New Patient Face sheet

New Patient Face Sheet

1527 State Route 27, Suite 2100, Somerset NJ 08873
Date

Day Month Year
Date
Name *

First Name Last Name
Gender

Male Female
Birth Date *

Month Day Year
Date
Email
example@example.com
Home Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Telephone Number (Home)
Please enter a valid phone number.
Phone Number ( Cellular)
Please enter a valid phone number.
Employed By
Company
Occupation
Job Title
Business Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Emergency Contact Name

First Name Last Name
Relationship to the Patient
Phone Number
Please enter a valid phone number.
Payment/ Insurance Information
Active Medical Insurance Coverage:

Yes No
Self Pay

Yes No
Insurance Plan
Name of Insurance Plan
Responsible Person

Self Spouse Parent Other
Subscriber Name

First Name Last Name
Subscriber ID Number
Birth Date

Month Day Year
Date
Do you have a secondary Insurance

Yes No
Name of Insurance Plan
Subscriber Name

First Name Last Name
Relationship to Patient
Subscriber ID
Birth Date

Month Day Year
Date
General Information
Name of Primacy Care Physician:
PCP Doctor
PCP Telephone Number
Please enter a valid phone number.
Pharmacy Name
Pharmacy Address

Street Address

City State / Province

Postal / Zip Code
Pharmacy Telephone Number
Please enter a valid phone number.
Can we leave messages on your answering machine/ voice mail about medication or labs results?

Yes No
Can we use your email for correspondence?

Yes No
Can we text or send email appointment reminder?

Yes No
How did your hear about our medical practice?
Patient Enrollment Form

Patient Acknowledgement Form
We are required by applicable federal & 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 practice, our legal duties and your right concerning your health information. We must follow the privacy practice 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. I HAVE REVIEWED &/ RECEIVED A COPY OF THE OFFICE'S NOTICE OF PRIVACY PRACTICE *

Clear
Medical Insurance - Assignment of Benefits/Payment
I, the undersigned have medical Insurance coverage with Name of Insurance and assign directly to Dr. Aparna Chandrasekaran (Jersey Medical Weight Loss Center/ Aparna Medical Associates) all medical benefits, if any, otherwise payable to me for services rendered. I authorize release of all the information necessary to secure the payment of benefit. Also, I understand that I am financially responsible for all charges if not paid by the insurance and authorize the use of my signature on all my insurance submission.
Signature *

Clear
Self-Pay
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 restrictions. I do not wish to share any health-related information with my insurance company I do not have health insurance coverage. N/A
By signing below, you certify that all information provided is true, correct and complete. *

Clear
Name

First Name Last Name
Date signed

Day Month Year
Date
Should be Empty:

New Patient Face Sheet

Payment/ Insurance Information

General Information

Patient Enrollment Form

Medical Insurance - Assignment of Benefits/Payment

Self-Pay