RETURNING Patient

Returning Patient

Medicare
Appointment*
Full Name:*

First NameLast Name
Email:*
example@example.com
Birth Date: *

MonthDayYear
Date
Sex:*
Marital Status:*
Address*

Street Address

Apartment / Building Number:

CityState / Province

Postal / Zip Code
City
State / Province:
Postal / Zip Code
*Primary / Cell Phone #:*
Please enter a valid phone number.
Home / Other Phone #:
Please enter a valid phone number
Work / Other Phone #:
Please enter a valid phone number.
Emergency Contact Name:*
Emergency Contact Phone #:*
Please enter a valid phone number.
How did you hear about us?
Other:
If applicable.
*Primary / Cell Phone #:
Please enter a valid phone number.
Insurance Company:
Insurance Company:
Insurance ID #:
Primary Medicare Insurance Information:
Medicare Part-B ID #:*
Part-B Eff Date:*

MonthDayYear
Date
Address

PO Box or Claims Street Address:

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Phone #:
Secondary Insurance:
Secondary Insurance Company:*
Sorry, you will not be able to make an appointment at our office, as we do not participate with your plan.
Insurance ID #:*
Insurance Effective Date:*

MonthDayYear
Date
Address

PO Box or Claims Street Address:

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Name of Insured

If same, put same:

Insurance Company:

Insurance Phone #:Policy ID or SSN:

Other:
Third Insurance:
Third Insurance Company:*
Sorry, you will not be able to make an appointment at our office, as we do not participate with your plan.
Insurance Company:
Insurance ID #:*
Insurance Effective Date:*

MonthDayYear
Date
Address

PO Box or Claims Street Address:

Street Address Line 2

CityState / Province

Postal / Zip Code
CANCELLATION POLICY:
At Alan Dayan MD, PC, FAAOS, we understand your time is important, as a result, we have reserved time for your visit with us. If you need to change the appointed time, we request at least 48 business hours (2 business days) notice. To maintain quality of care and keep from overbooking, our office requires such notice, otherwise, a $50 NO-SHOW FEE will apply. We understand that emergencies and illnesses may arise at the last minute, but please give us enough time so that other patients can use that reserved time. By signing below, you acknowledge you have listed all pertinent information, read and understand our Cancellation Policy, and have had the opportunity to review or receive a copy of our Privacy Practices.
By signing below, you acknowledge you have listed all pertinent information, read and understand our Cancellation Policy, and have had opportunity to review or receive a copy of our Privacy Practices.
Patient/Responsible Party Signature:

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Date:

MonthDayYear
Date
Should be Empty:

Primary Medicare Insurance Information:

Secondary Insurance:

Sorry, you will not be able to make an appointment at our office, as we do not participate with your plan.

Third Insurance:

Sorry, you will not be able to make an appointment at our office, as we do not participate with your plan.

CANCELLATION POLICY: