Narendra Kansal, MD - Publicforms

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APPOINTMENT REQUEST BACK OR LEG DISABILITY FORM HIPPA NOTICE/ CONSENT FORM MEDICATION REFILL REQUEST NECK DISABILITY FORM NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW ASSIGNMENT OF BENEFITS FORM NO FAULT CLAIMANT HISTORY FORM NO FAULT INFORMATION SHEET PATIENT INFORMATION PART 2 PATIENT INFORMATION SHEET 1 RECORDS RELEASE FORM REVIEW OF SYSTEMS Welcome to our Neurosurgery practice. WORKERS COMPENSATION INFORMATION SHEET

PATIENT INFORMATION SHEET 1

PATIENT NAME *

BIRTHDATE *

AGE *

SEX *

MALE

FEMALE

ADDRESS *

CITY *

ZIP *

HOME PHONE

CELL PHONE *

WORK PHONE

BEST NUMBER TO BE REACHED AT

EMERGENCY CONTACT NAME & PHONE *

SOCIAL SECURITY NUMBER

EMAIL ADDRESS *

MARITAL STATUS *

NAME OF SPOUSE/ D.O.B

RACE

ETHNICITY

LANGUAGE PREFERENCE *

ARE YOU RIGHT OR LEFT HANDED?

PRESENT EMPLOYER *

POSITION

ADDRESS OF EMPLOYER *

PHONE NUMBER *

FAMILY DOCTOR *

FAMILY DOCTOR NUMBER *

ADDRESS

REFERRING DOCTOR *

REFERRING DOCTOR NUMBER *

ADDRESS

DO YOU SEE A CHIROPRACTOR OR ARE YOU GOING FOR PHYSICAL THERAPY?

If YES, with who and for how long?

PHARMACY NAME/ADDRESS/PHONE *

INSURANCE INFORMATION

INJURED IN A MOTOR VEHICLE ACCIDENT? *

YES

IF YES, WILL NEED TO FILL OUT NO FAULT INFORMATION SHEET

INJURED IN A WORK RELATED ACCIDENT? *

YES

IF YES, WILL NEED TO FILL OUT WORKERS COMPENSATION INFORMATION SHEET

REGULAR INSURANCE, WE WILL NEED YOUR INSURANCE CARDS.

TYPE *

IDENTIFICATION NUMBER *

GROUP NUMBER *

POLICY HOLDER *

RELATIONSHIP TO PATIENT *

POLICY HOLDER D.O.B *

EMPLOYER OF POLICY HOLDER *

DO YOU HAVE OTHER HEALTH INSURANCE? *

YES

IF YES FILL OUT INFORMATION BELOW

TYPE

IDENTIFICATION NUMBER

GROUP NUMBER

POLICY HOLDER

RELATIONSHIP TO PATIENT

EMPLOYER OF POLICY HOLDER

BY SIGNING BELOW, I UNDERSTAND THAT I AM RESPONSIBLE FOR THE FULL COST OF SERVICES RENDERED TODAY. I AUTHORIZE THE RELEASE OF ANY MEDICAL OR OTHER INFORMATION NECESSARY FOR THE PROCESSING OF MY MEDICAL CLAIMS. I RECOGNIZE THAT IF 1) I HAVE NO INSURANCE 2) I HAVE HMO INSURANCE BUT FAIL TO OBTAIN A REFERRAL WHEN NECESSARY OR 3) ANY BALANCE DUE AFTER INSURANCE SETTLEMENT, THEN I AM PERSONALLY RESPONSIBLE. I AUTHORIZE MY INSURANCE BENEFITS TO BE PAID ON MY BEHALF TO NARENDRA KANSAL M.D. I UNDERSTAND IT IS MANDATORY TO NOTIFY THE HEALTH CARE PROVIDER OF ALL THE PARTIES WHO MAY BE RESPONSIBLE FOR PAYING FOR MY TREATMENT. I CERTIFY THAT THE ABOVE PERSONAL AND INSURANCE INFORMATION IS ACCURATE.

SIGNATURE *

DATE *

* Required field