Patient Name. DOB: Patient Signature: Date: Provider Signature: Date:
Patient Name. Date: Patient Signature: (or legal representative or guardian, if applicable) Jinnah Internal Medicine, LLC By: Xxxxxxx Xxxxxx, M.D., Member Xxxxxxx Xxxxxx, M.D, Personally APPENDIX 1: Medicare Patient Acknowledgements Member is a Medicare Part B beneficiary seeking services covered under Medicare Part B pursuant to Section 4507 of the Balanced Budget Act of 1997. T h e Practice has informed Member or his/her legal representative that Dr. Jinnah and the Practice have opted out of the Medicare program. Note, Dr. Jinnah has never been excluded from participating in Medicare Part B under [1128] 1128, [1156] 1156, or [1892] 1892 of the Social Security Act; he simply has elected to opt out as a provider in the program. Member or his/her legal representative agrees, understands and expressly acknowledges the following (initial each): Member or legal representative accepts full responsibility for payment of the Practice’s membership fees. Member or legal representative understands that Medicare limits do not apply to what the Practice may charge for the Services. Member or legal representative agrees not to submit a claim to Medicare or to ask the Practice to submit a claim to Medicare. Member or legal representative understands that Medicare payment will not be made for any of the Services furnished by Dr. Jinnah that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted. Member or legal representative enters into this contract with the knowledge that he/she has the right to obtain Medicare-covered items and services from practitioners who have not opted out of Medicare, and member is not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other practitioners who have not opted out. Member or legal representative understands that Medi-Gap plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare. Member or legal representative acknowledges that they are not currently experiencing an emergency or urgent health care situation. Member or legal representative acknowledges that a copy of this contract has been made available to him/her.
Patient Name. Diagnosis: Admission Dates: Length of Stay: Patient – age 57 years Severe subarachnoid haemorrhage with hydrocephalus 2.9.09 – 1.4.2010 7 months (initial 24 weeks with extension 10 weeks) Discharge destination: Home
Examples of Patient Name in a sentence
Patient Name Enter last name, first name and middle initial as shown on the ID card.2. Participant MO HealthNet ID NumberEnter the 8-digit MO HealthNet ID number exactly as it appears on the participant’s ID card or letter of eligibility.
Example: Patient Module includes Patient Name, Patient ID, Patient Birth Date, and Patient Sex.
Email Address: Updated April 2021 – 45 CFR 164.520(c)(2)(ii) Designation of a Personal Representative Form Patient Name: Date of Birth: A patient may designate a personal representative in writing.
Patient Name (please print) Signature of Patient (if Patient is 12 or older) Date Signature of Representative (and relationship to Patient) Date Signature of Representative (and relationship to Patient) Date I understand that I am financially responsible to Therapist for all charges, including unpaid charges by my insurance company or any other third-party payor.
Patient Name (please print) Signature of Patient (or authorized representative) Date I understand that I am financially responsible to Therapist for all charges, including unpaid charges by my insurance company or any other third-party payor.
More Definitions of Patient Name
Patient Name. Address: City: State: Zip: Home Phone: Employer: Work Phone: Social Security #: Birth Date: Sex: M F (circle one) Primary Insurance Company: Group #: Address: Phone #: Subscriber Name: Co-Pay Amount: Secondary Insurance Company: Group #: Address: Phone #: Subscriber Name: Co-Pay Amount: Physician: Phone #: Address: City: State: Zip: Responsible Party: Relationship: Address: City: State: Zip: Home Phone: Work Phone:
Patient Name. Cardholder Name: Card Type: Card Number: Expiration Number: Security Code: Opt into paper billing statement: Opt out of paper billing statement: Billing Address: Patient/Guardian Consent: I give my consent to allow CorsoCare Pharmacy to charge the above checking account on a monthly basis for any prescriptions that are ordered on my behalf. Signature Date PHARMACY XxxxxXxxxXxxxxxxx.xxx | 000-000-0000 Fax: 000-000-0000 | 00000 Xxxxx Xxxx, Eastpointe, MI 48021 Notice of Privacy Agreement This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. CorsoCare Pharmacy, LLC and its affiliated entities (collectively “CorsoCare Pharmacy, LLC”) use health inform at ion about you for treatment, to obtain payment for treatment, to evaluate the quality of care you receive, and for other administrative and operational purposes. Your health information is contained in a medical record that is the physical property and responsibility of CorsoCare Pharmacy, LLC.
Patient Name. DOB: Patient Signature: Date: Please mail or fax this form to: The University of Scranton Student Health Services 000 Xxxxxx Xxxxxx Scranton, PA 18510 Phone: 000-000-0000
Patient Name. Patient CHI: I have read the Atomoxetine Shared Care Agreement. Please circle a response
Patient Name. DOB: Address: Social Security#: You Should Know the Following • Psychotherapy evaluation and treatment work best when you and your doctor work cooperatively. • During the course of your evaluation/treatment, you may discuss things that will be upsetting but necessary to help you resolve your psychological difficulties. • What you and your doctor discuss and all records will be held in the strictest confidence. Information can only be released with your written consent, except where stated and/or federal law directs otherwise. • State law requires that your doctor report all cases of abuse or neglect of minors and, in some states, abuse of vulnerable adults as well. • Your doctor has a legal duty to take action and break confidentiality if you are a danger to yourself or others. • Please ask your doctor any questions you may have about your psychological services. The policies stated below help us provide psychotherapeutic services to you in the most effective way.
Patient Name. Date: Patient Signature: (or legal representative or guardian, if applicable) Jinnah Internal Medicine, LLC By: Xxxxxxx Xxxxxx, M.D., Member Xxxxxxx Xxxxxx, M.D, Personally APPENDIX 1: Periodic & Enrollment Fees and Services This agreement is for the ongoing primary care services described below. It is not health insurance. You may need additional care provided through specialists, hospitals, ERs, surgery centers, and/or urgent care centers. Those facilities and services are outside the scope of this agreement. You may also need tests, scans, therapies and other diagnostics or care that are not covered by this agreement. You will be responsible for paying for these to the extent they are not covered by separate insurance You have obtained. Fee Schedule: Enrollment Fee – You pay a non-refundable $150 fee to enroll unless You have seen Dr. Jinnah for direct care during the 12 month period prior to Your initial enrollment. If You discontinue Your membership for any reason, and later request to re-enroll we may decline re- enrollment. If we welcome You back, You will be required to pay a new enrollment fee. Monthly Membership Fee – The monthly membership fee is for the ongoing primary care Services we offer. We prefer that You schedule visits more than 24 hours in advance when possible. And note, we do not provide walk-in urgent care services. Monthly periodic fees are: ● $50 per month for patients 17 years of age to 44 years of age. ● $90 per month for patients ages 45 through 64. ● $130 per month for patients 65 years of age and older. Bonus! If you prepay for a 12 month period You receive a one-month discount! Summary of What You Can Expect From Your Membership: Ongoing Primary Care and In-Office Procedures. There are no fees for office visits. Available in- office procedures are included for no additional fee. See the List of Services that follows. Pathology. Pathology studies such as biopsies and pap smears will be ordered at Your cost, always in the most economical manner possible. Surgery and Specialist Referrals and Consults. Outside consults will be available at Your cost, requested only in consultation with You, and generally arranged as quickly as possible and in the most economical manner available.