ATLANTA INTERNATIONAL PHYSICAL THERAPY, INC.
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1 .Specwtlfczlkuj Ut Pedlfltric. physical, occ.upflt«>ithl, Speech Therapy sen/tees PATIENT INFORMATION Patient Name (Nombre del paciente] Date of Birth (Fecha de nacimiento] Address (Direccion] City [Cuidad] State (Estado] '.. Zip Code (Codigo Postal] Insurance Carrier (Seauro de Saludl. Medicaid Peachcare Private insurance Peachstate Amerigroup Wellcare Medicaid Number (Numero de Medicaid] Parents and pediatrician information [Information de IPS padres vpediatra] Full mother's name (Nombre de la rnadre] Phone number [Telefono] Mobile [Celular]. Full father's name (Nombre del padre] Phone number (Telefono] Mobile (Celular]. Pediatrician name [Nombre del pediatraj Address (Direccion] City [Cuidad] State (Estado] Zip Code (Codigo Postal]. Phone (Telefono] Fax I authorize payment of medical benefits to undersigned physician or supplier for services provided in this office. [Yo autorizo elpago de beneficios medicos al doctor o compania por los servicios provefdos en este local). Signature [Firma] Date (FechaJ
![. Zip Code (Codigo Postal] Insurance Carrier (Seauro de Saludl.](/docs-images/49/17530856/images/page_1.jpg "Medicaid Peachcare Private insurance Peachstate Amerigroup Wellcare Medicaid Number (Numero de Medicaid] Parents and pediatrician information [Information de IPS padres vpediatra] Full mother's name")
2 spec.lallzlv(q in- periiatnc Physical, occupational, g speech Therapy services Norcross, GA _ Fax: ADULT PATIENT INFORMATION Patient Name (Nombre del Paciente]. Date of Birth [Fecha de Nacimiento] _ Address (Direccion) City (Cuidad) State (Estado) Zip (Codigo Postal). Home Phone (Telefono) Mobile (Celular) Insurance carrier [Seguro Medico):. Member ID# with Insurer (Numero de Identification):. Doctor Information Referring Doctor (Nombre de su Doctor) Address (Direccion) City (Cuidad) State (Estado) Zip (Codigo Postal). Phone [Telefono) Fax I authorize payment of medical benefits to undersigned physician or supplier for the services provided in this office. [Yo autorizo el pago de beneficios medicos al doctor o companfa con la cual en este rnomento firmo por los servicios en este local). Signature (Firma) Date (Fecha).
3 SpeciflUzu/wg LI^ Pediatric. Physical, octu-patioi/uil, a; speech Therapy sen/ices Appointment Cancellation Policies 1. If you know in advance that you will not be able to attend to your appointment please call us twenty four hours in advance so we may book another patient in that time slot. 2. If you or your child is ill the day of the appointment and are unable to attend please call us that morning and leave a message if no one answers. 3. If these policies are not adhered to we will charge a fee of $25 for the missed appointment. 4. If you consistently cancel your appointments with us, as stated above, we reserve the right to discharge you or your child from our practice for non compliance. Patient's name Signature of patient/guardian
4 , -Speaiatfekig w*. T>edt«tyift Pky steal, oeocpottataly speech Tfoerapw services 3985 Steve Reynolds Blvd. Suite G, Teh Morcross,CA Fax: NORMAS PARA CANCELAR TERAPIAS LjUsted Debera UamarCpn Al Menos48 Horas (2 Dias) Previo A Su cita Reservada. 2. ptras Citas Medicas o Dentales No Son Excusa Para Cancelar Las terapias De Su Hijo (A), Sabiendo con Anticipacion Su O'ta De La Terapia, usted Siempre Puede Solicitar Otros Dias Para i Sus Cftas Medicas. :; 3. Frecuentes Cancelaciones Por Cualquier razon Pueden Y Seran Causa De Canceiacion De Sus Terapias. 4. Problemas De transporte tampoco Son Causa de Canceladon Justificada. Usted Tiene Tiempo Suficiente Para Planear Su Transporte Previo A Su Cita.,,' 5. Si Usted Cancela Por Enfermedad De Su Hijo (A) Debera Presentar Alguna Prueba Que El Nine Fue Visto Por Su Pediatra, Asistio A La sala De Emergencias U otras Pruebas Aceptables Incluyen Prescription Medica, Carta De La Oficina Medica. 6. Al No Cumplir Con Estas Normas Basicas, Esta Oficina Penalizar A los Padres Por Un Total De U$25.00 (Veintitinco Dolares). 7. El Nino Podra Comenzar Con Sus Terapias Nuevamente Despues De La Canceiacion De La Malta, NoHay Excepdones. Nombre De padre o tutor Firma/Fecha
5 spe&lfluzwig ut vedlatrlc. Physical, 0c.cwf>«tk>i/u?l, g speech TVierapLj sen/tees Consent for Treatment I consent to the necessary treatment of (patient's name) Atlanta International Physical Therapy Inc. by Assignment of Benefits If I am entitled to benefits under Medicaid, Medicare, or any other insurance policy for services provided to me by Atlanta International Physical Therapy PT Inc. I assign transfer of and convey the benefits payable for services rendered. I authorize payment of benefits directly to Atlanta International Physical Therapy PT Inc applied to my bill. I am responsible for and agree to pay for charges not paid under this assignment including any insurance amount and deductibles. Patient Patient/Parent Signature Date Consent to the release of information I authorize the release of information to Atlanta International Physical Therapy, Inc. I also authorize Atlanta International Physical Therapy Inc. to release information to my referring physician and my insurance company for purposes of continued care or treatment and/or to any insurance company, service coordinator, or any other person financially responsible for my treatment for all purposes related to a claim for payment and/or for approval of services Guarantor/Patient/Parent Signature Relationship to patient Date Witness
