Hover Drop Down Menu HTML by Css3Menu.com

Information Required for New Patients

PATIENT INFORMATION

     
Name of Patient   
Date of Birth    
Social Security Number   
     
Patient lives in   Private Home
Facility
Name of Facility  
     
Address where Patient Resides  
Unit #  
City  
ZIP  
     
Telephone where patient resides  
Cell  
     
Facility Contact Name  
Facility Contact Phone    
Facility Fax #  
     
Does Patient Have a Medical Power of Attorney (MPOA)   Yes
No
    (If yes, copy of POA paperwork is required)
     
POA or Primary Contact Name  
POA or Primary Contact Phone Number  
     
Is Patient on Hospice?     Yes
No
Name of Hospice  
Term Date  
     
Has Patient applied or in the process of applying for AHCCCS   Yes
No
If Yes, what month did the process begin  
     
Current/Preferred Pharmacy Name  
Pharmacy Phone  
     

 

GUARANTOR INFORMATION

(Person responsible for payment if not patient)

     
Bill To Name  
Bill To Address  
Unit #  
City  
Zip Code  
Bill To Phone- Primary    
Bill To Phone- Secondary    
     
     

 

INSURANCE INFORMATION

(Please Fax Copies of Insurance Cards)

     
Medicare ID #
(Including Alpha Letter)  
 
REQUIRED FOR ALL PATIENTS
     
     
Case Manager
(if applicable) 
   
Name  
Phone  
     
Primary Insurance Company
Address  
Phone  
Policy ID #  
    Enter Information.  Do not write see attached
     
Additional Insurance Company
Address  
Phone  
Policy ID #  
    Enter Information.  Do not write see attached
     

 

ASSIGNMENT OF BENEFITS

     

I hereby authorize my insurance company to make direct payments to Geriatric Solutions.

I understand that I am ultimately responsible for my bill.

I am aware that Medicare does not pay for preventative medicine, routine screening tests, or routine physician examinations.  I also understand that I will be responsible for the deductible and co-insurance amount.

     
Type Insured/Policyholder Name  
Date  
     

 

PATIENT PRIVACY

     
May Geriatric Solutions release medical information to specified persons other than you   Yes
No
     
If yes, please specify to whom this information may be released  
Authorized Person Relationship to You
     

I understand that as part of my continuing healthcare, my physician maintains medical records in his/her office, which contain my health history, symptoms, examination test results, diagnoses and treatment plans, to be used as a basis for planning my care and treatment, and that this information may be released to my other physicians/healthcare providers.

I understand that I have the right to request restrictions as to how my medical record may be used or disclosed.

I understand that my physician keeps on premises and on their website a copy of the “Notice of Privacy Practices for Protected Health Information” which provides a more complete description of the uses and disclosures of my medical record, and that I have been provided the opportunity to review this document prior to signing this consent, and that a written copy will be provided to me on request. The "Notice of Privacy Practices for Protected Health Information" is located in the forms section of the website.

I understand that this document is a part of my permanent medical record, and that I may make changes regarding the disclosure of my health information at any time and that I need to notify my physician in writing of these changes.

     
Type Your Name  
Date