odessageneralsurgery.com - New Patient Registration

NEW PATIENT REGISTRATION
Name

First NameMiddle NameLast Name
Marital Status
Sex
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Age
Social Security #
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Spouse Name
Social Security #
Spouse Date of Birth

MonthDayYear
Date
Spouse Cell #
Please enter a valid phone number.Format: (000) 000-0000.
Patient's Employer
Occupation
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If Patient Is A Minor
Father's Name
Employer
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mother's Name
Employer
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Responsible Party

Other
Father's Social Security #
Father's Date of Birth

MonthDayYear
Date
Mother's Social Security #
Mother's Date of Birth

MonthDayYear
Date
Insurance Information
Do you have health insurance converage?
Insurance Company
Name of Insured
Subscriber or Policy #
I authorize payment of medical benefits to the physician for service provided.

I authorize the release of medical information necessary to process the calm.
Signature
Date

MonthDayYear
Date

FINANCIAL POLICY
Filing Your Insurance Claim:
We will file your claims for all offce visits and surgical procedures if you have Medicare, Medicaid, Champus, pre-approved assistance, or if we participate in your PPO network (call the number on your insurance card to verify.)

If we are not listed as a participating provider and are considered "out of network", payment is due in full at the time service is rendered. As a courtesy to you, we will still be happy to file your claim with your insurance company if you so desire. Credit balances will be promptly refunded.

CO-PAYS:
If your card states "co-pay", this amount will be due and collected at the time of your visit.

Deposits:
A deposit, or advance payment, may be required if you are scheduled for a surgical procedure. Payment terms will be discussed with you prior to your scheduled procedure date.

PATIENT BALANCES:
Any balance due after your insurance claim is either paid or denied is your responsibility. Patient Statements are generated monthly and balances are due upon receipt of your statement. If you are unable to pay the balance due, you must contact the omce to make payment arrangements and sign a payment agreement. Patient balances that are not kept current according to the payment agreements are considered delinquent and will be referred to an outside agency for collections.

Should you have any further questions, please contact our office prior to your appointxnent or surgery.

I HAVE READ AND UNDERSTAND THE ABOVE FINANCIAL POLICY
Signature: (Patient or Parent if minor)
Date:

MonthDayYear
Date

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
Judith Birungi, MD FACS reserve the right to modify the privacy practices outlined in the notice.

SIGNATURE

I have received a copy of the Notice of Practice for Judith Birungi, MD, FACS
Name of Patient
Signature of Patient
Signature of Patient Representative
Date

MonthDayYear
Date
Relationship of Patient Representative to Patient
I give permission to disclose my personal health information with my family and/or caregivers.

NEW PATIENT REGISTRATION

Insurance Information

FINANCIAL POLICY

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

MEDICAL HISTORY

Review of Symptoms: