If you require films or CD, kindly give us 48 hour notice or make technologist aware at the time of your study.

Size: px
Start display at page:

Download "If you require films or CD, kindly give us 48 hour notice or make technologist aware at the time of your study."

Transcription

1 A Note to Our Patient: Your physician will be receiving a copy of your results via fax within two business days. Please contact your physician to go over your results and to obtain a copy of your report. A copy of your report may also be faxed to any physician that you request. ************************************************ We do our best to confirm your insurance requirements, however we do advise that you become familiar with your particular plan requirements as well (authorizations, referrals, pre-certifications, etc.). Unpaid amounts become the patient s responsibility. If you have a copayment, it is due at the time of service. ************************************************* If you require films or CD, kindly give us 48 hour notice or make technologist aware at the time of your study. If your physician requires a copy of your images please inform the technologist at the time of your procedure. Additional CDs are charged at $5.00 per copy. Film is charged at $5.00 per sheet. A COPY OF YOUR PATIENT RIGHTS IS MADE AVAILABLE TO YOU AT THE TIME OF YOUR VISIT. (Please refer to the bottom of your clipboard or ask the front desk for a copy). Signature Date If you would like to receive updates from us in the future, please provide your below: (Please note: reports and personal information cannot be faxed or ed.)

2

3 MEANINGFUL USE REQUIRED INFORMATION Patient ID: Patient Name: Patient DOB: Height Weight Gender M or F (circle one) Patient Race (check all that apply) Asian White Black/African American Other American Indian/Alaskan Native Native Hawaiian/Pacific Islander Patient Ethnicity (check one) Hispanic or Latino Non-Hispanic or Latino Blood Pressure Smoking Status (check one) Every day smoker Current some day smoker Smoker, current status unknown Former smoker Never smoker Unknown if ever smoked Vaccinations (Please check all that you have had) Flu Vaccination Pneumonia Vaccination Childhood Vaccinations Please list any known medical conditions/problems (such as asthma, diabetes, high blood pressure, ETC ) (use back if needed): Please list medications currently taken (use back of page if needed): Please list any known drug allergies (use back of page if needed): Lab Results: BUN Creatinine EGFR List any Stents, Valves, Pacemakers, Implants, ETC., Initials: Date

4 OPEN MRI AND DIAGNOSTIC IMAGING OF WALL Acknowledgement of OPEN MRI AND DIAGNOSTIC IMAGING OF WALL notice of HIPAA Privacy Name of Patient Date of Birth Signature of parent/guardian Designation of certain relatives, close friends and other caregivers: I agree that Open MRI and Diagnostic Imaging of Wall may disclose certain health information to a family member, close personal friend or other caregivers, since such person is involved with my health care. In that care, Open MRI and Diagnostic Imaging of Wall will disclose only information that is directly relevant to the person s involvement with my healthcare. I wish to be contacted in the following manner (check all that apply): Home telephone number: OK to leave message with detailed information* Leave message with call back number only OK to mail to my home address as listed on patient registration sheet Work telephone number: OK to leave message with detailed information* OK to leave message with call back number * Detailed information includes and not limited to reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others. I designate the following persons listed below as persons involved with my healthcare, for the purpose of the practice making the limited disclosures as described above. I understand that I am not required to list anyone. I also understand that I may change this list at any time. ****PLEASE NOTE*** WE WILL NOT RELEASE INFORMATION TO ANYONE WHO IS NOT LISTED ON THIS FORM The privacy rule generally requires healthcare providers to take reasonable steps to limit the use of disclosure of, and request for, patient health information to the minimum necessary to accomplish the intended purpose. These provisions do not apply to uses or disclosures made pursuant to an authorization requested by the patient/parent/guardian. Healthcare entities must keep records of protected health information disclosures. Uses and disclosures for treatment, payment and healthcare operations may be permitted without prior consent. Signature of patient/parent/guardian Date

5

MAIN STREET MEDICAL NEW PATIENT QUESTIONNAIRE

MAIN STREET MEDICAL NEW PATIENT QUESTIONNAIRE NEW PATIENT QUESTIONNAIRE Patient Name: Date: Date of Birth: SSN: Male Female Guarantor Name: SSN: DOB: Home Phone: Cell Phone: Street Address: Apt#: City: State: Zip: Billing Address (if different): Email

More information

PEDIATRIC CENTER FOR WELLNESS, P.C. CRYSTAL B. HOOD, M.D KLONDIKE RD SW SUITE 205 CONYERS, GA TELEPHONE FAX

PEDIATRIC CENTER FOR WELLNESS, P.C. CRYSTAL B. HOOD, M.D KLONDIKE RD SW SUITE 205 CONYERS, GA TELEPHONE FAX PEDIATRIC CENTER FOR WELLNESS, P.C. CRYSTAL B. HOOD, M.D. 1506 KLONDIKE RD SW SUITE 205 CONYERS, GA 30094 678-750-4000 TELEPHONE 678-750-4005 FAX www.pcfwellness.com Dear Family, We are excited to welcome

More information

PATIENT REGISTRATION FORM (ecw)

PATIENT REGISTRATION FORM (ecw) PATIENT INFORMATION PATIENT REGISTRATION FORM (ecw) (Please print) Patient s Name: (Last) (First) (MI) Address: City, State, Zip: Home: Cell: Work: E-Mail Address: DOB: Sex: Female Male Transgender Race:

More information

INFORMED CONSENT FOR TREATMENT

INFORMED CONSENT FOR TREATMENT INFORMED CONSENT FOR TREATMENT I (name of client) agree and consent to participate in behavioral healthcare services offered and provided by Methodist Services - Community Counseling Services (CCS). I

More information

W e l c o m e t o B i l l e r i c a C h i r o p r a c t i c

W e l c o m e t o B i l l e r i c a C h i r o p r a c t i c W e l c o m e t o B i l l e r i c a C h i r o p r a c t i c N E W P A T I E N T I N T A K E F O R M Print Name Today s Date Address City State Zip Email Address Date of Birth Male Female Social Security

More information

Allergy Consultants, P.A. Visit Date: Specialist in Pediatric and Adult Allergy, Asthma, and Sinus Disease

Allergy Consultants, P.A. Visit Date: Specialist in Pediatric and Adult Allergy, Asthma, and Sinus Disease Allergy Consultants, P.A. Visit Date: Specialist in Pediatric and Adult Allergy, Asthma, and Sinus Disease Arthur Fost, M.D. David Fost, M.D. Satya Narisety, M.D. Anthony J. Piccolo, PA-C Patient s Name

More information

Bring your insurance card(s) and a picture identification card to your appointment.

Bring your insurance card(s) and a picture identification card to your appointment. Your appointment is on / / at :. Thank you for choosing Midwest Ear Specialists (a member of the BJC Medical Group) as your healthcare partner. We value communication, beginning with the new patient registration

More information

If you would like your child to participate in the Life Health Center School Wellness Program, please complete pages 1-5.

If you would like your child to participate in the Life Health Center School Wellness Program, please complete pages 1-5. If you would like your child to participate in the Life Health Center School Wellness Program, please complete pages 1-5. Student Name of Birth Sex: Male Female Address Street City State Zip Grade Room

More information

NORTH COUNTY PHYSICAL THERAPY, INC. DBA MISSION PHYSICAL THERAPY GROUP

NORTH 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 information

Patient Information. Date of Birth Sex Marital Status / / Male Female Single Married Other. Address

Patient Information. Date of Birth Sex Marital Status / / Male Female Single Married Other.  Address Patient Information Patient Information Date of Birth Sex Marital Status Male Female Single Married Other Social Security Number - - Why We Ask for Race and Ethnicity Patient Goes By: Email Address In

More information

NAME SS# ADDRESS CITY STATE ZIP. TELEPHONE (home) (business) Cell SEX M F BIRTH DATE PLACE OFBIRTH RACE ETHNICITY LANGUAGE

NAME SS# ADDRESS CITY STATE ZIP. TELEPHONE (home) (business) Cell  SEX M F BIRTH DATE PLACE OFBIRTH RACE ETHNICITY LANGUAGE REGISTRATION (please print) PATIENT INFORMATION DATE: NAME SS# ADDRESS CITY STATE ZIP TELEPHONE (home) (business) Cell Email SEX M F BIRTH DATE PLACE OFBIRTH RACE ETHNICITY LANGUAGE MOTHER'S FIRST NAME

More information

2011 Measures 2013 Objectives Goal is to guide and support care processes and care coordination

2011 Measures 2013 Objectives Goal is to guide and support care processes and care coordination Improve quality, safety, efficiency, and reduce health disparities Provide access to comprehensive patient health data for patient s health care team Use evidencebased order sets and CPOE Apply clinical

More information

HARBOR CARE HEALTH & WELLNESS CENTER Patient Intake Form Please print clearly. Please ask for assistance in completing this form if needed.

HARBOR CARE HEALTH & WELLNESS CENTER Patient Intake Form Please print clearly. Please ask for assistance in completing this form if needed. Today date: HARBOR CARE HEALTH & WELLNESS CENTER Patient Intake Form Please print clearly. Please ask for assistance in completing this form if needed. Patient Full Name: Of Birth: Street: City: Zip Code:

More information

Patient: Gender: Male Female. Mailing Address: Ethnicity: Not Hispanic or Latin Hispanic/Latin Home Phone #:

Patient: Gender: Male Female. Mailing Address: Ethnicity: Not Hispanic or Latin Hispanic/Latin Home Phone #: 5002 Highway 39 N Bldg. A Meridian, MS 39301 Phone: 601-512-0500 Fax: 601-512-0505 Patient Information Patient: Gender: Male Female First Middle Last Primary Language: English Spanish Other Mailing Address:

More information

Responsible Party Information (Information used for patient balance statements) Responsible Party Another Patient Guarantor Self

Responsible Party Information (Information used for patient balance statements) Responsible Party Another Patient Guarantor Self Patient Information (Please Print) Dr. Miss Mr. Mrs. Sir Patient s Name (Last) (First) (MI) Previous Name Address Line 1 City, State ZIP Home Phone Cell No. Work Phone Ext. Primary Care Provider (PCP)

More information

PATIENT'S NAME DATE OF BIRTH SOCIAL SECURITY # HOME PHONE # CELL PHONE # WORK PHONE #

PATIENT'S NAME DATE OF BIRTH SOCIAL SECURITY # HOME PHONE # CELL PHONE # WORK PHONE # PATIENT INFORMATION PATIENT'S NAME DATE OF BIRTH SOCIAL SECURITY # STREET ADDRESS CITY, STATE, ZIP HOME PHONE # CELL PHONE # WORK PHONE # Emergency Contact & relationship: Phone #: Pharmacies local and

More information

MRI Patient Screening and History

MRI Patient Screening and History Griffin Imaging, LLC 220 Rock Street Griffin, GA 30224 (770) 229-4660 Fax:: (770) 229-4632 Specializing In Open MRI, CT & Ultrasound MRI Patient Screening and History Patient Information Sheet PATIENT

More information

Houston Rheumatology Center Sabeen Najam, MD, PA Board Certified in Rheumatology

Houston Rheumatology Center Sabeen Najam, MD, PA Board Certified in Rheumatology Houston Rheumatology Center Sabeen Najam, MD, PA Board Certified in Rheumatology Patient Health Questionnaire Patient s Name: Date of Birth: Drug / Food Allergies: Please list any and all allergies you

More information

Staff Training. Understanding Healthix Patient Consent

Staff Training. Understanding Healthix Patient Consent Staff Training Understanding Healthix Patient Consent Healthix Facilitates Exchange of Data Healthix Policy and Patient Consent Work Responsibilities: Training, Documenting and Preparing for Audit 1. Let

More information

ACKNOWLEDGEMENT OF HIPAA PRIVACY INFORMATION CONSENT TO USE OR DISCLOSE MEDICAL INFORMATION

ACKNOWLEDGEMENT OF HIPAA PRIVACY INFORMATION CONSENT TO USE OR DISCLOSE MEDICAL INFORMATION Patient Name (PLEASE PRINT): Date of Birth: ACKNOWLEDGEMENT OF HIPAA PRIVACY INFORMATION The & Center of Southern Oregon, PC s Notice of Privacy Practices contains information about the uses and disclosures

More information

Welcome to the Southeastern Urology Associates meridianemr Patient Portal

Welcome 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 information

WILMINGTON HEALTH Patient Information

WILMINGTON HEALTH Patient Information WILMINGTON HEALTH Patient Information Account No. Doctor s No. PLEASE ANSWER ALL QUESTIONS PATIENT INFORMATION NAME: LAST BIRTHDATE SS# HOME PHONE CELL PHONE EMAIL ADDRESS FIRST MIDDLE SEX M F RACE White/Caucasian

More information

Thank you, in advance, for being a partner in your care.

Thank you, in advance, for being a partner in your care. 477 Cooper Road, Suite 220 Westerville, OH 43081 614-818-0215 Your appointment with: Dr. David H. Brown Dr. Jed W. Henry Dr. Adam J. Clemens is scheduled for. Welcome to our practice. It is our desire

More information

Bay area Advanced Gastroenterology Care

Bay area Advanced Gastroenterology Care 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 information

PATIENT REGISTRATION FORM PARENTAL MEDICAL CONSENT FORM FOR A MINOR CHILD

PATIENT REGISTRATION FORM PARENTAL MEDICAL CONSENT FORM FOR A MINOR CHILD PATIENT REGISTRATION FORM PARENTAL MEDICAL CONSENT FORM FOR A MINOR CHILD General Consent for Treatment I have the legal right to consent to medical and surgical treatment because (a) I am the patient

More information

NEW PATIENT PACKET. Address: City: State: Zip: Home Phone: Cell Phone: Primary Contact: Home Phone Cell Phone. Address: Driver s License #:

NEW PATIENT PACKET. Address: City: State: Zip: Home Phone: Cell Phone: Primary Contact: Home Phone Cell Phone.  Address: Driver s License #: Patient s Name: NEW PATIENT PACKET Last Middle First Address: City: State: Zip: Home Phone: Cell Phone: Primary Contact: Home Phone Cell Phone Email Address: Driver s License #: DOB: Gender: Male Female

More information

Pediatric New Patient Intake Form

Pediatric New Patient Intake Form Name: DOB: Page 1 of 5 Pediatric New Patient Intake Form Patient Information Last Name: First Name: DOB: Home Mobile Preferred (circle) : Home / Cell Email: Gender: Primary Pediatrician: Pediatrician Address:

More information

Mobile Mammo Registration Instructions

Mobile Mammo Registration Instructions Mobile Mammo Registration Instructions 1. Call to schedule your appointment @ 239-936-4068 2. Fill out the following forms Note: All forms must be completed even if you were a previous patient on RRC Mobile

More information

CURE CARDIOVASCULAR CONSULTANTS

CURE CARDIOVASCULAR CONSULTANTS NEW PATIENT PACKET There are six pages in this packet that will help us get a clearer picture of your medical history and physical health. Please note: SIGNATURES are required on pages 2, 4, and 6. Please

More information

New Patient Intake Form

New Patient Intake Form Phone: (336) 538-0089 Fax: (336) 538-0097 Burlington, NC 27253 New Patient Intake Form Provider: Dr. Martin DeFrancesco Melody Burr Lindsey Overton Patient Name: DOB: Marital Status: Single Married Divorced

More information

James B. Duke, MD PA Orthopedic Surgery 2300 SE 17 th Street, Suite 500 Ocala, FL

James B. Duke, MD PA Orthopedic Surgery 2300 SE 17 th Street, Suite 500 Ocala, FL James B. Duke, MD PA Orthopedic Surgery 2300 SE 17 th Street, Suite 500 Ocala, FL 34471 352-867-0444 Dear Patients: Welcome to our orthopaedic office. We appreciate your confidence and will take great

More information

Adult Health History

Adult Health History Adult Health History Name: DOB: Please list medications, including: vitamins, herbs, homeopathic remedies, and nonprescription medicines on the attached medication sheet. Medical History: High blood pressure

More information

REGISTRATION FORM (Minors)

REGISTRATION FORM (Minors) LEGAL NAME REGISTRATION FORM (Minors) Social Security#: Date of Birth: Sex: M or F Nickname: Religion: Church: Race (circle one): White Black-Asian AM Indian Alaska Native Native Hawaiian Pacific Islander-Unknown

More information

Columbia Medical Practice- Pediatrics Ken Klebanow M.D. and Associates

Columbia Medical Practice- Pediatrics Ken Klebanow M.D. and Associates HOWARD COUNTY HEALTH DEPARTMENT SCHOOL-BASED WELLNESS CENTERS PROGRAM TELEMEDICINE SERVICES A partnership between the Howard County Health Department and the Howard County Public School System What is

More information

Family Care Health Centers

Family Care Health Centers Family Care Health Centers New/Established Patient Information (Please Print) Account # Date: Circle One: New Patient or Established Patient Last: First: M.I. Date of Birth: Address: City: State: Zip:

More information

PATIENT NOTICE. If you are already taking any of the above medications, your provider may want to talk to you about alternative treatments.

PATIENT NOTICE. If you are already taking any of the above medications, your provider may want to talk to you about alternative treatments. PATIENT NOTICE Our goal at is to provide quality medical care. Because of our concern for your health and well-being, there are certain types of medications we may not be able to prescribe to you. Examples

More information

St. Mary s Health Professions Academy Student Application

St. Mary s Health Professions Academy Student Application St. Mary s Health Professions Academy Student Application Tenth and eleventh grade students in tri-state area who are interested in a health care career will be considered for the St. Mary s Health Professions

More information

MAIN STREET RADIOLOGY

MAIN STREET RADIOLOGY MAIN STREET RADIOLOGY PATIENT REGISTRATION FORM **OFFICE USE ONLY** TODAY S DATE: MR#: LAST NAME: FIRST NAME: ADDRESS: APT: CITY: STATE: ZIP CODE: HOME PHONE #: ( ) - CELL PHONE#: ( ) - DATE OF BIRTH:

More information

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

PLEASE FILL OUT FORM BELOW AND THEN FAX BACK TO: ADDITIONALLY, PLEASE BRING FORM WITH YOU ON THE DAY OF YOUR SCHEDULED APPOINTMENT. PLEASE FILL OUT FORM BELOW AND THEN FAX BACK TO: 516-354-8597 ADDITIONALLY, PLEASE BRING FORM WITH YOU ON THE DAY OF YOUR SCHEDULED APPOINTMENT. THANK YOU - 1 - NEW PATIENT MEDICAL INFORMATION Steven J.

More information

Initial Child & Adolescent Questionnaire

Initial Child & Adolescent Questionnaire 7300 New LaGrange Rd. Louisville, KY 40222 502-326-9950 www.lfchiro.net Initial Child & Adolescent Questionnaire Child s Name: Mom: Dad: Child s Date of Birth: / / Address: City: ST: Zip: Phone: For appointment

More information

Meaningful Use Stage 1 Guide for 2013

Meaningful Use Stage 1 Guide for 2013 Meaningful Use Stage 1 Guide for 2013 Aprima PRM 2011 December 20, 2013 2013 Aprima Medical Software. All rights reserved. Aprima is a registered trademark of Aprima Medical Software. All other trademarks

More information

ASHBY HOUSE DIGNITY COMMONS HOUSE OF DIGNITY

ASHBY HOUSE DIGNITY COMMONS HOUSE OF DIGNITY TRANSITIONAL HOUSING PROGRAM TENANT APPLICATION FORM FOR ASHBY HOUSE DIGNITY COMMONS HOUSE OF DIGNITY OPERATION DIGNITY INC. Transitional & Permanent Housing 160 Franklin St., Suite103 Oakland, CA 94607

More information

APPOINTMENT INFORMATION SHEET

APPOINTMENT INFORMATION SHEET APPOINTMENT INFORMATION SHEET All appointments for new patients will require a one-time, refundable deposit of $50.00 to secure your appointment. You may use cash, check or credit card. The check or credit

More information

Stage 1 Meaningful Use Objectives and Measures

Stage 1 Meaningful Use Objectives and Measures Stage 1 Meaningful Use Objectives and Measures Author: Mia Evans About Technosoft Solutions: Technosoft Solutions is a healthcare technology consulting, dedicated to providing software development services

More information

Dear New Patient: Sincerely, The Scheduling Staff

Dear New Patient: Sincerely, The Scheduling Staff Dear New Patient: Welcome to Garden State Urology. The physicians in our group are board-certified, fellowship trained urologists who provide stateof-the-art care that rivals the finest academic institutions

More information

Neck & Spine Patient Demographic

Neck & Spine Patient Demographic Neck & Spine Patient Demographic o New Patient o Return Patient o Update Account #: Physician: Last Name First Name MI: Address City State Zip Home Phone o OK to Leave Msg. Work Phone o OK to Leave Msg.

More information

Fax: Do not mail the forms!

Fax: Do not mail the forms! Associates in Pediatric and Adult Urology The Morristown Medical Center Health Pavilion 333 Mount Hope Avenue Suite 250 Rockaway, NJ 07866 973-895-6636 Dear New Patient: Welcome to Associates in Pediatric

More information

We welcome you as a patient

We welcome you as a patient St. Augustine Cardiology Associates, P.A. Ferris E. George, M.D. Robert N. Signor, M.D. Billie J. Russell, PhD, ARNP-BC Susan W. Morrow, ARNP 201 Health Park Blvd., Suite 105 St Augustine, FL. 32086 904-824-1776

More information

PATIENT S NAME: LAST NAME: FIRST NAME: MI: DOB: MARRIED: SINGLE: SOCIAL SECURITY: HOME ADDRESS: APT# CITY: STATE: ZIP: CELLULAR PHONE:

PATIENT S NAME: LAST NAME: FIRST NAME: MI: DOB: MARRIED: SINGLE: SOCIAL SECURITY: HOME ADDRESS: APT# CITY: STATE: ZIP: CELLULAR PHONE: 5056 THOROUGHBRED LANE BRENTWOOD, TN 37027 TODAY S DATE: PHONE: 615-373-3337 FAX: 615-373-3782 PATIENT S NAME: DATE OF BIRTH: M F RESPONSIBLE PARTY/GUARANTOR INFORMATION LAST NAME: FIRST NAME: MI: DOB:

More information

Please 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. 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 information

Computer Provider Order Entry (CPOE)

Computer Provider Order Entry (CPOE) Computer Provider Order Entry (CPOE) Use computerized provider order entry (CPOE) for medication orders directly entered by any licensed healthcare professional who can enter orders into the medical record

More information

Facility Name: Patient Registration. Name: Address: Home: Work: Mobile: Race: Gender: Marital Status: Emergency Contact Information

Facility Name: Patient Registration. Name: Address: Home: Work: Mobile: Race: Gender: Marital Status: Emergency Contact Information Facility Date: MRN/Jacket: Patient Registration Address: Home: Work: Mobile: Email: Date of Birth: Race: Gender: Marital Status: SSN: Employer: Registered Location: Physician: Emergency Contact Information

More information

Patient Information Form

Patient Information Form Francisco J. Gomez, MD, FAHS, FAHA Tracy Posdzich, PMHNP-BC 110 Wolf Rd. Albany, NY 12205-1244 www.gomezneurology.com voice: 518-650-2090 fax: 888-698-2021 Patient Information Form Chief Complaint (reason

More information

PATIENT REGISTRATION. Street City State Zip WORK INJURY/ ACCIDENT

PATIENT REGISTRATION. Street City State Zip WORK INJURY/ ACCIDENT PATIENT REGISTRATION, Last First M.I. SEX: Male Female DOB: / _/ AGE: MARITAL STATUS: SS#: - - PHYSICIAN: ADDRESS: Street City State Zip (HOME) (WORK) TEL: - - TEL: - _- CELL: - _- EMAIL: PRIMARY INSURANCE:

More information

Date: PATIENT REGISTRATION Chart # PLEASE PRINT FILL OUT ALL AREAS PATIENT INFORMATION CHILD S NAME BIRTHDATE SSN SEX CELL PHONE# (14 YRS & OLDER)

Date: PATIENT REGISTRATION Chart # PLEASE PRINT FILL OUT ALL AREAS PATIENT INFORMATION CHILD S NAME BIRTHDATE SSN SEX CELL PHONE# (14 YRS & OLDER) PEDIATRIC ASSOCIATES OF MADISON 21 Hughes Rd., Suite 2 Madison, Alabama 35758 256-772-2037 Fax 256-772-9523 www.pedsofmadison.com Tonya T. Zbell, M.D. Robbie F. Dudley, M.D. Charlotte M. Meadows, M.D.

More information

Fulcrum Orthopaedics Patient Registration Packet

Fulcrum Orthopaedics Patient Registration Packet Fulcrum Orthopaedics Patient Registration Packet 2 Patient Information Form 8 Consent for Use and Disclosure of Information 9 Authorization for Use and Disclosure of Protected Health Information 10 Notice

More information

Sage Medical Center New Patient Forms

Sage Medical Center New Patient Forms Sage Medical Center New Patient Forms Patient Name: DOB: Providers and Suppliers of Your Medical Care: Please list all providers and suppliers of your medical care such as primary care physicians, specialty

More information

HOMELESS VETERAN REGISTRY NORTHWEST MINNESOTA

HOMELESS VETERAN REGISTRY NORTHWEST MINNESOTA STATE OF MINNESOTA MINNESOTA DEPARTMENT OF VETERANS AFFAIRS HOMELESS VETERAN REGISTRY NORTHWEST MINNESOTA TENNESSEN WARNING YOUR PRIVACY RIGHTS The State of Minnesota and its partners have committed to

More information

North Carolina Extension Master Gardener Volunteer Application Guilford County

North Carolina Extension Master Gardener Volunteer Application Guilford County North Carolina Extension Master Gardener Volunteer Application Guilford County Please return all seven (7) pages of the completed Application to: 3309 Burlington Rd, Greensboro, NC 27405 GENERAL INFORMATION

More information

Meaningful Use: Review of Changes to Objectives and Measures in Final Rule

Meaningful Use: Review of Changes to Objectives and Measures in Final Rule Meaningful Use: Review of Changes to Objectives and Measures in Final Rule The proposed rule on meaningful use established 27 objectives that participants would meet in stage 1 of the program. The final

More information

Surgical Associates of Central FL, PA 1181 Orange Avenue Winter Park, FL

Surgical Associates of Central FL, PA 1181 Orange Avenue Winter Park, FL Surgical Associates of Central FL, PA 1181 Orange Avenue Winter Park, FL 32789 407-647-1331 Name Date Email @ Please Circle One: Ethnicity: Hispanic or Latino American/White Not Hispanic or Latino Unknown

More information

Thank you for choosing Oakland Medical Center as your Patient-Centered Medical Home

Thank you for choosing Oakland Medical Center as your Patient-Centered Medical Home Thank you for choosing Oakland Medical Center as your Patient-Centered Medical Home We ask that you complete the enclosed paperwork and bring it with you at the time of your appointment. We also ask that

More information

Hale Ola Kino Maika i

Hale Ola Kino Maika i We ve teamed up to make it easier for students to access healthcare in their school! Together, we are your School-Based Health Center! Waianae High School (WHS) is proud to partner with Waianae Coast Comprehensive

More information

THE MEANING OF MEANINGFUL USE CHANGES IN THE STAGE 2 MU FINAL RULE. Angel L. Moore, MAEd, RHIA Eastern AHEC REC

THE MEANING OF MEANINGFUL USE CHANGES IN THE STAGE 2 MU FINAL RULE. Angel L. Moore, MAEd, RHIA Eastern AHEC REC THE MEANING OF MEANINGFUL USE CHANGES IN THE STAGE 2 MU FINAL RULE Angel L. Moore, MAEd, RHIA Eastern AHEC REC WE WILL BRIEFLY DISCUSS Meaningful Use (MU) Incentive Programs, Eligibility & Timelines WE

More information

To All Mission Ranch Primary Care Patients:

To All Mission Ranch Primary Care Patients: To All Mission Ranch Primary Care Patients: At Mission Ranch Primary Care we strive to provide the best possible customer service. As a part of this, we ask that you fill out this paperwork and return

More information

Please bring your ID and Medical/Dental Insurance cards to all appointments PATIENT REGISTRATION PATIENT INFORMATION. Cell Phone ( ) Employer s Name

Please bring your ID and Medical/Dental Insurance cards to all appointments PATIENT REGISTRATION PATIENT INFORMATION. Cell Phone ( ) Employer s Name Please bring your ID and Medical/Dental Insurance cards to all appointments PATIENT REGISTRATION PATIENT INFORMATION Name Last First M.I. Social Security. Home Address Street City State Zip Mailing Address

More information

Patient Registration. City, State & Zip Code Date of Birth Age. Occupation: Family Physician: Married Single Other Spouse's Name

Patient Registration. City, State & Zip Code Date of Birth Age. Occupation: Family Physician: Married Single Other Spouse's Name *SHAREDID-42* Date of Birth: Page 1 of 2 Patient Registration Account # Patient Name Home Telephone # Work Telephone # Social Security Number Cell Telephone # Address Patient Sex City, State & Zip Code

More information

2017 Adult Social Recreation Registration

2017 Adult Social Recreation Registration 2017 Adult Social Recreation Registration What is The Arc Adult Social Recreation Program? We are a membership program in which a group of people participate in various fun activities. The program is sponsored

More information

Last 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 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 information

ADMISSION FORM. Employment Status: Retired Unemployed Employed Full Time Employed Part Time

ADMISSION FORM. Employment Status: Retired Unemployed Employed Full Time Employed Part Time Patient ID Number A. PATIENT INFORMATION: First Name & Middle Initial: Home Address: ADMISSION FORM Last Name: Apartment Number: City: State: Zip: Phone: Home Cell Second Phone: Work Cell Email Address:

More information

Patient Name:,, Address: Phones:,, Home Work Cell. Primary Physician: Emergency Contact: Phone#:

Patient 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 information

REGISTERING A PATIENT

REGISTERING A PATIENT REGISTERING A PATIENT Patient Eligibility It is important for the institution staff to review all eligibility criteria and follow-up requirements. A patient failing to meet all protocol eligibility requirements

More information

Patient Information & Medical History Nurse/Doctor appointment

Patient Information & Medical History Nurse/Doctor appointment 18 William Street Bellingen NSW 2454 Phone: 6655 0000 Fax: 6655 0266 ABN 35 616 896 074 bhc@bellingenhealingcentre.com.au www.bellingenhealingcentre.com.au Patient Information & Medical History Nurse/Doctor

More information

Patient Registration Form

Patient Registration Form 908 South 10 th Street Office: 337.392.2330 Fax: 337.392.2580 West State Orthopedics and Sports Medicine Clinic, LLC Patient Registration Form Date: / / Patient Name: Birth Date: / / (last) (first) (mi)

More information

School Based Health Consent for Services Grace Community Health Center, Inc.

School Based Health Consent for Services Grace Community Health Center, Inc. School Based Health Consent for Services Grace Community Health Center, Inc. Please read carefully: In order for us to see your child in school based clinics, all pages of this form must be completed by

More information

PLASTIC SURGERY ASSOCIATES OF LEHIGH VALLEY MEDICAL HISTORY QUESTIONNAIRE (MR: )

PLASTIC SURGERY ASSOCIATES OF LEHIGH VALLEY MEDICAL HISTORY QUESTIONNAIRE (MR: ) PLASTIC SURGERY ASSOCIATES OF LEHIGH VALLEY MEDICAL HISTORY QUESTIONNAIRE DATE: (MR: ) Office Use Only PATIENT S NAME: (FIRST, MIDDLE INITIAL, LAST) DATE OF BIRTH AGE SOCIAL SECURITY # MALE/FEMALE ADDRESS

More information

Print Guardian Name (If not patient) DOB: Patients Name: (Last, First, MI): Circle One: - - / / Mailing Address: Apt. #: City: State: Zip Code:

Print Guardian Name (If not patient) DOB: Patients Name: (Last, First, MI): Circle One: - - / / Mailing Address: Apt. #: City: State: Zip Code: Patients Name: (Last, First, MI): SSN: DOB: Circle One: Male Mailing Address: Apt. #: City: State: Zip Code: Female Race: Ethnicity Primary Language: Home Phone: Preferred? Cell Phone: Preferred? Employer:

More information

Hope Academy of Public Service GENERAL STUDENT INFORMATION

Hope Academy of Public Service GENERAL STUDENT INFORMATION Hope Academy of Public Service GENERAL STUDENT INFORMATION First Name: Middle Name: Last Name: SSN: Current Grade: Birth date: Age: Gender: M or F Ethnicity (check one): Primary Race (check only one):

More information

MR #: Patient Name: Page: 1 of 4 PROGRESSIVE PHYSICAL THERAPY PATIENT DATA SHEET. May we send you text messages relating to your care with us?

MR #: Patient Name: Page: 1 of 4 PROGRESSIVE PHYSICAL THERAPY PATIENT DATA SHEET. May we send you text messages relating to your care with us? MR #: Patient Name: Page: 1 of 4 PROGRESSIVE PHYSICAL THERAPY PATIENT DATA SHEET First: MI: Last: of Birth: Age: Gender: Male Female Mailing Address: Physical Address: May we send you text messages relating

More information

Eligible Professionals (EP) Meaningful Use Final Objectives and Measures for Stage 1, 2011

Eligible Professionals (EP) Meaningful Use Final Objectives and Measures for Stage 1, 2011 Eligible Professionals (EP) Meaningful Use Final Objectives and Measures for Stage 1, 2011 1 On demand webinars are best heard through a headset or earphones (ipod for example) that can be plugged into

More information

History Form. PAST SURGICAL HISTORY Surgeries/Hospitalizations Year Complications/Problems with anesthesia

History Form. PAST SURGICAL HISTORY Surgeries/Hospitalizations Year Complications/Problems with anesthesia History Form Name: Date of Birth: Today's Date: Height: Weight: Date of Injury: Primary Care Physician: Address Who recommended this office? Address CHIEF COMPLAINT Why are you seeing the doctor today?

More information

2201 Murphy Avenue, Suite 307 Nashville, TN Phone Fax Date. Patient s Full Name

2201 Murphy Avenue, Suite 307 Nashville, TN Phone Fax Date. Patient s Full Name Patient Information 2201 Murphy Avenue, Suite 307 Nashville, TN 37203 Phone 615-401- 9454 Fax 615-873- 1934 www.robbinsplasticsurgery.com Date Patient s Full Name Last First M.I. Preferred Name (if different

More information

PATIENT REGISTRATION FORM

PATIENT REGISTRATION FORM PATIENT REGISTRATION FORM PATIENT INFORMATION Name: Date of Birth: Age: Address : Social Security #: City: Sex: Marital Status: State: Zip: Language: Pt Declines Home Phone#: Race: Pt Declines Work Phone#:

More information

Signature (Patient or Legal Guardian): Date:

Signature (Patient or Legal Guardian): Date: X-Ray Patient Information: [ ] Male [ ] Female Patient Name: Date of Birth: / / SS#: Mailing Address: City: State: Zip: Phone # s: (Home) (Work) (Cell) Referring Physician: Phone #: /Fax#: Additional Physician:

More information

PATIENT INFORMATION. ETHNICITY: (Please circle one) Hispanic or Latin, Not Hispanic or Latin, Refuse to Report

PATIENT INFORMATION. ETHNICITY: (Please circle one) Hispanic or Latin, Not Hispanic or Latin, Refuse to Report PATIENT INFORMATION NAME: DOB: AGE: ADDRESS: CITY: STATE: ZIP: HOME PHONE: CELL: WORK: *Please list your email address for the patient portal. It will not be used for any commercial communication. RACE:

More information

Emergency Contact Name: Relationship: Home #: ( ) Cell #: ( ) Alternate #: ( ) Pharmacy Information Pharmacy Name: Phone #: ( ) Location:

Emergency Contact Name: Relationship: Home #: ( ) Cell #: ( ) Alternate #: ( ) Pharmacy Information Pharmacy Name: Phone #: ( ) Location: New Patient Office Information Last Name: First Name: Initial Date of Birth: SSN # Marital Status: Single Married Divorced Widowed Address: City: State: Zip: Gender: M Parent/ Legal Guardian if Patient

More information

School-Based Health Center William Penn High School 713 E. Basin Road New Castle, DE Phone: Fax:

School-Based Health Center William Penn High School 713 E. Basin Road New Castle, DE Phone: Fax: School-Based Health Center William Penn High School 713 E. Basin Road New Castle, DE 19720 Phone: 324 5740 Fax: 324 5745 Dear Parents/Guardians: The William Penn School Based Health Center (SBHC) is a

More information

DECLARATION AND CONSENT TO TREATMENT

DECLARATION AND CONSENT TO TREATMENT 3160 Steeles Avenue East, Suite 204 Markham, ON L3R 4G9 T. 905.477.0200 F. 905.477.0028 E. info@mnhc.ca W. www.mnhc.ca DECLARATION AND CONSENT TO TREATMENT Patients Name _ Date City Province Postal Code

More information

Dear 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.

Dear 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

Meaningful Use Hello Health v7 Guide for Eligible Professionals. Stage 2

Meaningful Use Hello Health v7 Guide for Eligible Professionals. Stage 2 Meaningful Use Hello Health v7 Guide for Eligible Professionals Stage 2 Table of Contents Introduction 3 Meaningful Use 3 Terminology 4 Computerized Provider Order Entry (CPOE) for Medication, Laboratory

More information

STAGE 2 PROPOSED REQUIREMENTS FOR MEETING MEANINGFUL USE OF EHRs 1

STAGE 2 PROPOSED REQUIREMENTS FOR MEETING MEANINGFUL USE OF EHRs 1 STAGE 2 PROPOSED REQUIREMENTS FOR MEETING MEANINGFUL USE OF EHRs 1 Requirement CPOE Use CPOE for medication orders directly entered by any licensed health care professional who can enter orders into the

More information

Planned Respite Referral Application

Planned Respite Referral Application Planned Respite Referral Application White Plains, NY 10605 (914) 948-4993 or (914) 564-3749 FAX: (914) 813-4364 Dear Applicant: Thank you for your interest in Planned Respite. Planned Respite is a short-term

More information

WITHOUT YOUR WRITTEN CONSENT, WE CAN NOT SPEAK TO ANYONE REGARDING YOUR MEDICAL CARE due to privacy laws. You have the right to list anyone you

WITHOUT YOUR WRITTEN CONSENT, WE CAN NOT SPEAK TO ANYONE REGARDING YOUR MEDICAL CARE due to privacy laws. You have the right to list anyone you PATIENT REGISTRATION FORM PLEASE PRINT : Referring Physician: Primary Care: Patient s Name: Last First: M.I. Address: City: State: Zip: Home Phone: Cell: Work: Email: Preferred Contact Method Race: Ethnicity:

More information

School-Based Health Center Wilmington Charter/Cab Calloway High Schools 100 N. Dupont Road Wilmington, DE Phone: Fax:

School-Based Health Center Wilmington Charter/Cab Calloway High Schools 100 N. Dupont Road Wilmington, DE Phone: Fax: Dear Parents/Guardians: School-Based Health Center Wilmington Charter/Cab Calloway High Schools 100 N. Dupont Road Wilmington, DE 19807 Phone: 651-2100 Fax: 651-2111 The Wilmington Charter/Cab Calloway

More information

2018 Geriatric Oncology: Educating Nurses to Improve Quality Care

2018 Geriatric Oncology: Educating Nurses to Improve Quality Care Institution/Program Information Thank you for your interest in participating in the NIH funded program, Geriatric Oncology: Educating Nurses to Improve Quality Care. We request that each institution interested

More information

School Manual Statewide Vision Program School Year

School Manual Statewide Vision Program School Year 601 Southwest 8 th Avenue Phone: (305) 856-9830 Fax: (305) 856-9840 School Manual 2011-2012 School Year Approved by: Ed Largespada, CFO Signature: Date: Phone: (305) 856-9830 / 1(888) 996-9847 Fax: (305)

More information

INSURANCE INFORMATION

INSURANCE INFORMATION 2014 575 Hill Country Dr. Ste 202 Kerrville, TX 78028 (830)258-6237 Office (830)315-1366 Fax Patient Name (last, first, MI) of Birth Social Security Number Mailing Address Home Telephone Work Telephone

More information

King County City Health Profile Seattle

King County City Health Profile Seattle King County City Health Profile Seattle Shoreline Kenmore/LFP Bothell/Woodinville NW Seattle North Seattle Kirkland North Ballard Fremont/Greenlake NE Seattle Kirkland Redmond QA/Magnolia Capitol Hill/E.lake

More information

R. B. KO L A C H A L A M M. D. GENERAL SURGERY

R. B. KO L A C H A L A M M. D. GENERAL SURGERY GENERAL SURGERY Patient Information (Please Print and Circle or check the appropriate response) Patient s Name: DOB: _ Address: City: _ Zip: Home Phone: Cell: Work:_ Email Address: Patient s SSN: Male

More information

Appendix 4 CMS Stage 1 Meaningful Use Requirements Summary Tables 4-1 APPENDIX 4 CMS STAGE 1 MEANINGFUL USE REQUIREMENTS SUMMARY

Appendix 4 CMS Stage 1 Meaningful Use Requirements Summary Tables 4-1 APPENDIX 4 CMS STAGE 1 MEANINGFUL USE REQUIREMENTS SUMMARY Appendix 4 CMS Stage 1 Meaningful Use Requirements Summary Tables 4-1 APPENDIX 4 CMS STAGE 1 MEANINGFUL USE REQUIREMENTS SUMMARY 1. Use CPOE (computerized physician order entry) for medication orders directly

More information