drmatthewlublin.com - Registration Form

REGISTRATION FORM
Today’s Date:

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Date
Primary Care Physician:
PATIENT INFORMATION
Patient’s Name

First NameMiddle NameLast Name
Sex:

MaleFemale
Age:
Birth Date:

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Date
Social Security #:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home phone #
Please enter a valid phone number.
Cell phone #
Please enter a valid phone number.
Email:
example@example.com
Occupation:
Employer:
Work #.
Please enter a valid phone number.
Driver’s License #:
Spouse Name:
Spouses Social Security #:
PHARMACY INFORMATION
Pharmacy Name:
Pharmacy Number:
Please enter a valid phone number.
Pharmacy Address:
IN CASE OF EMERGENCY
Name:
Relationship to patient:
Home phone #:
Please enter a valid phone number.
Work phone #:
Please enter a valid phone number.
MEDICARE PATIENTS
I authorize payment directly to the physician services and benefits for Accept Assignment services: all other services are responsibility of the patient.
Signature

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Date

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PRIVATE INSURANCE / SELF PAY PATIENTS
We will be happy to bill your insurance; All services not covered by insurance are the financial responsibility of the patient, however you are responsible for any co-payment or co-insurance at the time of service.
Signature

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Date

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Our Financial Policy
We are dedicated to providing the best possible care for you and we want you to completely understand our financial policy. Please take the time to review and feel free to ask any questions before signing.
1. Payment is due at the time of service. We are currently in network with Medicare, and most PPO plans. You are responsible for your co-pay, co-insurance or deductible as outlined in your insurance plan.
2. Medicare Patients: You are responsible for your yearly deductible and 20% coinsurance as outlined by Medicare. If you have a secondary insurance carrier, a portion of your co insurance may be covered. Any outstanding balance not picked up by insurance will fall into patient responsibility.
3. Keep in mind that your insurance policy is a contract between you and your carrier. Plan details were picked out by you and it is your responsibility to be aware of those plan details.
4. If you are insured by a plan we do not have a prior arrangement with, we will prepare and send the claim for you on an unassigned basis. This means the insurer will send the payment directly to you. Therefore, our charges are due at the time of service.
5. As a service to you we will file your insurance claim if you assign the benefits to the doctor. In other words: you agree to have the insurance company pay the doctor directly. If your insurance company does not pay the practice within a reasonable period, you will be responsible for the charges.
6. Not all insurance plans cover office visit charges, diagnostic tests, lab work etc. In the event that your insurance determines a service as “not covered” you will be responsible for the charges. Please be aware your signature below is your agreement to payment upon receipt of statements from our office.
7. We will bill your insurance company for all doctor services provided in the hospital. You will be responsible for any remaining balance.
8. Payment may be made in cash, personal check or Visa/Mastercard. There will be a $25.00 charge for all checked that are returned for insufficient funds.
9. Statements are sent out on a monthly basis. If it is necessary to assign your account to our collection agency and/or attorney, you will be responsible for any potential collection agency and attorney fees/costs we incur.
I have read and understand the practice’s financial policy. I agree to be bound by it’s terms. I also understand and agree that such terms may be amended by the practice from time to time.

We are proud to serve your health needs and look forward to working with you in the future.
Print Name
Signature of Patient

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AUTHORIZATION FOR RELEASE OF INFORMATION
Section A: Must be completed for all authorizations
PATIENT NAME:
DATE OF BIRTH:

MonthDayYear
Date
I hereby request the release my personal health and medical information to be forwarded to Matthew Lublin, MD

Address:

Matthew Lublin
2001 Santa Monica Blvd. Suite 1170W
Santa Monica, CA 90404
P: (310) 828-2212 Fax: (310) 828-6829
Information to be disclosed:

Complete health recordConsultation report onlyX-ray reports onlyLaboratory reports only
From (date)

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Date
to (date)

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Section B: Must be completed for all authorizations.

The patient or patient’s representative must read and initial the following:

I understand that this authorization will expire on   Date   initial
I understand that this authorization is voluntary.   initial
I understand that I may revoke this authorization at any time by notifying the office in writing, but if I do, it will have no effect on actions taken prior to receipt of the cancellation.    initial
Signature of patient/patient’s representative

Clear
Date

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Printed name of patient’s representative (if applicable)
Relationship to the patient (if applicable)