Patient Introduction Form

Download a blank fillable Patient Introduction Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Patient Introduction Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Pediatric Associates of Northern Colorado (PANC) Patient Introduction Slip
Date: _________________
Date of Birth: ________________
Patient Name: First_______________________Middle_______________ Last________________________ (Male/Female)
Address: ___________________________________ City: ___________________ State: _______ Zip Code: ________
Parent #1 Name: ________________________________________ Employer: ___________________________________
Parent #1 Address (
): ___________________________________________________________________________
if different
Parent #2 Name: ________________________________________ Employer: ___________________________________
Parent #2 Address
: ___________________________________________________________________________
(if different)
Phone Numbers: Please list in order of preference how we should contact you (reminders, appointments, emergencies, etc.)
Preferred Contact (Home/Cell): ____________________________
Parent Work: ____________________
2nd Phone # (Parent/Patient) + (Home/Cell): _______________________
Preferred Email Address: _______________________________________________________________________________
Nearest Friend or Relative: __________________________________________ Phone: ____________________________
Name of Insurance Company: __________________________________________________________________________
Insured or Responsible Parent: _________________________ Insured or Responsible Parent DOB: _________________
Insured or Responsible Parent SS: ______________________
Ethnicity: Hispanic Non-Hispanic Declined to Specify
Race: White
Asian
Black Native American
Native Hawaii
Other Polynesian
More than one
Declined
Credit/Financial Policies
Welcome to Pediatric Associates of Northern Colorado (PANC). Please take a few minutes to review the following information. Please
sign the Credit/Financial Policies, Receipt of Notice of Privacy Practices and Authorization to File Claims with Insurance. We hope you
understand that our credit and collection policies are a necessary part of assuring the financial resources needed to maintain this medical
office for our patients and the community.
Charges for medical services at our office are due and payable at the time services are rendered. We do give a discount when paying
at the time of service. We accept cash, checks, Visa, MasterCard and Discover. For in-hospital services provided by our physicians we
will submit the charges to your insurance and allow 45 days for payment. After that time you are required to pay the charges and then
settle with your insurance company. If you have health insurance, please understand that this is an agreement between you and your
insurance company to pay a certain amount for your medical care. Our bill for medical service is an agreement between you and our
office. You are responsible for the payment of your bill regardless of the status of your insurance claim.
If unusual circumstances should make it impossible to meet our credit terms, please call or personally discuss the matter with our
Office Manager. This will help avoid misunderstandings and enable you to keep your account in good standing. Accounts 90 days past
due are referred to a collection agency, unless prior payment arrangements have been made with our office. In the event that your
account is turned over to collection you will be responsible for the collection fee in addition to your balance. Also, we will no longer be
your primary care physician. In order to keep your appointments on time it has become necessary for us to charge extra for walk-in and
unscheduled appointments (each child to be seen must have an appointment time). If you are unable to keep your appointment, please
cancel within 24 hours for well care & medication appointments. A one hour notice of cancellation is required for any other appointment.
You will be charged a fee of $25 for a sick visit, $10 for a nurse visit and $50 for a well check if you fail to meet the required cancellation
notification. There is a charge for after-hours phone calls; however no charge will be assessed if the child is seen on the next business
day. If you have any questions regarding our office policies please feel free to discuss them with our Office Manager.
Signature: _______________________________________________________ Date:________________________________________
Acknowledgement of Receipt of Notice of the Privacy Practices of PANC
I have received a copy of the Notice of Privacy Practices for PANC. This notice describes how PANC may use and disclose my protected
health information, certain restrictions on the use and disclosure of my healthcare information, and rights I may have regarding my
protected health information. Pediatric Associates reserves the right to modify the practices outlined above.
Name of Patient: _______________________________________________________________________________________________
Signature of Patient or Patient Representative: ______________________________________________________________________
Relationship of Patient Representative of Patient: _________________________________________Date:_______________________
Revised: 11/13/2014

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go
Page of 2