Patient Signature. Patient Name (print): Date: The patient signed the PATIENT AGREEMENT in my presence after I counseled her and answered all her questions. I have given her the MEDICATION GUIDE for Mifeprex. Provider’s Signature: Name of Provider (print): Date: After the patient and the provider sign this PATIENT AGREEMENT, give 1 copy to the patient before she leaves the office and put 1 copy in her medical record. *MIFEPREX is a registered trademark of Danco Laboratories, LLC.
Patient Signature. DATE: GUARANTOR SIGNATURE: DATE: (If different from patient) GUARANTOR NAME (Please print): REFERRAL SOURCE: (please circle one) Friend/Family Member Insurance Website Google Social Media Doctor: Other: PHARMACY INFORMATION: I understand that the State of Texas now requires certain prescriptions to be sent to the pharmacy electronically. Please provide below your preferred pharmacy and your personal e-mail for ePrescribe. PHARMACY NAME & STORE NUMBER: PHARMACY ADDRESS: CITY, STATE & ZIP CODE: PHARMACY PHONE NUMBER: **If the pharmacy information is not filled out in detail this will delay processing of all prescriptions** Texas Knee and Sports Medicine Center X. X. Xxxxxxxx, X.X. ACCIDENT DETAILS Patient Name: Insurance companies require information about how you were injured. They would like to have this information in your writing. Please complete every line of this form, as this information will be sent to your insurance company, if it is requested, to expedite claim processing. Please circle one: Is this a work injury? YES NO Is this a third party liability claim (auto accident/business liability) YES NO Date injury occurred: What body part was injured? Where injury occurred: In your own words, describe how the injury happened in detail: AUTHORIZATION Patient and/or guarantor are responsible for charges incurred. It is a courtesy for our office to file your insurance; however, you are responsible for your co-pay and/or percentage, which the insurance company is not liable for on the day of your visit. In the event that your insurance company has not paid within 60 days, you are responsible for the balance due. It is also the patient’s responsibility to obtain referrals from your primary care physicians when required. If the referral is not obtained before the visit, the patient is liable for payment in full on the date of service. If we are unable to obtain payment within a reasonable amount of time from the patient and/or guarantor we will place your account with a collection agency, which will leave you liable for additional expenses incurred if applicable. I have fully read and understand the above statement of payment policy. I hereby request any benefits on my behalf, to be paid to the physician. I also authorize the release of any information acquired in the course of my treatment to my insurance company as needed to issue benefits. I authorize the physician to administer such treatment, as they may deem advisable for my diagnosis and treatment. I...
Patient Signature. Date: 3rd Party Guarantor (Organization & Authorized Agent): 3rd Party Guarantor Authorized Signature: Date: Patients who are unwilling or unable to agree to the financial responsibility terms regarding Custom Orthotics at County Physical Therapy may proceed as follows: • For patients who desire Custom Orthotics to be paid only through their insurance coverage, County Physical Therapy can direct you to an alternate provider. Maine Orthotics and Prosthetics, which is the manufacturer CPT is affiliated with, is based in Portland and does participate with most insurances to bill your Custom Orthotics. • Alternative, non-custom orthotics are usually available. Although they are not custom-molded to your foot, they provide a lower-cost alternative to Custom Orthotics. • Patients may also reimburse County Physical Therapy in full for their Custom Orthotics, and seek reimbursement directly from their insurance company or 3rd party.
Examples of Patient Signature in a sentence
I agree that all information provided above by me in the claim documents is true and that if I have provided any false or untrue information, my right to claim the reimbursement of expenses shall be absolutely forfeited.Name of Patient / Relative: Relationship with Patient: Signature of Patient / Relative Date: DD / MM / YYYYPlease attach this form in Original to the hospital bill and other claim documents.
Signature: Patient Signature: Authorized Healthcare Professional obtaining and witnessing patient’s signature Signature: Attending physician (if applicable) Date: Time Date: Time Date: Time To be used if the patient is a minor, unconscious, or otherwise lacking decision making capacity.
Patient Print Name Patient Signature Date Responsible Party Print Name (if not patient) Responsible Party Signature (if not patient) Date Important Note Regarding After Hours/Weekend Services Relievus provides care for chronic problems.
Patient Name (printed) Date Patient Signature (18yrs and older) Parent/Guardian Signature (if applicable) Patient Responsibility Agreement & Therapy Terms/Conditions I, as myself, or as a representative for my child would like to pursue all means necessary to obtain speech/language/feeding services for myself/my child.
