Face sheet

Jersey Medical Weight Loss Center
Face Sheet
Name*

First NameLast Name
Gender

MaleFemale
Birth Date *

MonthDayYear
Date
Email*
example@example.com
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number (Home)
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number (Cell)*
Please enter a valid phone number.Format: (000) 000-0000.
Employed By
Company
Occupation
Job Title
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Name

First NameLast Name
Relationship to the Patient
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Payment/ Insurance Information
Active Medical Insurance Coverage:*

YesNo
Self Pay*

YesNo
Insurance Plan
Name of Insurance Plan
Responsible Person

SelfSpouseParentOther
Subscriber Name

First NameLast Name
Subscriber ID Number
Subscriber's DOB

MonthDayYear
Date
Do you have a secondary Insurance

YesNo
Name of Insurance Plan
Subscriber Name

First NameLast Name
Relationship to Patient
Subscriber ID
Subscriber's DOB

MonthDayYear
Date
Name of Primacy Care Physician/Pediatrician:
PCP Doctor
Office Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Pharmacy Name
Pharmacy Address

Street Address

CityState / Province

Postal / Zip Code
Pharmacy Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Can we leave messages on your answering machine/ voice mail?*

YesNo
Can we use your email for correspondence?*

YesNo
Can we text or send email appointment reminder?*

YesNo
How did your hear about our medical practice?
Patient Privacy Notice
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
Signature of patient/guardian*
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 of patient/guardian
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 companyI do not have health insurance coverage.N/A
Signature of patient/guardian
By signing below, I certify that all information provided is true, correct and complete.
Signature of patient/guardian*
Name of the patient/guardian*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

Jersey Medical Weight Loss Center

Face Sheet

Payment/ Insurance Information

Patient Privacy Notice

Medical Insurance - Assignment of Benefits/Payment

Self-Pay