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Patient Information:


Patient Information:

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Patient Employer


Patient Employer

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Person Responsible for Bill:


Person Responsible for Bill:

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Patient Pharmacy


Patient Pharmacy

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Primary Care Physician


Primary Care Physician

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Emergency Contact:


Emergency Contact:

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Primary Insurance


Primary Insurance

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Secondary Insurance


Secondary Insurance

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Dr. Nayak is NOT a MEDICAID Provider.
FAILURE TO PROVIDE SECONDARY INSURANCE INFORMATION PRIOR TO VISITS WILL RESULT IN PATIENT BEING RESPONSIBLE FOR BALANCE ON ACCOUNT.
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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
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NEW PATIENT MEDICAL FORM


NEW PATIENT MEDICAL FORM

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System Review


System Review

Please Check Any Symptoms You Are Currently Experiencing
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Family Health History (Please list their Significant Health Problems)


Family Health History (Please list their Significant Health Problems)

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Is there a Family Medical History of the following conditions:
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Billing Policy


Billing Policy

Patient benefits will be verified with insurance prior to your office visit and co-pay will be collected at the time of service by cash or credit card (NO CHECKS).
ALL CO-PAYS ARE DUE AT THE TIME OF SERVICE.
Deductibles will be collected in full at the time of follow up appointment, after insurance has processed claims.
Patients with outstanding balances will be requested to pay the balance in full, prior to their appointment, by cash or credit card (NO CHECKS).
If amount remains unpaid after 90 days, the account will be referred to collection agency and an additional 10% fee will be applied to cover collection fee.

NO SHOW/CANCELATION POLICY:


NO SHOW/CANCELATION POLICY:

Any cancellation for an appointment without a 24-hour notice, depending on the circumstances of course, there will be charge a $25, that will have to be collected at the time of your next visit by cash or credit card.
If you do not show up for an appointment, there will be a $25 charge, that will have to be paid at the time of your next visit.
If you do not show up/cancel an appointments 3 times consecutively, we will not be able to schedule any further appointments with our practice.

NOTICE TO ALL HMO PATIENTS


NOTICE TO ALL HMO PATIENTS

It is the patient’s responsibility to obtain valid updated referrals for each office visit. If for some reason you do not have a referral to cover services here in our office, your appointment will be cancelled. Any office visits that do not have a referral to cover the services, the patient will be responsible for any balance, which your insurance will not cover without having a referral.
NOTE: If you need to cancel your appointment prior to the scheduled date, and we are not in the office, you are always welcome to leave a message with our answering service at 708-283-2600.
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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
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Patient Consent:


Patient Consent:

Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in the treatment directly and indirectly.
Obtain payment from third-party payers.
Conduct normal healthcare operations such as quality assessments and physician certifications.
I have been informed the Notice of Privacy Practices containing a more complete description about the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that Southland Rheumatology Center has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of the Notice of Privacy Practices.
I understand that I may request in writing to restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations.
I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.

HIPAA DISCLOSURE AUTHORIZATION


HIPAA DISCLOSURE AUTHORIZATION

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I, further authorize Southland Rheumatology Center to contact me and leave messages on:
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This authorization will remain in place until rescinded by me.
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