Patient Full Name (please print) Patient Signature Date Signed (YYYY/MM/DD) FOR PATIENTS OVER THE AGE OF 65 OR THOSE RESIDING IN BC, MB, AND SK:Certain drugs require prior approval from Provincial or Pharmacare Programs before they are eligible for coverage.ALL INITIAL AND RENEWAL SUBMISSIONS FOR PROVINCIALLY ELIGIBLE DRUGS MUST BE SUBMITTED TO THE PROVINCIAL PLAN FIRST.
More Definitions of Patient Signature
Patient Signature. NAME IN PRINT: DATE: --------------------- --------------------- --------------- SURGEON ACKNOWLEDGMENT: "I certify that I (or a member of my staff) have discussed all of the above with the patient, in a language that the patient understands, and have offered to answer any questions regarding the procedure. I believe that the patient fully understands the explanations given and the answers provided."
Patient Signature. Date: GP Signature: Date:
Patient Signature. Date: Name: Date: W here is your pain now? Mark the areas on your body where you feel discomfort, using the symbols found below include ALL affected areas. Circle the area where your pain is the worst: Right Left Left Right ↓↓↓↓ Aching ==== Numbness ●●●● Pins & Needles XXXX Burning ∕ ∕ ∕ ∕ ∕ ∕ Stabbing List any current symptoms related to this injury: How bad is your pain now? Mark on the line below how bad your pain is now. No Pain Worse Possible Name: Date: y with an X”) k clear Review of Systems H ave you had any of the following in the last 1 to 2 weeks (Mar l General: □ No Problems □ Fever/ Chills □ Weight loss □ Weight gain □ Fatigue/ weakness Eyes: □ No Problems □ Blurry vision □ Double vision □ Change in vision □ Glasses/ contacts/ LASIK Ears, Nose Mouth Throat: □ No Problems □ Congestion □ Ringing in ears □ Hearing loss □ Sore throat □ Teeth/ Gum disease □ Allergies □ Nose Bleeds □ Swollen Glands Cardiovascular: □ No Problems □ Chest pain □ Swollen ankles/ feet / hands □ Palpitations □ Blood Pressure Problems □ Heart problems Respiratory: □ No Problems □ Wheezing □ Coughing □ Shortness of breath □ Asthma □ Spitting up Blood Skin/Breasts: □ No Problems □ Dry Skin □ Skin lesions/ Rash / moles □ Pigmentation changes □ Nipple discharge □ Change in Skin Color □ Itching Neuro/Psych: □ No Problems □ Numbness/Tingling □ Fainting / Dizziness □ Tremor □ Depression □ Anxiety / Stress □ Memory loss/ Confusion or Cloudiness □ Sleep disorder/Insomnia □ Head injuries □ Headaches □ Seizures □ Balance issues Hematology/Endocrine: □ No Problems □ Anemia □ Bleeding/Bruise tendency □ Blood clots □ Heat/cold intolerance □ Hormone problems □ Diabetes □ Excessive Thirst or Urination □ Slow healing cuts □ Night sweats Gastrointestinal: □ No Problems □ Abdominal pain □ Nausea/vomiting □ Heartburn □ Blood in stool □ Constipation/diarrhea □ Liver disease □ Loss of Appetite Genitourinary: □ No Problems □ Painful urination □ Frequent urination □ Blood in urine □ Urine incontinence □ Kidney disease/Stones □ Sexual Difficulty Musculoskeletal: □ No Problems □ Joint pain / arthritis □ Joint Swelling □ Muscle weakness □ Back pain □ Chest wall pain □ Cold Extremity □ Extremity pain □ Loss of motion □ Amputation
Patient Signature. Date: / / Authorized Representative Signature (if applicable): Date: / / If signed by Authorized Representative, please confirm the nature of your relationship with Patient: and check reason why Patient is unable to sign: Patient is a minor under the age of 18 years and parent or legal guardian signature is required. Patient is not competent to give consent due to a physical or mental condition. Other (please specify): Corporate Headquarters 000 Xxxxx Xxx. N.W. New Prague, MN 56071 Phone: 000-000-0000 Fax: 000-000-0000
Patient Signature. Date: Patient Name (Printed): Pain Doctor Name: Interpreter’s Statement: I have provided interpretation of Your Chronic Pain Care Agreement to the patient or their representative in a language or means of communication that the patient or representative has indicated they are reasonably likely to know. Language: Name of Qualified Medical Interpreter: Interpreter Signature: _Date: Time: In-Person Interpretation Video Remote Interpreter Language Line Used Atrium Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex.
Patient Signature. Date: Patients DOB: Nominated Repeat Dispensing Pharmacy name, address and tel no:
Patient Signature. Date: Legal Guardian: Date: