Sarita Kansal, MD - Publicforms

Available Forms

APPOINTMENT REQUEST HIPPA NOTICE/CONSENT FORM MEDICAL INFORMATION FORM MEDICATION REFILL REQUEST PATIENT INFORMATION SHEET RECORDS RELEASE FORM

PATIENT INFORMATION SHEET

PATIENT NAME *

BIRTHDATE *

AGE *

ADDRESS *

CITY *

ZIP *

PHONE (H) *

CELL

EMERGENCY CONTACT *

name & number

EMAIL ADDRESS *

This will only be utilized for the patient portal.

MARITAL STATUS *

RACE

ETHNICITY

LANGUAGE

SOCIAL SECURITY NUMBER

PRESENT EMPLOYER

POSITION

ADDRESS

PHONE NUMBER

PHARMACY NAME *

PHARMACY ADDRESS

PHARMACY NUMBER

INJURED ON A MOTOR VEHICLE ACCIDENT?

If checked, you will need another form.

INJURED IN A WORK RELATED ACCIDENT?

If yes, you will need another form.

REGULAR INSURANCE (WE WILL NEED YOUR INSURANCE CARD AT APPOINTMENT.)

TYPE *

IDENTIFICATION NUMBER *

GROUP ID NUMBER *

POLICY HOLDER *

RELATIONSHIT TO PATIENT *

POLICY HOLDER D.O.B *

EMPLOYER OF POLICY HOLDER *

DO YOU HAVE OTHER HEALTH INSURANCE?

If checked, fill out the next section.

TYPE

IDENTIFICATION NUMBER

GROUP ID NUMBER

POLICY HOLDER

RELATIONSHIP TO PATIENT

EMPLOYER OF POLICY HOLDER

I UNDERSTAND THAT I AM RESPONSIBLE FOR THE FULL COST OF SERVICES RENDERED AT EACH APPOINTMENT. 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 WEN NECESSARY OR 3) ANY BALANCE DUE AFTER INSURANCE SETTLEMENT, THEN I AM PERSONAL RESPONSIBLE. I AUTHORIZE MY INSURANCE BENEFITS TO BE PAID ON MY BEHALF TO SARITA 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. BY SIGNING BELOW I CERTIFY THAT THE ABOVE PERSONAL AND INSURANCE INFORMATION IS ACCURATE.

SIGNATURE *

DATE *

* Required field