2008 PATIENT UPDATE FORM

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2008 PATIENT UPDATE FORM Powered By Docstoc
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                                       PATIENT INFORMATION

                            (Please print all information clearly and accurately.)

First Name: _______________________         MI: _____     Last Name: _______________________________

Date of Birth: _____/_____/_____      Gender (circle one): M F Social Security #: ______-_____-______

Marital Status (circle one): Single    Married    Divorced    Other (please indicate): ____________________

E-mail Address: _____________________________________             Home Phone: (_______) ______________

Cell Phone: (_______) ______________       Work Phone: (_______) ______________, extension _________

Street Address: ____________________________________________________                  Apt. / Unit #: _________

City: _________________________________________              State: __________       Zip: ___________________

                                      INSURANCE INFORMATION

                                      (A copy of all cards is mandatory.)

PRIMARY INSURANCE CARRIER: ______________________________________________________________

   Insurance ID: ____________________________________             Group ID: _________________________

   Claim Address: ____________________________ City: ______________ State: _____ Zip: _______

   Subscriber Name (if other than patient): _____________________ Date of Birth: ____/_____/______

   Social Security #: ______-_____-______        Relationship to Patient: _____________________________

SECONDARY INSURANCE CARRIER: ____________________________________________________________

   Insurance ID: ____________________________________             Group ID: _________________________

   Claim Address: ____________________________ City: ______________ State: _____ Zip: _______

   Subscriber Name (if other than patient): _____________________ Date of Birth: ____/_____/______

   Social Security #: ______-_____-______        Relationship to Patient: _____________________________

TERTIARY INSURANCE CARRIER: _____________________________________________________________

   Insurance ID: ____________________________________             Group ID: _________________________

   Claim Address: ____________________________ City: ______________ State: _____ Zip: _______

   Subscriber Name (if other than patient): _____________________ Date of Birth: ____/_____/______

   Social Security #: ______-_____-______        Relationship to Patient: ____________________________
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Is this visit due to a workplace injury, car accident, or disability claim?     YES      NO (please circle one)

                    **If you answered yes, please ask for the appropriate insurance form.**


                                         EMERGENCY CONTACT

Who may we contact in case of an emergency? ___________________________________________________

Relationship to Patient: _________________       Phone #: 1 (_____) ____________ 2. (_____)____________


                                             OFFICE POLICIES

Missed Appointments: We require reasonable notice for cancellation of appointments. For appointments
scheduled for Tuesday-Friday, please inform us at least 24 hours prior to your appointment if you need to
cancel. For Monday appointments, we must be notified no later then 10 a.m. on Friday morning of the
previous week. Ultrasound appointments require 72 hours cancellation notice.

Please be aware that there is a charge for missed appointments (this includes “no-shows” and late
cancellations). This fee will need to be paid before scheduling another appointment.

       Missed Appointment Charges:
       Follow-ups / Sick Visits = $25
       Physical Exams / Pre-operative Exams / Well Woman Exams = $50
       Ultrasounds (echo, carotid, AAA, etc) = $75 per test

Financial: If you are covered by an insurance plan with which we participate, we will submit all claims
directly to your insurance company. Any required copayments must be made at the time of service. Any claims
not covered by your insurance, or that have not been paid after 3 months, are your responsibility. For those
insurance carriers with which we do not participate, payment must be made at the time of service. All
outstanding patient balances need to be paid at the time of the appointment. Unpaid patient balances of 30 days
or more are subject to a $10 late fee per month. After 90 days, the account will be sent to collections, and this
will terminate the relationship with our practice.

Patient Statement: I have read and understand the above policies. I authorize payment of medical benefits to
the practice of Dr. Scott Maron, Dr. Anisha Rodrigues, and Dr. Claire Grigaux for professional services
rendered. I authorize release of medical information necessary to process medical claims. I have read and
signed a patient record of disclosure (HIPAA) form and a Medicare Advanced Beneficiary Notice form (if
applicable). If the insurance information I have supplied is inaccurate or invalid, I assume full financial
responsibility. I understand that professional services are rendered to the patient, and that the patient is
responsible for charges incurred. I understand that I am financially responsible for the charges not covered by
my insurance company. I understand that knowledge of in-network or out-of-network status ultimately resides
with the patient. I understand that the provider does not accept responsibility for collecting insurance claims or
for negotiating a settlement of disputed claims later then 3 months from when services are rendered.


NAME (please print): ______________________________________________________________________

SIGNATURE: ____________________________________________                    DATE: ______________________

				
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