CRDO New Patient Form

If you are filling this form out in-office, please hand your insurance cards to the front desk. Fill in "STAFF" on the required lines.

Please fill the required personal information accordingly.

Assignment and Release
I certify that I and my dependents have insurance coverage with name of insurance* and assign directly to Center for Rheumatic Diseases and Osteoporosis, P.A. all insurance benefits, if any otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature of all insurance admissions. The Center for Rheumatic Diseases and Osteoporosis, P.A. may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent includes my authorization to release medical information to my primary care physician and/or consulting physicians to assist with continuity of my healthcare. This release will remain in effect until I cancel this release in writing.
Signature of Patient, Parent, Guardian, or Personal Representative*

Clear
Printed Name*
Relation to Patient*
Date*

MonthDayYear
Date

	Age	Health	Age at death	Cause
Father
Mother

At any time, has a blood relative had any of the following? (Give relationship):

Consents and Acknowledgements
By signing and submitting this form, you agree to all of the consents and acknowledgements listed above.
Signature*

Clear
Date*

MonthDayYear
Date
Initials*
Please type "N/A" if you have active insurance*
If no insurance, please initial

Financial Policy
Printed Name*
Signature*

Clear
Date*

MonthDayYear
Date
By signing and submitting this form, you agree to all of the financial policy listed above.

HIPAA
By signing and submitting this form, you agree to all of the HIPAA guidelines listed above.
Printed Name*
Signature*

Clear
Date*

MonthDayYear
Date

Patient Authorization Consent Form
By signing and submitting this form, you agree to all of the Patient Authorization & Consent Form listed above.

This form is not required however it is highly recommended to ensure maximum efficiency regarding any prior authorizations for special treatment and or medications.
Printed Name
Signature

Clear
Date*

MonthDayYear
Date

Medical Records & Other Documents
Please upload any relevant medical records or documents you wish for us to have on file

Cancelof
Should be Empty:

	Name of Drug	Dose	No. of pills and how often?	How long have you taken this medication?
1
2
3
4
5
6
7
8
9
10

Patient Information