6 spetializifv^ tw- Perfifltrie Physical, o&au.patw>i^l, g speech Therapy -Services 3985 Steve Reynolds'. Blvd. Suite G Tel: Summary of Notice of Privacy Practices Our legal duty; We have the duty to protect the confidentiality of medical information. The notice also describes your legal rights and our obligation regarding the disclosure of your medical information. Parties followine the notices: The notice will be followed by Atlanta International P.T. together with its health care providers and staff. How we mav use and disclosure medical information about you: We may use or disclose identifiable health information about you for many reasons including: Treament Payment Healthcare operations As required by law Appointment reminders Research Health oversight activities Lawsuits and disputes Law enforcement authorities To military command authorities Public health risk Auditing Your privacy rights: You have the following rights with respect to your health information: The right to request confidential communications and alternative notes of communication with you. Request restrictions or certain uses of your health information. Inspect and copy certain medical information that we maintain above you. Request an amendment of your health information. Changes to the notice; We reserve the right to change the notice. We will post any revised notice in the' office of AIPT, Inc. Complaints: If you believe your rights have been violated you may file a written complaint of AIPT, Inc. with the privacy officer of the US Department of Health and Human Services. Print name of client or parent/guardian Signature of client or parent/guardian
7 aaalpt I\V. ATLANTA INTERNATIONAL PHYSICAL THERAPY, INC. spec-la ILZLI/U;} in Pedlatric PhystGnU oc-cupatioi'ual,, g speech Therapy sen/ices AUTHORIZATION FOR THE DISCLOSING OF MEDICAL INFORMATION I hereby request and authorize ATLANTA INTERNATIONAL PHYSICAL THERAPY, INC 3985 STEVE REYNOLDS BLVD, SUITE G NORCROSS, GA To use and disclose the protected health information described below to I authorize the release of my complete health record (including permanent medical records/information to identify diagnosis and potential need for therapy services for the purpose of planning and providing essential and necessary). This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct. I understand that the Federal Privacy Rule (HIPPA) does not protect the privacy of information if re-disclosed and therefore request that all information obtained from the person or agency be held strictly confidential and not be further released by the upon provision of this authorization. I intent this document to be valid and remain in effect for the period necessary to complete all transaction on matters related to services provided to me. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. I understand that rny treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and my no longer be protected by federal or state law. Patient's name Signature of patient/parent/guardia» Date
DAMAR MEDICAL CENTER, INC
PATIENT INFORMATION TODAY S DATE: / / (INFORMACION DEL PACIENTE) MES/DIA /AÑO: / / PATIENT S NAME: NOMBRE Y APELLIDO: D.O.B.: / / FECHA DE NACIMIENTO / / ADDRESS: CITY: ZIP CODE DIRECCION CIUDAD: CODIGO
PATIENT'S INFORMATION REGISTRATION SHEET / INFORMACION DEL PACIENTE
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PATIENT INFORMATION. Today s Date. I do not currently carry insurance (initial) Patient s Last Name: Patient s First Name: MEDICAL INSURANCE
PATIENT INFORMATION Please present a Photo ID and ALL insurance cards to receptionist. If items are not presented, full payment will be due at time of service. Please know ALL Co-Pays are due at time of
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7887 North Kendall Drive Suite 210 Miami, Florida 33156 305.598.1555 office 305.598.1155 fax www.vascularandspine.com Patient Information NAME SOCIAL SECURITY # (NOMBRE) LAST/APELLIDO FIRST/PRIMER INITIAL
PATIENT INFORMATION PATIENT NAME: BIRTHDATE: / / AGE: SOCIAL SECURITY # MARITAL STATUS: ( ) S ( ) M ( ) W ( ) D HOME TELEPHONE # CELLULAR # RELIGION:
NEW PATIENT INFORMATION PRIMARY CARE DOCTOR: PCP # FAX # PATIENT NAME: BIRTHDATE: / / AGE: SOCIAL SECURITY # MARITAL STATUS: ( ) S ( ) M ( ) W ( ) D HOME TELEPHONE # _ CELLULAR # RELIGION: STREET ADDRESS:
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Dear Parents: Welcome and thank you for choosing Coastal Pediatrics! We appreciate the opportunity to provide your child with the highest quality
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Registration Information Authorization form: Last First Middle Address: City: State: Zip: DOB: / / - - Home # ( ) - - Cell # ( ) - - Email Address: Alternate Contact Information Phone Number Relationship
Notice of Privacy Practices. Human Resources Division Employees Benefits Section
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SOUTHLAKE DERMATOLOGY 1170 N. Carroll Ave. Southlake, TX 76092 www.southlakedermatology.com Main 817-251-6500 Fax 817-442-0550
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. EFFECTIVE September 15, 2014 This Notice of
ACE PHYSICAL THERAPY & SPORTS MEDICINE INSTITUTE PATIENT REGISTRATION
ACE PHYSICAL THERAPY & SPORTS MEDICINE INSTITUTE PATIENT REGISTRATION ALEXANDRIA FAIRFAX FALLS CHURCH LEESBURG HERNDON TYSONS CORNER PATIENT INFORMATION (Please Print Clearly) Name Last First Middle of
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TOO Patient Information Name of Minor/Child Last Name First Name Middle Name Nickname Sex: Male Female Date of Birth Social Security Mailing Address Street City State Zip Contact Number Home Mother Mobile