHNP PATIENT INFORMATION
More informationDirections to our office are included in this mailing.
Welcome to University Audiology Associates. We appreciate the opportunity to provide you with comprehensive hearing services. are services. Please complete the enclosed forms and bring these completed
More informationDear New Patient, Once again, we would like to thank you for choosing us as your primary health care provider. We look forward to working with you.
307 West Central Street Wendy J. Parker, M.D. Natick, MA 01760 Deborah J. Riester, M.D. Telephone: 508-820-8383 Jo-Ann Suna,M.D. Fax: 508-820-0250 Hadia F. Tirmizi, M.D. Natalia Sedo, N.P. Christine Chang,
More information- Cardiac Catherization - Cardiac Angioplasty - Cardiac Bypass - MUGA - CT Scan
Thank you for making an appointment with our office. We look forward to meeting you. Please help us to prepare for your appointment by gathering the information we will need to make the most of your time
More informationADMISSION CONSENTS. 1. Yes No Automobile Medical or No Fault insurance due to an accident?
Patient Name: I.D. Number: Section A: Identifying Proper Payor ADMISSION CONSENTS Are services provided to you by Hospice reimbursements through health insurance other than Medicare due to one of the following
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Authorization to Release Medical Information Date: Patient s Name: Patient s Address: Date of Birth: I hereby authorize you to transfer or make available all medical records or reports relating to my care
More informationPatient Name:,, Address: Phones:,, Home Work Cell. Primary Physician: Emergency Contact: Phone#:
Patient Information Patient Name:,, Last First middle initial Address: Phones:,, Home Work Cell Sex: Female Male E-Mail: Date of Birth: / / Mo. Day Year Primary Physician: Marital Status: Single Married
More informationBasic Information. Date: Patient s Name: Address:
1 Basic Information : Patient s Name: Address: Home Phone: Work Phone: Cell Phone: Email: Age: Birth : Marital Status: Occupation: Educational History: Name, Address and Phone of Child s School Counselor
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