Date: _____________           

Patient Name: _________________________                      Patient Address: ______________________________

Sex:  Male  Female             SS#: ___________________ __________________________Zip:_______________

Date of Birth: ____________             Age: ______   Primary Care Provider (Doctor):_______________________           

Referred By:   Doctor   Family/Friend   Newspaper    Phonebook    Radio   Insurance Company

Home Phone: ______________                     Work Phone: ______________         __        Cell Phone: ________________

Which number is the best to reach you at? _______________                    OK to leave Message:    Y    N

Occupation: ______________­­­______________                   Employer: __________________________

Email: (Optional) _______________________                     Drivers Lic. #: _______________________

IN CASE OF EMERGENCY, CONTACT

Name: _____________________________              Relationship: ___________________________

Home Phone: _______________________               Work Phone: ___________________________

PAYMENT POLICY:            Self Pay:     Yes   or     No                    Insurance Pay: Yes   or    No

Self-paying patients must pay in full at the time of the visit. Insurance will be verified and accepted, however, the co-pay, deductible, and/or charges not covered must be paid in full at time of visit.

Without a copy of your insurance card, we will be unable to bill your insurance.

PRIMARY INSURANCE: Insurance Co.__________________     Group Name or # __________________

Subscribers Name: _____________________Subscriber Birthdate: ____________ ID/SS#_________________

Patient’s relationship to the Subscriber: _____________________

APH Policy for Secondary Insurance: Secondary Insurance is to be processed by the patient. When you receive your Explanation of Benefits (EOB) from your primary insurance, attach the EOB to your secondary insurance form and send it in, along with a copy of your original office visit bill.

 

Financial Policy Regarding Insurance:

1. Patients are responsible for all charges regardless of insurance coverage.

2. Patients are responsible for any pre-authorizations and referrals required for payment.

3. We will not be involved in disputes between you and your insurance company regarding deductibles, covered charges and usual and customary fees, other than to provide factual information.

4. Co-payments must be paid in cash, check, or credit card. (Visa, Mastercard, or Discover)

5. Past due accounts will be subject to a  40% collection fee or $35 NSF check, and will be sent to collections after 90 days.

I, the patient/guardian, have accurately and truthfully completed the patient information listed above. I agree that all fees incurred are my responsibility regardless of insurance coverage.

 

Signature__________________________________________         Date________________

APH adheres to all HIPAA privacy rules. Full version of APH Privacy Policy is available at the front desk. By signing here, I certify that I have been notified of the APH Privacy Policy.

 

Signature_________________________________________           Date________________