Personal Habits. 1. Uses the bathroom appropriately, including dressing and hand washing.
Personal Habits. Students are expected to abstain from the use of any tobacco, alcoholic beverages and illicit drugs, both on and off campus. They will also maintain behavior above reproach in all relationships, avoiding appearances of evil. Students not maintaining these standards will be dismissed from the College.
Personal Habits. Do you currently smoke: □ No □ Yes Former smoker: □ No □ Yes Type and amount: Do you currently use alcohol: □ No □ Yes Type and amount: Do you currently use drugs: □ No □ Yes Type and amount: Do you currently follow any special diet: □ No □ Yes Explain: Do you currently exercise: □ No □ Yes Type and frequency: List highest grade completed or degree received: Physician signature Date: Patient Medical History Patient Name: Date of Birth: Today’s Date: Family History: List all major medical illness for each member. Mother: Father: Grandparents: Siblings: Children: The information on this form is accurate to the best of my knowledge. I understand this Practice does not participate in the New York State Medicaid program, and, failure to disclose my coverage with the Medicaid program, prior to receiving services, may result in a balance being owed by me. I understand it is my responsibility to notify the office of any changes in the information contained on this form. I hereby give my consent to Trinity Medical, WNY to use and disclose protected health information about me to carry out treatment, payment, and health care operations. I authorize payment of medical benefits to the named physician/practice for services rendered. I understand that I am responsible for any additional fees incurred as a result of placing my account with an outside collection agency. x Date: Signature of Patient or Parent/Legal Guardian (if patient under 18 years of age) x Printed Name of person signing form if different from patient Physician signature Date: Payment Policies We would like to thank you for choosing Trinity Medical, WNY as your healthcare provider. We are committed to providing you with the best possible medical care and make every effort to keep down the cost of this medical care. The following information outlines your financial responsibilities related to payment for your care. Accepted Insurance plans: Please contact your practice directly for accepted Insurance plans Copays/Deductible/Co-Insurance: We are contractually obligated to report visits to an individual’s insurance provider. When the insurance processes these bills, they charge all out of pocket expenses (copay, deductible, and co-insurance) based on the individuals policy contract which we are obligated to collect. We will collect these payments due at time of service. For your convenience we accept Visa, MasterCard, Discover, personal checks and cash. If you do not have your payment at time of service, y...
Personal Habits. 3. At what times does the apartment need to be quiet? Weekdays: Weekends:
