How were you referred to us? PhysicianPhone BookWebsiteFriend Other:
First Name:
Middle Name:
Last Name:
Date of Birth:
Age:
Gender: MaleFemale
Social Security No.:
Occupation: Full TimePart TimeFull Time StudentDisabilityHomemakerUnemployedRetired
Employer:
Employer Phone No.:
Marital Status: SingleMarriedDivorcedWidowed
Other:
Home Phone No.: PrimarySecondary
Cell Phone No.: PrimarySecondary
Email Address:
May we email you? YesNo
Text Appointment Reminders? YesNo
Address:
City, State: Zip Code:
If your billing address is the same as mailing address check yes, if no fill out the form below: YesNo
Billing Address:
Is this a Skilled Nursing Facility? YesNo If yes, Name of Facility:
Have you received a same/similar device? YesNo If yes, from whom and when?
Referring Physician:
Primary Care Physician:
(Present your insurance card to the receptionist.)
Name of Primary Insurance:
Subscriber’s Name:
Subscriber’s Date of Birth:
Patient’s relationship to subscriber:
Policy No.:
Group No.:
Name of Secondary Insurance:
Is this the result of a work-related injury? YesNo If yes, please provide your claim number:
Date of Injury:
Employer at time of injury:
Claims Adjustor’s Name:
Claims Adjustor’s Phone No.:
Name of local friend or relative (not living at same address):
Relationship to patient:
Home Phone No.:
Work Phone No.:
Printed Name:
Private Insurance Authorization for Assignment of Benefits and Information Release
I authorize payment of medical benefits to Advanced P&O of the Pacific for any services furnished to me (or to the patient for whom I am the responsible party) by the Practitioners. I understand I am financially responsible for any amount not covered by my contract. I authorize you to release to my insurance company information concerning health care, advice, treatment, or supplies provided to me. I understand I am financially responsible for services provided to me if I am uninsured. Initial
Medicare Lifetime Signature on File
I request payment of authorized Medicare benefits be made on my behalf to Advanced P&O of the Pacific for any services provided me by the Practitioners. I authorize any holder of medical information about me to release to the Heath Care Financing Administration and its agents any information needed to determine these benefits or benefits payable for related services. Initial
Friends and Family Release
The name(s) listed below are family members or friends to whom I wish to grant access to my health care information. I will rely on the professional judgment of my provider and his/her designee to share such information, as they deem necessary. I understand information is limited to verbal discussions and that no paper copies of my patient information will be provided without my signature to release any “sensitive” information. Initial
The consent will be considered valid until such time that I revoke it. I reserve the right to revoke it at any time. It will be my responsibility to keep this information up to date, as I recognize relationships and friendships change over time.
Relationship 1
Name:
Relationship:
Phone:
Relationship 2
Acknowledgement of Notice of Privacy
I certify I have received a copy of the Advanced P&O of the Pacific Privacy Policy. The policy describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment of my bills, or in the performance of Advanced P&O of the Pacific. The policy also describes my rights and Advanced P&O of the Pacific duties with respect to my protected health information. Advanced P&O of the Pacific reserves the right to change the privacy policy and I may obtain a revised policy by calling the office and requesting a revised copy be sent to me in the mail or by asking for one at the time of my next appointment.
May we call you at home? YesNo
May we leave a voice message? YesNo
Patient Signature:
Date:
