Confidential Patient Information Form - North Florida Ob Gyn Llc
ADVERTISEMENT
1North Florida OB GYN LLC
Confidential Patient Information Form - Form must be filled out completely to ensure correct claim processing.
Social Security ___________________Patient ___________________________________________________________________
(Last)
(First)
(Middle Initial)
Date of Birth_________________Address________________________________________________________________________
(Street #)
(City)
(State)
( Zip)
Home Tel#: _________________________Work Tel#: _______________________Patient Cell # _________________________
(If Cell # is provided, the office may text you appointment reminders)
Employer_________________________________
Patient E-Mail___________________________ Marital Status ______________ Employment Status ___________________
(S M D W Sep)
(FT PT Ret N)
How did you hear about our office? ________________________________________________Student___________ (FT PT)
Referring Physician _________________________________Primary Care Physician __________________________________
Emergency Contact _______________________________ Relationship__________________ Phone # ____________________
Spouse’s name or other responsible party: __________________________________ Phone # ____________________________
Pharmacy Name, Phone #, Fax # and address______________________________________________________________________
Primary Insurance: _______________________Subscriber (Insured) Name ____________________________________
Subscriber: Date of Birth_________________ Social Security # ___________________________Employer____________________
ID#____________________ Group Name & #________________________ Patient Relationship to Insured________________
(Self, Spouse, Child)
Insurance Address__________________________________________________________________________________________
(City)
(State)
(Zip)
Second Insurance: ________________________ Subscriber (Insured) Name______________________________________
Subscriber: Date of Birth___________________ Social Security # ___________________________Employer__________________
ID#____________________ Group Name & #________________________ Patient Relationship to Insured_________________
(Self, Spouse, Child)
Insurance Address___________________________________________________________________________________________
I understand that I am directly and primarily responsible to North Florida Obstetrical & Gynecological Associates, P.A., the parent company of North
Florida OB GYN, LLC, for its customary fee for the services rendered to me by North Florida OB GYN, LLC. I realize that if my insurance
company fails to pay or if there is any delay in paying North Florida Obstetrical & Gynecological Associates, P.A., it is my responsibility to pay my
doctor’s bill directly. I further understand and agree if I fail to make timely payments to North Florida Obstetrical & Gynecological Associates, P.A.,
that I will be responsible for any and all reasonable cost of collection including filing fees as well as any reasonable attorney’s fee(s).
For the services rendered by North Florida OB GYN, LLC, I authorize the release of any medical or other information necessary to process claims to
my insurance carrier. This may include the diagnosis and records in the course of my examination or treatment. I also request payment of
government benefits either to myself or the party who accepts assignment (North Florida Obstetrical & Gynecological Associates, P.A.). I authorize
payment of medical benefits to the physician who submits the claim. I agree to hold North Florida OB GYN, LLC harmless from any and all costs,
liability and damages of and nature whatsoever including reasonable attorney’s fees, resulting directly from the release of my medical records
pursuant to this consent. North Florida OB GYN, LLC and other PA subsidiaries may share one electronic medical record. To facilitate the provision
of my medical care, I consent for North Florida OB GYN, LLC to access my medical records maintained by any other PA subsidiary.
I understand the office may employ an Advanced Registered Nurse Practitioner (“ARNP”), Midwife (“ARNP/CNM”) or Physician Assistant (“PA”),
and if I am scheduled with them, I am willing to see them instead of the doctor. I hereby consent to and authorize the performance of all appropriate
procedures and courses of treatment, the administration of all anesthetics, and any and all medications which in the judgment of my provider may be
considered necessary or advisable for my diagnosis and/or treatment. I consent to electronic access to my medication history.
This form was last modified on 10/1/2015. I acknowledge that I have read this authorization and fully understand its contents.
Signature_____________________________________________________________________________Date___________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical