SEACOAST AREA PHYSIATRY, P.C.
You may type your responses then print the form or print it then complete in ink, please.
Name___________________________________________________ Birth Date______________ Age_____ Sex_____
Mailing Address___________________________________________ E-mail address _____________________________
Town____________________________________________________ State_____ Zip_____________
Home Phone_______________________ Cell Phone _______________________ Social Security #____________________
Primary Language ________________________________ Race _______________ Ethnicity __________
_______________
Employment status:
Retired
Disabled Disability Carrier__________________________________________________________
Employed Employer/Phone number____________________________________________________
Occupation_______________________________________________________________
Referred By ______________________________________ Primary Care Physician _________________________________
Pharmacy Name____________________________ Phone # ___________________ Address ___________________________
INSURANCE INFORMATION/RESPONSIBLE PARTY: ____________________________________________________
Primary ___________________________________________ Secondary ___________________________________
Address___________________________________________ Address____________________________________
Subscriber’s Name__________________________________ Subscriber’s Name___________________________
Birth Date_____________ SS#________________________ Birth Date____
_____ SS#_____________________
Relation to Patient___________________________
_______ Relation to Patient____________________________
Certificate #_____________________ Group #__________ Certificate #__________________Group #_______
PRESENTING PROBLEM:_____________________________________________________________________
Date of Injury or date symptoms first appeared_______________________________________________________
Is this: ____Work Related ____ Auto _____ Other (Explain)________________________________________
IF INJURY OR CONDITION IS WORK RELATED, PLEASE COMPLETE THE FOLLOWING:
(If you are filing Workmen’s Compensation, please complete this area)
Employer____________________________________ WC Carrier _______________________________________
Address______________________________________ Address___________________________________________
Phone #______________________________________ Phone #___________________________________________
Job Title_____________________________________ Claim #________________________________________
___
I AUTHORIZE MY INSURANCE COMPANY TO PAY BENEFITS DIRECTLY TO SEACOAST AREA PHYSIATRY, P.C. AND
THAT ANY BALANCE AFTER MY INSURANCE HAS PAID IS MY RESPONSIBILITY. (This applies to inpatient and outpatient
services). I ALSO UNDERSTAND THAT I AM RESPONSIBLE FOR SERVICES RENDERED TO MYSELF OR MY DEPENDENT
AT THE TIME OF SERVICE, AND THAT ANY FINANCIAL ARRANGEMENT WILL BE DISCUSSED PRIOR TO TREATMENT.
THE OFFICE OF SEACOAST AREA PHYSIATRY, P.C. IS HEREBY AUTHORIZED TO RELEASE ANY INFORMATION TO MY
INSURANCE CARRIER FOR CLAIMS PROCESSING
AND PAYMENT OF MY BILL RELATIVE TO ANY TREATMENT
RENDERED TO ME.
Signature of Responsible Party______________________________ Date _________________________
WELCOME TO OUR PRACTICE!
PLEASE LET US KNOW IF THERE ARE ANY SPECIAL NEEDS THAT YOU MAY HAVE OR IF THERE ARE
ANY QUESTIONS YOU MAY HAVE REGARDING OUR POLICIES.
1. Understanding Your Provider’s Role: PLEASE UNDERSTAND THAT WE ARE NOT PRIMARY CARE
PHYSICIANS. Your provider at Seacoast Area Physiatry will be serving as a CONSULTANT in evaluating and treating the
condition you have described. You may have other medical problems not related to Physical Medicine and Rehabilitation that
require evaluation and treatment by a Primary Care Physician or other medical specialist. Your care provider at SAP is NOT A
SUBSTITUTE FOR CARE PROVIDED BY A PRIMARY CARE PHYSICIAN. As such, we recommend that ALL PATIENTS
have a Primary Care provider in addition to your provider at Seacoast Area Physiatry. As consultants we are not available nights
and weekends. You are expected to call your referring provider, primary care provider, or if not available, go to the emergency
room if an emergency arises.
2. Financial Policy: Payment is expected at time of service. If you need to make other arrangements, please inquire. In the
event that your account balance becomes delinquent, you will be responsible for collection agency fees and/or attorney court
fees. If payment by your insurance company is delayed, we request your assistance in hastening the process. Please remember
that medical insurance is a benefit that you have subscribed to help you with your health expense(s) and usually covers less than
100% of the total bill. Therefore, we must look to the patient (responsible party), not the insurance company, as the person
responsible for payment of the bill. We do provide the necessary paperwork for you to bill your insurance.
All self pay accounts will require full payment at the time of the initial visit. Billing staff will provide the best possib
le
estimate at time of scheduling of the cost of anticipated service. Payment plans are only available for established accounts
and with approval of the billing manager.
Copays are part of our contractual participation with your insurance and will be collected at the check-in desk.
Braces and supplies are non-returnable and non-refundable.
There will be a $25.00 charge for a returned check.
There will be a minimum charge of $50.00 for the completion of FMLA, loan deferral forms, etc.
3. Cancellation Notice: This office has a policy of charging a fee for missing an appointment or canceling with less than one
working day’s notice. This policy is explained at the time of the first visit. The fee is $50.00 The purpose of this fee is to encourage
our patients to take their appointments as seriously as we do. If you do not keep the scheduled appointment, other patients who need
“same day” urgent visits or earlier appointments than the schedule permits are being obliged to wait longer than necessary.
Excessive no-shows or late cancellations may jeopardize future appointments with our practice. Please also be informed if you are
seen here for a worker’s compensation injury, the insurance carrier and/or case manager will be notified of all no-shows.
4. Commun
ication: Please complete your communication preferences.
You have my permission to confirm my appointment by leaving a message at the following phone number:
_________________________.
You may discuss my medical condition or leave test results with the following person: ___________________________.
You may leave a message with test results at the following phone number ___________________________.
5. HIPAA: I have reviewed a copy of the Joint Notice of Privacy Practices. The Joint Notice describes how my health information
may be used or disclosed. I understand that I should read it carefully. I am aware that the Joint Notice may be changed at any time.
I may obtain a revised copy of the Joint Notice by calling (603) 431-5529 or by requesting one at the office. You can complain to
us and to the federal Secretary of the Department of Health and Human services if you believe your privacy rights have been
violated. To lodge a complaint with us, please file a written complaint with Ellen, the HIPAA Privacy Officer. Ellen will also
provide you with further information about our privacy policies upon request. No action will be taken against you for filing a
complaint. _______Initial here
I HAVE READ AND UNDERSTAND THE ABOVE POLICIES:
___________________________________ ____________
Signature of Patient or Responsible Party Date
Date Initials
I.D. verified _______ ______
I.D. verified _______ ______
I.D. verified _______ ______
I.D. verified _______ ______
I.D. verified _______ ______
Click here to Print
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome