Patient Information

Patient Information

Please print clearly and complete all information requested. This will ensure that your claim is being processed efficiently. Thank you!

Patient Name _________________________________ DOB ___________ Age ______

Mailing Address ________________________ City__________ State ____ Zip_______

Home # __________________ Work # __________________ Cell # _______________

Occupation ___________________________ Employer _________________________

Marital Status: M S D W Sex: M F

Social Security # __________________________ Drivers License # ________________

In case of emergency, please contact _______________________ Phone _____________

How did you hear about us? _________________________________________________

Instructions for leaving messages or giving medical information:

May we speak to:

Your Spouse	____ Yes	____ No	____ Initials
Your Parent / Child	____ Yes	____ No	____ Initials
Speak only to me	____ Yes	____ No	____ Initials

May we leave a message on:

Answering Machine	____ Yes	____ No	____ Initials
Voicemail	____ Yes	____ No	____ Initials

If there is anyone else you authorize us to give medical information to, please specify:

______________________________________________________________________

I have received the Notice of Privacy Practices and I have been provided an opportunity to review it.

Name ________________________ Signature _______________________________

Date _________________________

Health Questionnaire

Please Print

Date of visit: ______________

Current Concerns: ________________________________________________________

Hospital Admissions (Indicate the year you were admitted to the hospital and the reason. Do not include normal pregnancies.)

Year / Illness or Operation __________________________________________________

Medications (List all medications you are currently taking. Include over the counter Rx as well.)

Name / Strength / How Often _______________________________________________

Drug Allergies___________________________________________________________

Medical History

Main Problems: 1.________________ 2. ____________________ 3.________________

Medical conditions in your family: __________________________________________

______________________________________________________________________

For Female patients only:

Date of last pap _________________

Date of last mammogram ________________

Number of pregnancies _________________

Number of miscarriages ________________

Birth control method__________________

Menstrual history/ Regular ___ Irregular___

Do you have advanced directives? YES NO

If yes, where are they kept? _____________________________________________________
Insurance Information

Primary Carrier _______________________________ Phone # __________________

Carrier’s Address ________________________________________________________

Insured (Policy holder) ______________________________ DOB _________________

Relationship to Patient ____________________________________________________

Insurance ID# ___________________________________ Effective Date ____________

Have you met your annual deductible? ___YES ___ NO

Secondary Carrier _______________________________ Phone # ________________

Carrier’s Address ________________________________________________________

Insured (Policy holder) ______________________________ DOB _________________

Relationship to Patient ____________________________________________________

Insurance ID# ___________________________________ Effective Date ____________

Please present your Medicare or insurance card to the receptionist for photo duplication.

Payment for all professional services is expected at the time services are rendered, unless alternative arrangements have been made in advance. All deductibles and co-payments must be paid at the time of the office visit.

Services provided for a minor are the responsibility of the accompanying adult, regardless of custodial status. I understand it is the policy of this office to report any delinquent balances to the credit bureau. I authorize the release of any medical information necessary to process insurance claims and authorize payment of medical benefits to the party, which accepts assignment for the services rendered.

I have completed this form fully, and I certify that I am the patient or the general agent or legal guardian of the patient duly authorized to furnish the information requested. I understand that I am fully responsible for payment of all services performed at the time they are rendered, with exceptions only as listed above.

Patient or Guardian Signature _____________________________________________

Date __________________________________

Celina Medical Clinic Financial Policy

Due to the increase in high deductibles, co-insurance portions and co-payments, and due to the increase in insurance companies pending claims and withholding payments, it is necessary for our office to enact the following financial policies effective 5/21/2007. Please feel free to ask for clarification if necessary. We apologize for any inconvenience.

We ask for your insurance information with your first appointment, and we make every effort to verify your coverage and benefits. While we do our best to verify that our doctor is contracted and in-network with your insurance plan, it is ultimately your responsibility to ensure that this is the case. We call your insurance company and ask for specific benefits for procedures that are common in our family practice. Based upon the information provided to us by your insurance company, we will expect payment according to the benefits quoted. Upon checkout, we will expect payment of any deductible, co-payment or co-insurance based on the services rendered. We will then file your insurance claim with your insurance company for that visit. When they process your claim, they will mail both you and us an Explanation of Benefits (EOB). When we receive the EOB, we will adjust any contracted discounts off of your account for that visit. We will also post any payments received from the insurance company to your account for that visit. If there is a remaining balance due on your account for that visit, we will send you a statement in the mail. Payment for any outstanding balance due on that visit is due and payable upon receipt. Any outstanding balances from prior visits must be paid before your next appointment. If you are unable to pay your portion of the medical bill at that time, please ask to speak to our billing representative to make prior arrangements.

Many insurance plans have a requirement that patients must provide additional information to them before they will pay your claim. When this is the case, your insurance company will inform us that they have “pended” your claim for additional information. If this happens, the full balance due on your visit becomes your responsibility to pay. Once an insurance company pends a claim, there is nothing that our office can do to get the claim paid; it is completely up to the patient to contact their insurance company, provide the needed information, and ensure that the insurance company pays the claim within thirty days. Additionally, if your insurance plan, group number or policy number changes, you must notify us at the time of service. Failure to provide us with the current valid insurance information will result in the entire balance becoming your responsibility. This is because health care providers only have a certain amount of time in which to file your insurance claim; this timely filing deadline varies from insurance company to insurance company.

It is important to remember that your insurance policy is a contract between you and the insurance company. We will do everything possible to assist you in getting your claim paid; however, all charges incurred for your medical care are your sole financial responsibility. Medical insurance is like a “credit card with discounts”: by having insurance coverage and fulfilling all of your insurance plan policy provisions, you are not required to pay our full charges prior to service.

Your co-payment, deductible, or co-insurance and any past balances from previous visits must be paid at checkout for services rendered at that visit. If you are unable to pay your portion at that time, we ask that you either reschedule your appointment or make prior financial arrangements with our billing representative.

I,______________________________, do hereby affirm that I have read and understand the above financial policies. I understand that I am financially responsible for all medical fees incurred during my treatment, regardless of insurance coverage or benefits.

______________________________ ___________________________ ___________

(print name) (signature of Patient/Guardian) (date)