New Patient Facesheet

New Patient Facesheet

Date *

Date

Name: First Name Last Name
Gender Male / Female Birth Date: Month/Day/Year
Email Address: Email
Home Address: Street Address      City
State   Zip
Cell Phone:    Phone Number  Home Phone: Phone Number
Employed By: Company
Occupation:
Business Address:       Street Address   Address Line 2   City   State   Zip
Emergency Contact Name:   name
Relationship:  Phone:      Phone Number
Address:   Street Address   Address Line 2   City   State   Zip

PAYMENT/ INSURANCE INFORMATION

Active Medical Insurance Coverage :    Yes/No
Self Pay:  Insurance Plan: Name of Insurance
Responsible Person:  Self/ Spouse/Parent/Other
Subscriber Name     Last NameFirst Name
Subscriber ID:   DOB :  Date
Additional Insurance? Yes/ No
Insurance Plan: Name of Insurance
Subscriber Name :       First Name   Last Name
Relation to Patient :
Subscriber ID:    DOB:   Date

GENERAL INFORMATION

Primary Care Physician:   name
Phone:     Phone Number
Pharmacy Name:
City/State:
Phone:      Phone Number
Can we leave message on your answering machine/voice mail?   Yes / No
Can we use your email for appointment remainder/correspondence?    Yes / No
How did you hear about our medical practice?

PATIENT ACKNOWLEDGEMENT

We are required by applicable federal and state laws to maintain the privacy of your health information. We are also required for you to review and if requested, give you the Privacy Notice that outlines our privacy practices, our legal duties and your right concerning your health information. We must follow the privacy practices that are described in our Privacy Notice while it is in effect. PLEASE READ OUR PRIVACY NOTICE BEFORE SIGNING. I have reviewed and / or received a copy of the office's Notice of Privacy Practices.

ASSIGNMENT AND RELEASE

I, the undersigned have medical insurance covergage with _________________ and assign directly to Dr. Aparna Chandrasekaran ( Jersey Medical Weight Loss Center/ Aparna Medical Assocaites) all medical benefits, if any, otherwise payable to me for services rendered. I authorized the physician to release all information necessary to secure the payment of benefits. Also, I understand that I am financially responsible fo all charges if not paid by the insurance and authorize the use of my signature on all my insurance submissions.

SElf PAY PLAN

I understand that my office visit will not be billed to my insurance and agree to pay "out of pocket" for my office visits at Jersey Medical Weight Loss under the care of Dr. Aparna Chandrasekaran.

I give expressed consent to release my health-related information to my insurance company without any restriction I do not wish to share any health-related information with my insurance company I do not have Health Insurance coverage, and I agree to pay for the services at the time of the visit. Not Applicable

By signing below, you certify that all the information provided is true, correct and complete.

Name

First Name Last Name

Date

Signature

Clear

Jersey Medical Weight Loss/ Aparna Medical Associates