Driver's License or ID# and State
Please add the main phone number where you can be reached.
Please add an alternate phone number where you can be reached.
Spouse's Full Name if applicable
If employed: Please give us your employer's information.
Nearest relative or emergency contact not living with you that we can contact in case of emergency, such as hospitalization
Please add your insurance company name. If no insurance, please add Not Applicable or N/A in the fields regarding insurance.
From the back of your insurance card, please indicate the insurance company address. Insurance companies offer different products and they are processed differently. That's why it's important that we have the correct address for your insurance.
Person under which the insurance is under.
Please indicate what's the relationship of the person who has the insurance to you.
Insurance Phone Number
Please read and sign all required areas.
Please enter the name of the person responsible for the payments on this account.
BY CHECKING THE BOX I AGREE THAT ALL SERVICES ARE DUE WHEN PERFORMED. I UNDERSTAND THAT I'M RESPONSIBLE FOR ALL CHARGES INCURRED, EVEN IF I HAVE MEDICAL INSURANCE COVERAGE. IN THE EVENT OF DEFAULT, I AGREE TO PAY ANY COLLECTION COST AND OR ATTORNEY FEES, AS REQUIRED, TO COLLECT CHARGES INCURRED. I AGREE TO PAY INTEREST OF 1% OVER THE PRIME RATE IN EFFECT, ACCRUING MONTHLY, ON ALL UNPAID PATIENT BALANCE. IF ELIGIBILITY OF INSURANCE CANNOT BE VERIFIED, OF IF THE DEDUCTIBLE HAS NOT BEEN MET, I UNDERSTAND THAT I WILL BE RESPONSIBLE FOR THE COST OF ALL MEDICAL SERVICES.
I UNDERSTAND THAT ALL NON-COVERED SERVICES ARE TO BE PAID BY ME AT THE TIME THE SERVICE IS PROVIDED. NON COVERED SERVICES INCLUDE FORMS AND ANY OTHER SERVICE NOT COVERED BY MY INSURANCE.
BY CHECKING THE BOX, I AUTHORIZE PAYMENT DIRECTLY TO Arrowhead Internal Medicine, PC; Michael Castro, MD; Srivani Shrikantiah, MD, PLLC; OR Elfat Rumman, MD, LLC FOR THE MEDICAL BENEFITS, IF ANY, OTHERWISE PAYABLE TO ME UNDER TERMS OF MY INSURANCE FOR ANY SERVICES FURNISHED BY MY HEALTH PRACTITIONER.
I acknowledge that I have received a copy of AIMPC, SS and/or ER ?Notice of Privacy Practices.? This notice describes how AIMPC, SS and/or ER may use and disclose my protected health information, certain restrictions on the use and disclosure of healthcare information and rights I may have regarding my protected information.
BY CHECKING THE BOX I AGREE TO AIMPC, SS and/or ER to release information about all vaccinations given to me or to the person for whom I am authorized to consent, to the Arizona State immunization Information System (ASIIS), other health care providers and schools in order to avoid receiving unnecessary vaccinations and to the provide information about what immunizations have been received. I understand that I am not required to agree to the release of this information in order to receive the vaccine I request.
For the following statements, Arrowhead Internal Medicine, PC and Michael Castro, MD FACP are also known as AIMPC; Srivani Srikantiah, MD PLLC is also known as SS; Elfat Rumman, MD PLLC is also known as ER.
BY CHECKING THE BOX I AUTHORIZE AIMPC, SS and/or ER and its affiliated Providers to view my external prescription history via the ePrescribing services. I understand that prescription history from other unaffiliated medical providers, insurance companies, and pharmacy benefit managers may be viewable by my providers and the staff and it may include prescriptions back in time for several years.
BY CHECKING THE BOX I AGREE TO AIMPC, SS and/or ER to release any information required in the course of the patient?s examination of treatment to Insurance companies for payment. I hereby authorize any photocopies of this form to be valid as the original.
BY CHECKING THE BOX I AGREE TO AIMPC, SS and/or ER to take photographs of me. I understand that these photographs will be used for medical and administrative purposes, such as documenting or planning of care; or to identify patients. These photos will be stored in our electronic medical records.