FORM: demographic info

113 Views 0 Comments December 28, 2023

FORM: demographic info

BeWellRX Patient Info and Consent to Treat

PATIENT INFORMATION

Last name*

First Name*

Date of Birth*

Sex*

Home Address*

City*

State*

Zip Code*

Daytime Phone

Cell Phone*

Please list any allergy information

PHARMACY INFORMATION

Pharmacy Name*:

Phone*

Fax:

EMERGENCY CONTACT INFORMATION

Full Name*:

Phone*:

Relationship*:

PARTY RESPONSIBLE FOR PAYMENT

(If different from patient)

Relationship to patient*:

First Name*:

Last Name*:

Date of Birth*:

Social Security #*:

Home Address*:

City*:

State*:

Zip Code*:

Cell Phone:

Business Phone:

I authorize any treatment or medical procedure necessary for the medical care of my child that is required by Children's Cardiovascular Medicine & amp; Family Preventive Medicine.

Name of patient*:

Signature of legal custodian*:

Date*:

Children’s Cardiovascular Medicine & Family Preventive Medicine
Financial Policy

Insurance

We participate with most insurance plans. If you are not insured, payment for services is required in full at each visit. We will submit your claim(s) to your insurance company and assist you in any way we can to expedite the processing of your claim. Please be aware that at times your insurance company may request certain information directly from you in order to process your claim. It is your responsibility to comply with their request. Please notify our office immediately should you have any changes to your insurance information. You may be responsible for the claim(s) should you fail to provide the current insurance information in a timely manner. If your insurance company does not process your claim in 60 days, the balance of the claim(s) will automatically be billed to you.

Please initial that I have read and agreed to the above statement*.

Co-payments and Deductibles

All co-payments and deductibles must be paid at the time of service as part of your contract with your insurance company. Payment in full is required at the time of service for any past due balance on your account. Any check returned for insufficient funds will be subject to a $25.00 service charge. Please be aware that if an unpaid balance remains on your account and is over 90 days past due, we may refer your account to a collection agency.

Please initial that I have read and agreed to the above statement*.

Appointment Cancellations

Our policy is to charge for missed appointments as this may prevent another patient from their treatment. However, we understand that there are times when you must miss an appointment due to prior obligations or an unseen emergency. We ask that you notify our office within 24 hours of your scheduled appointment so that we may assist you. If you are unable to reach our office during business hours, please leave a message on our voice mail. .

Please initial that I have read and agreed to the above statement*.

We realize that temporary financial situations may affect timely payment on your account. We encourage you to contact our billing department within our office and we will gladly work out payment arrangements on your account. .

Our practice is committed to providing the best treatment to our patients. Please let us know if you have any questions or concerns.

I authorize Children’s Cardiovascular Medicine & Family Preventive Medicine to release any medical or other information to the insurance carrier, which may be necessary to process the claims. I authorize my insurance company to pay for services provided. I have read and understand the financial policy and its guidelines.

Name of Legal Custodian (Written)*:

Name of patient*:

Signature of legal custodian*:

Date*:

PATIENT AUTHORIZATION TO USE AND DISCLOSE
MEDICAL INFORMATION CONFIDENCEL

i, authorize the adults I name below to take my child and discuss the necessary information with the Children's Cardiovascular doctor Medicine & amp; Family Preventive Medicine, for the well-being of the patient.

Name*:

Relationship with the Patient*:

Phone*:

Name:

Relationship with the Patient:

Phone:

Name:

Relationship with the Patient:

Phone:

With my consent, Children’s Cardiovascular Medicine & Family Preventive Medicine may use and disclose protected Health Information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Please refer to Children’s Cardiovascular Medicine & Family Preventive Medicine Notice of Privacy Practices for a more complete description of such uses and disclosures.

I have the right to review the Notice of Privacy Practices prior to signing this consent. Children’s Cardiovascular Medicine & Family Preventive Medicine reserves the right to revise its Notice of Privacy Practices at any time.

A revised Notice of Privacy Practices may be obtain by forwarding a written request to, Children’s Cardiovascular Medicine & Family Preventive Medicine Attn: Privacy Officer at 780 Canton Rd., Suite 350, Marietta, Georgia 30060.

With my consent, Children’s Cardiovascular Medicine & Family Preventive Medicine may call my home or other designated location and leave a message on voice mail or in person in reference to any items and any call pertaining to my clinical care, including laboratory results among others.

With my consent, Children’s Cardiovascular Medicine & Family Preventive Medicine may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment cards and patient statements.

With my consent, Children’s Cardiovascular Medicine & Family Preventive Medicine may e-mail my appointment reminder cards and patient statements. I have the right to request that Children’s Cardiovascular Medicine & Family Preventive Medicine restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bounded by this agreement.

I may revoke my consent in writing except that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent Children’s Cardiovascular Medicine & Family Preventive Medicine may decline to provide treatment to me.

Signature of Father / mother or legal guardian:

Date:

Written name of Father / mother or legal guardian:

Name of patient:

Visiting Hours

Gallery Posts

FORM: demographic info

FORM: demographic info

BeWellRX Patient Info and Consent to Treat

PATIENT INFORMATION

PHARMACY INFORMATION

EMERGENCY CONTACT INFORMATION

PARTY RESPONSIBLE FOR PAYMENT

(If different from patient)

I authorize any treatment or medical procedure necessary for the medical care of my child that is required by Children's Cardiovascular Medicine & amp; Family Preventive Medicine.

Children’s Cardiovascular Medicine & Family Preventive Medicine
Financial Policy

Insurance

Co-payments and Deductibles

Appointment Cancellations

PATIENT AUTHORIZATION TO USE AND DISCLOSE
MEDICAL INFORMATION CONFIDENCEL

Comments are closed

Contact Us

888-311-6507

[email protected]

Terms & Conditions

FDA Disclaimer

Visiting Hours

Gallery Posts

FORM: demographic info

FORM: demographic info

BeWellRX Patient Info and Consent to Treat

PATIENT INFORMATION

PHARMACY INFORMATION

EMERGENCY CONTACT INFORMATION

PARTY RESPONSIBLE FOR PAYMENT

(If different from patient)

I authorize any treatment or medical procedure necessary for the medical care of my child that is required by Children's Cardiovascular Medicine & amp; Family Preventive Medicine.

Children’s Cardiovascular Medicine & Family Preventive Medicine Financial Policy

Insurance

Co-payments and Deductibles

Appointment Cancellations

PATIENT AUTHORIZATION TO USE AND DISCLOSE MEDICAL INFORMATION CONFIDENCEL

Comments are closed

Contact Us

888-311-6507

[email protected]

Terms & Conditions

FDA Disclaimer

Children’s Cardiovascular Medicine & Family Preventive Medicine
Financial Policy

PATIENT AUTHORIZATION TO USE AND DISCLOSE
MEDICAL INFORMATION CONFIDENCEL