Rheumatology & Arthritis Center

Rheumatology & Arthritis Center

HIMMAT S. GILL, M.D., INC.

_{7135 N. Chestnut Avenue, Suite 104, Fresno, CA 93720
Phone: (559) 447-8632 Fax: (559) 447-8872}
Welcome to Rheumatology & Arthritis Center

New patient forms must be submitted online or mailed our office prior to your appointment. If new patient forms cannot be seen, and your appointment are not received, you will be If forms are submitted online, medications must be listed in designated section. rescheduled.

Please bring your current insurance cards and driver's license/ID card (any form of ID) to your appointment.

Your co-payment/ co-deductible/balance is payable upon check-in. If you do not your pay payment/deductible/balance and our office has to bill you, there will be an additional charge.

of any insurance change/cancellation prior to your appointment, Please inform our office if the insurance provided is inactive/terminated, your appointment will be canceled valid until insurance is supplied to our office.

We accept cash, Discover American Express, no checks MasterCard, Visa, and will be accepted.

Our office is located at on the Northwest corner of Herndon and Chestnut Avenues.

Directions from Hwy 41-take the Herndon Ave exit and proceed East on Herndon Ave until you reach Chestnut Ave, make a left on to Chestnut Ave, stay in the left lane, make the first left hand turn in you can after turning onto Chestnut Ave, this will bring you into the complex, once the complex, make the first right hand turn you can and we are at the end of that row.

168 - Directions from Hwy take the Herndon Ave exit, and proceed West on Herndon Ave until you the lane reach Chestnut Ave, make a right turn onto Chestnut Ave, immediately get into left and make the first left hand turn you can after turning onto Chestnut Ave, this will bring you into the once in the complex, make the first right hand turn you can and we are at the end of that complex, row.

Thank you, we look forward to seeing you.

New Patient Information

Please fill out all required fields
Full Name*
Full Name
Date of Birth*

MonthDayYear
DOB
SS*
Social Security Number
Address:*
Address
City:*
City
Zip:*
Zip
Cell Phone:
Please enter a valid phone number.
Home Phone:*
Please enter a valid phone number.
Work Phone:
Please enter a valid phone number.
Email Address:

Confirmation EmailEmail address on first line and type confirmation on second line
Gender*
Select Gender
Age:*
Your age
Spouse Name:
Spouse Name
Marital Status:*
Select Marital Status
Ethnicity:*
Select Ethnicity
Race*
Select Race
Employer:
Employer if applicable
Employer Address:

Address

Street Address Line 2

CityState / Province

Zip
Emergency Contact:*
Emergency Contact
Relation:*
Relation
Phone*
Phone
Primary Insurance*
Primary Insurance
Insurance Id:*
Insurance ID
Secondary Insurance
Secondary Insurance (if any)
Secondary Insurance ID:
Secondary Insurance ID (if any)
Signature*

Clear
Date*

MonthDayYear
Date

Patient Questionnaire

Please fill out all required fields
Name:*
Name
DOB:*

MonthDayYear
Date of Birth
Date: *

MonthDayYear
Today's Date
Name of Primary Care Physician*
Primary Care Physician
Have you seen a rheumatologist before?*
Please select
Name of Doctor
If YES to above - Name of Doctor
Any Past Medical History?*
Any Past Medical History
Previous Surgeries/Procedures?*
Previous Surgeries/Procedures?
Medication Allergies: *
Medication Allergies
Type of Reactions
Allergy Reactions (if any)
Do You Smoke?*
Do You Smoke
How Long
How Long
Do You Drink?*
Do you Drink?
Number per week:
Drinks per week
Do you use drugs for reasons that are not medical?*
Non medical drug use
List all Medications with dosage. Separate list of Medications will not be accepted.*
Medications List
Name of Pharmacy:*
Name of Pharmacy
Pharmacy Phone#*
Pharmacy Phone#

Financial Policy
As a courtesy to our patients, our office will bill your primary and secondary insurance company if applicable. It is your responsibility to make sure that we have current copies of your insurance card(s), both primary and secondary, as well as the correct home address. Ultimately, it is the patient/guarantor's responsibility to know the scope of your health coverage benefits.
1. Insurance: We participate in most insurance plans, include Medicare. We are not contracted with Medi-Cal primary. If you do not have an up-to-date insurance card,payment in full for each visit is required until we can verify your coverage. Knowingyour insurance benefits is your responsibility. Please contact your insurance companywith any questions you may have regarding your coverage.
2. Co-payment/deductibles/balances: All co-payments, deductibles and outstandingbalances must be paid at time of service. This arrangement is part of your contract withyour insurance company.
3. Proof of Insurance: All patients must complete our patient information form beforeseeing the doctor. We must obtain a copy of your current valid insurance as proof ofinsurance and will request a copy of your driver's license/ID card. If you fail to provideus with correct insurance information in a timely manner, you will be responsible forthe balance of the claim.
4. Claims Submission: We will submit your claims and assist you in any way wereasonably can to help get your claims paid. Your insurance company may need you tosupply certain information directly. It is your responsibility to comply with their request.Please be aware that the balance of your claim is your responsibility whether or not yourinsurance company pays your claim.
5. Secondary Insurance: As a courtesy to you we will bill your secondary insurancecompany once. If payment is not received within 3 0 days of the date the secondaryinsurance was billed, it will be your responsibility to pay Himmat S Gill MD Inc.
6. Coverage Changes: If your insurance changes, please notify us so we can make theappropriate changes. If your insurance company does not pay your claim within 45days, the balance will automatically be billed to you.
7. Nonpayment: If your account is over 90 days past due, you will receive a letter statingthat you have 20 days to pay your account in full, unless otherwise negotiated. Please beaware that if a balance remains unpaid, we will refer your account to a collection agency,and you will be discharged from this practice.
8. HMO Referrals: If your insurance requires an HMO referral for office visits, we willassist you in this process but, it is your responsibility to see that one is obtained prior to receiving this service.
9. Returned checks: Checks received by mail, returned for non-sufficient funds will be charged an additional $25.00 service fee.
10. Failed Appointments: No show appointments and failure to cancel your appointmentwithin 24 hours will result in $50.00 fee. If you no show one appointment, medicationrefills will NOT be given, if you no show a second appointment you may be dischargedfrom this practice.
11. Monthly Statements: The balance of your account is due and payable upon receipt ofmonthly statement from Rheumatology & Arthritis Center, Himmat S Gill MD, Inc.
12. For your convenience, we accept cash, Mastercard, Visa, Discover and American Express, no checks will be accepted.
Our practice is committed to providing the best treatment to our patients. Thank you for understanding our payment policy. Please let us know if you have any questions or concerns.

I have read the above policy and agree to comply with its provision. I understand that I am responsible for all medical services rendered.

Assignment and Release: I hereby authorize my insurance benefits to be paid directly to Rheumatology & Arthritis Center, Himmat S. Gill MD, Inc. and that I am financially responsible for services that the insurance considers my responsibility. I authorize Rheumatology & Arthritis Center, Himmat S. Gill MD, Inc. to release any information required to process my claim.
Patient Signature*

Clear
Date*

MonthDayYear
Date

Acknowledgement of Receipt of Notice of Privacy Practices
I hereby acknowledge that I can review and receive a copy of Himmat S. Gill MD Inc’s Notice of Privacy Practices. I further acknowledge that a copy of the current notice will be available in the reception area, or website www.racfresno.com. I may ask for a copy of this or any amended Notice of Privacy Practices at each appointment.
I,*
Type Your Name
authorize Himmat S. Gill MD Inc to discuss medical information related to my

care with the following individuals:
Name 1:

First NameLast Name
Name 1 Phone Number:
Please enter a valid phone number.
Name 1 Relationship to Patient:
Name 1 Relationship to Patient
Name 2:

First NameLast Name
Name 2 Phone Number:
Please enter a valid phone number.
Name 2 Relationship to Patient:
Name 2 Relationship to Patient
Name 3:

First NameLast Name
Name 3 Phone Number:
Please enter a valid phone number.
Name 3 Relationship to Patient:
Name 3 Relationship to Patient
Signature*

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Date of Birth*

MonthDayYear
Date
Todays Date:*

MonthDayYear
Date
Should be Empty:

Rheumatology & Arthritis Center

HIMMAT S. GILL, M.D., INC.

7135 N. Chestnut Avenue, Suite 104, Fresno, CA 93720 Phone: (559) 447-8632 Fax: (559) 447-8872

Welcome to Rheumatology & Arthritis Center

New Patient Information

Patient Questionnaire

Financial Policy

Acknowledgement of Receipt of Notice of Privacy Practices

_{7135 N. Chestnut Avenue, Suite 104, Fresno, CA 93720
Phone: (559) 447-8632 Fax: (559) 447-8872}