sedabadalyanmd.com - Patient Registration Form

Patient Registration Form
PATIENT NAME (As on Insurance Card):*

First NameMiddle NameLast Name
MAIDEN
HOME ADDRESS:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MAILING ADDRESS (If different from above):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PHONE (HOME)*
Please enter a valid phone number.
PHONE (CELL)*
Please enter a valid phone number.
PHONE (WORK)
Please enter a valid phone number.
DATE OF BIRTH*

MonthDayYear
Date
EMAIL ADDRESS*
example@example.com
EMPLOYMENT STATUS*

FTPTRetiredOther
NAME OF EMPLOYER*
EMPLOYER'S PHONE NUMBER*
Please enter a valid phone number.
PHARMACY NAME AND LOCATION (Street Name)*
RACE*

Hispanic or LatinoNot Hispanic or LatinoRefuse to Report
PRIMARY LANGUAGE*
NAME OF EMERGENCY CONTACT PERSON*
RELATIONSHIP TO PATIENT*
HIS/HER PHONE NUMBER*
Please enter a valid phone number.
PRIMARY INSURANCE*
SUBSCRIBER/ MEMBER ID #*
GROUP NUMBER*
SECONDARY INSURANCE
SUBSCRIBER/ MEMBER ID #
GROUP NUMBER
REFERRING DOCOTR
PHONE #
Please enter a valid phone number.
ASSIGNMENT OF BENEFITS/FINANCIAL AGREEMENT

The above information is true to the best of my knowledge. I hereby give authorization for payment of insurance benefits to be made directly to Dr. Seda Badalyan and/or assisting physicians for services rendered. I fully understand and agree that I am financially responsible for all charges whether or not they are covered by insurance. I hereby authorize Dr. Seda Badalyan to release all information necessary to secure the payment of benefits. I authorize the healthcare provider to act as my personal representative to submit appeals, release information and initiate formal complaints on my behalf regarding my insurance benefits. I further agree that a copy of this agreement shall be valid as the original.

NO SHOW/LATE CANCELLATION POLICY

I am aware that a fee of $25.00 may be assessed as a "no show" charge for an office visit and $100 for an annual exam/physical if I do not call to cancel my appointment 24hrs prior to my scheduled appointment time. This fee is not payable by insurance and is my responsibility.

ACKNOWLEDGEMENT OF PRIVACY PRACTICES

I hereby acknowledge that I am aware of this office's Notice of Privacy Practices. I further acknowledge that a copy of the current notice is available upon request, and that any amended Notice of Privacy Practices will be available at each appointment.
If not signed by the patient, please indicate relationship:

Parent or guardian of minor patientGuardian or conservator of an incompetent patient
SIGNATURE*

Clear
NAME*
DATE*

MonthDayYear
Date

Authorization to Release Health Information
Patient Name*
Date of Birth*

MonthDayYear
Date
Send Records to:

Dr. Seda Badalyan, MD
9850 Genesee Suite, 740
La Jolla, CA 92037
Phone: 858-457-5555
Fax: 858-457-1565
I authorize * , to release my medical records as requested below.
For Healthcare Covering the Period(s)- From: Date To: Date
Complete Health Record to be disclosed or (check appropriate boxes):*

NoneHistory & Physical ExamAll recordsDischarge SummaryX-Rays & UltrasoundsLaboratory TestsConsultationsConsent for Dr. Badalyan or staff to speak w/another provider:
Provider Name:
I understand that specific information to be released may include AIDS or HIV, Alcohol and/or Drug Abuse, and Mental Health or Sexually Transmitted Diseases.

I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or copy the information to be used or disclosed. I understand that any disclosure of information carries with the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules.

Unless otherwise indicated, this authorization will expire 1 year from the date of signature. The physician and employees are released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein. I understand that this authorization may be revoked in writing at any time, expect to the extent that the action has been taken in reliance on this authorization for the purposes stated above.

I understand that there may be a fee for preparing and furnishing thus information, for which I am responsible.
Signature of Patient Legal Representative*

Clear
Relationship to Patient*
Date*

MonthDayYear
Date

PATIENT RIGHTS
1. RIGHT TO FILE A COMPLAINT: IF YOU BELIEVE YOUR RIGHTS HAVE BEEN VIOLATED, YOU CAN FILE A COMPLAINT WITH OUR PRACTICE OR DR. BADALYAN. ALL COMPLAINTS MUST BE SUBMITTED IN WRITING. YOU WILL NOT BE PENALIZED FOR FILING A COMPLAINT.
2. RIGHT TO PROVIDE AN AUTHORIZATION FOR OTHER USES AND DISCLOSURES: OUR PRACTICE WILL OBTAIN YOUR WRITTEN AUTHORIZATION FOR USES AND DISCLOSURES THAT ARE NOT INDENTIFIED BY THIS NOTICE OR PERMITTED BY APPLICABLE LAW.
IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE OR OUR HEALTH INFORMATION PRIVACY POLICIES, PLEASE ADVISE SOME ONE IN OUR PRACTICE.

I HEREBY ACKNOWLEDGE THAT I HAVE BEEN PRESENTED WITH A COPY OF SEDA BADALYAN, MD A.P.C NOTICE OF PRIVACY PRACTICES.
SIGNATURE*

Clear
DATE*

MonthDayYear
Date
NAME OF PATIENT:*
EMPLOYEE INITIALS:

CANCELLATION POLICY
We strive to give each one of our patients the very best service possible. We value your patronage and look forward to a long and rewarding relationship.

It is in this spirit that we would like to inform you of our policy concerning missed appointments.

To discourage NO-SHOW and SAME DAY cancellations, we must require that 24-hours notice be given to cancel or reschedule appointments. If 24- hours notice is not given, for routine appointments there will be a fee of $25.00. For MISSED, NO-SHOW, SAME DAY CANCELLATIONS, or SAME DAY RESCHEDULING for annuals, physicals, or surgical procedures, there will be a fee of $100.00.

We regret the need for this policy and sincerely hope you will not be affected by it

PRESCRIPTION REFILLS

For your convenience, please allow our office 48 hours advance notice noticed for any prescription refills. Contact your pharmacy and have them fax a request to our office whether you have more refills left or not. PLEASE MAKE ARRANGEMENTS FOR REFILLS WHEN THERE IS AT LEAST A WEEK LEFT OF YOUR MEDICATION. FAX: (858) 457-1565
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

	Date	Disclosed to Whom Address or Fax Number	(1)	Description of Disclosure/ Purpose of Disclosure	By Whom Disclosed	(2)	(3)
1.
2.
3.
4.
5.

Patient Registration Form

Authorization to Release Health Information

PATIENT RIGHTS

CANCELLATION POLICY