Patient Name definition

Patient Name. Date: ________ Patient Signature: ___________________________ (or legal representative or guardian, if applicable) Shady Grove Direct Care, P.C. By: __________________________ ___________________________ Xxxxxxxx Xxxxxx, M.D., (Member) Xxxxxxxx Xxxxxx, M.D, (Personally) APPENDIX 1: Medicare Patient Acknowledgements Member is a Medicare Part B beneficiary seeking services covered under Medicare Part B pursuant to Section 4507 of the Balanced Budget Act of 1997. T h e Practice has informed Member or his/her legal representative that Xx. Xxxxxx and the Practice have opted out of the Medicare program. Note, Xx. Xxxxxx has never been excluded from participating in Medicare Part B under [1128] 1128, [1156] 1156, or [1892] 1892 of the Social Security Act; he simply has elected to opt out as a provider in the program. Member or his/her legal representative agrees, understands and expressly acknowledges the following (initial each): _____ Member or legal representative accepts full responsibility for payment of the Practice’s membership fees. _____ Member or legal representative understands that Medicare limits do not apply to what the Practice may charge for the Services. _____ Member or legal representative agrees not to submit a claim to Medicare or to ask the Practice to submit a claim to Medicare. _____ Member or legal representative understands that Medicare payment will not be made for any of the Services furnished by Xx. Xxxxxx that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted. _____ Member or legal representative enters into this contract with the knowledge that he/she has the right to obtain Medicare-covered items and services from practitioners who have not opted out of Medicare, and member is not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other practitioners who have not opted out. _____ Member or legal representative understands that Medi-Gap plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare. _____ Member or legal representative acknowledges that they are not currently experiencing an emergency or urgent health care situation. _____ Member or legal representative acknowledges that a copy of this contract has been made available to him/her. Member Name: _________________________ Date: __________________ Member Signature: ___________________...
Patient Name. DOB: Patient Signature: Date: Provider Signature: Date:

Examples of Patient Name in a sentence

  • Patient Name Enter last name, first name and middle initial as shown on the ID card.2. Participant MO HealthNet ID NumberEnter the 8-digit MO HealthNet ID number exactly as it appears on the participant’s ID card or letter of eligibility.

  • Example: Patient Module includes Patient Name, Patient ID, Patient Birth Date, and Patient Sex.

  • Please see clause 21 and Annexure-XI in this regard.2. ELIGIBILITY CRITERIA (a) Bidder should be a manufacturer having valid manufacturing license or direct importer holding valid import license.

  • Patient Name (please print) Signature of Patient (if Patient is 12 or older) Date Signature of Representative (and relationship to Patient) Date Signature of Representative (and relationship to Patient) Date I understand that I am financially responsible to Therapist for all charges, including unpaid charges by my insurance company or any other third-party payor.

  • Patient Name (please print) Signature of Patient (or authorized representative) Date I understand that I am financially responsible to Therapist for all charges, including unpaid charges by my insurance company or any other third-party payor.


More Definitions of Patient Name

Patient Name. Date: As a participant in buprenorphine treatment for opioid addiction, I freely and voluntarily agree and understand this treatment agreement, in its entirety, as follows:
Patient Name. Date: Responsible Party: Relationship to patient: Signature: Witness Initials:
Patient Name. [PatientFirstname] [PatientLastname] Consultant: ……………………………………. __________________________________________________________________________________MACS-202
Patient Name. Address: City: State: Zip: Home Phone: Employer: Work Phone: Social Security #: Birth Date: Sex: M F (circle one) Primary Insurance Company: Group #: Address: Phone #: Subscriber Name: Co-Pay Amount: Secondary Insurance Company: Group #: Address: Phone #: Subscriber Name: Co-Pay Amount: Physician: Phone #: Address: City: State: Zip: Responsible Party: Relationship: Address: City: State: Zip: Home Phone: Work Phone:
Patient Name. Diagnosis: Admission Dates: Length of Stay: Patient – age 57 years Severe subarachnoid haemorrhage with hydrocephalus 2.9.09 – 1.4.2010 7 months (initial 24 weeks with extension 10 weeks) Discharge destination: Home
Patient Name. Signature: Date: Address: Exhibit A Membership Services & Fees The following Membership Services are included within the Urgent Access Membership Agreement. The Provider retains complete discretion to determine which Membership Services or other medical services are medically appropriate. Should the Provider determine, in its sole discretion, that the Patient’s medical condition warrants treatment by a specialist, an emergency department, or if the Provider cannot adequately treat an Patient’s condition, then the Provider shall not be required to provide treatment. Similarly, the Provider shall not be required to provide any treatment which is not listed on this Exhibit as part of the Membership Service. The Provider will not be responsible for the cost of medical transportation for a Patient, whether it is an emergency or otherwise, should the Patient need to receive further treatment. URGENT ACCESS MEMBERSHIP MEMBERSHIP SERVICES MEMBERSHIP FEES • Clinic VisitSports Physicals • School Physicals • Travel Medicine Consultations • Telemedicine “eVisits”1 • In House Laboratory Services2 • In House X-Ray Services3 • Clinic Procedures4 • Monthly Fee of $45 • Utilization Fee of $15 per urgent care visit at start of each visit • 1Telemedicine “eVisits” at $15 per eVisit • 2In House Laboratory Services at 50% of Self Pay Prices • 3In House X-Ray Services at 50% of Self Pay Prices • 4Clinic Procedures at 50% of Self Pay Prices Membership DOES NOT cover the following: Medications Vaccinations Durable medical equipment (crutches, splints) and Immigration Physicals Occ Med & Workers Comp Services (such as Drug Testing, First Aid, pre-employment physicals, DOT Physicals) Services performed by outside facilities (such as specialist visits and lab work done outside the clinic, outside imaging, hospitalization, ambulance transportation). Services not provided at St. Xxxxxxx Urgent Care Center: Ambulance transportation Any hospitalization ER Visits Specialist referrals Outside Imaging Outside Labs **Provider has final determination of care. **Provider has exclusive discretion on any condition that requires an ER Visit, Hospitalization, Imaging, Specialist Referral, or any other tests. Exhibit B Cancellation Form St. Xxxxxxx Urgent Access Cancellation Form Date First Name Last Name Membership ID # Phone # (H) (W) (C) Email: I wish to discontinue my membership with St. Xxxxxxx Urgent Care Center. Upon cancellation I will be charged the prevailing fees offered to Non-Membe...
Patient Name. Cardholder Name: Card Type: Card Number: Expiration Number: Security Code: Opt into paper billing statement: Opt out of paper billing statement: Billing Address: Patient/Guardian Consent: I give my consent to allow CorsoCare Pharmacy to charge the above checking account on a monthly basis for any prescriptions that are ordered on my behalf. Signature Date PHARMACY XxxxxXxxxXxxxxxxx.xxx | 000-000-0000 Fax: 000-000-0000 | 00000 Xxxxx Xxxx, Eastpointe, MI 48021 Notice of Privacy Agreement This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. CorsoCare Pharmacy, LLC and its affiliated entities (collectively “CorsoCare Pharmacy, LLC”) use health inform at ion about you for treatment, to obtain payment for treatment, to evaluate the quality of care you receive, and for other administrative and operational purposes. Your health information is contained in a medical record that is the physical property and responsibility of CorsoCare Pharmacy, LLC.