Patient Form - Dr. James Linder

Patient Information
Name
Prefix First Last
Preferred Name
Birth Date
Month
Day
Year
SSN
Sex
- Male
- Female
Race
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone
Work Phone
Cell Phone
Is it OK to leave a message on your answering machine regarding your health information?
- Yes
- No
Email
Preferred Contact Method
- Home Phone
- Work Phone
- Cell Phone
- Email
Employer
Employer's Address
Emergency Contact Name
Relationship
Phone
Preferred Pharmacy
Pharmacy Phone Number
Referred by

Insurance Information
Primary
Insurance Company
Claims Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone
ID/Policy #
Group/Plan #
Secondary
Insurance Company
Claims Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone
ID/Policy #
Group/Plan #
Responsible Party's Name
Prefix First Last
Sex
- Male
- Female
Birth Date
Month
Day
Year
SSN
Relationship to Patient
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone
Work Phone
Cell Phone
Employer
Employer's Address
I have checked with my insurance company and verified that the provider I'm seeing is a participating provider on my insurance plan. If a referral from another provider is required before seeing the providers of James S. Linder, M.D., I agree that it is my responsibility to obtain such a referral. It is also my responsibility to advise the office in advance if precertifications are needed. If my insurance company requires the use of a specific lab, I have listed it above. If any charges remain unpaid because I have not provided the proper information itemized above or because services are not covered by my plan, I agree to be personally liable for those charges.
Signature of Patient/Responsible Party*
Date

We appreciate the opportunity to serve you and desire to provide you with the best service possible. The information below is intended to ensure you are aware of certain treatment, financial, and privacy policies. If you have any questions, please inform a member of our front desk staff.
Consent For Medical Treatment

In consideration of the treatment(s) rendered and to be rendered I hereby authorize the medical provider James S. Linder, M.D., P.C., "Dr. Linder", or any other medical providers authorized by it, to provide such medical services, either regular or emergency, as may be determined by the medical provider to be in my best interests (or the best interests of my dependent if I am signing as a parent/guardian).
Consent For Medical Treatment*

Consent For Electronic Prescribing

I authorize the physicians, and other appropriate licensed providers of James S. Linder, M.D., P.C. and their healthcare team to submit my prescriptions to my pharmacy using secure e-prescribing software. I further authorize access to my medical history, prescription history and current medications from any and all health care providers.
Consent For Electronic Prescribing*

Consent For Student Participation

I understand that my attending physician and/or other James S. Linder, M.D., P.C. personnel may be accompanied and/or assisted by students in various fields of study related to healthcare, such as nursing, physician assistant, medical students, interns, residents, and other allied health fields, and at various stages in their education. I consent to the presence and/or participation in my treatment by these persons while under the direction or supervision of my physician or other healthcare provider.
Consent For Student Participation*

Acknowledgement of Receipt of Privacy Practices Notice

I hereby acknowledge I have been offered and/or received a copy of the Privacy Practices Notice of James S. Linder, M.D., P.C. The practice and its representatives may contact me and leave a voicemail message if necessary unless I completed a REstriction Form which has been approved in writing by James S. Linder, M.D., P.C.
Acknowledgement Of Receipt Of Privacy Practices Notice*

Consent For Financial Responsibility

I hereby assign, transfer and set over to James S Linder, M.D., P.C. all of my rights, title and interest to medical reimbursement benefits provided by my insurance policy(ies) listed below and/or any other third-party payor responsible for paying for the services rendered by Dr. Linder or related medical providers. Should payment be made directly to me, I agree to immediately endorse such payment to Dr. Linder

In those cases where payment is not collected at the time of service, I understand that I am responsible for the cost of the medical services rendered and agree to pay any and all amounts not paid by other within sixty (60) days form the date billed unless there are other agreements in writing between me or my insurance company and James S. Linder, M.D., P.C. In the event of any dispute, I agree to pay Dr. Linder's collection costs, up to 33.3%, which will be added to the unpaid balance. Other charges may include bad check charges, court costs, witness expenses and reasonable attorney's fees. You agree, that in order for us to service your account or collect amounts you owe, we and our collection agency may contact you by any telephone number associated with your account, including wireless numbers, which could result in charges to you. We and our collection agency may also contact you by sending texts or emails, using any email address you provide us. Methods of contact may include pre-recorded/artificial voice messages and/or use of an automatic dialing device, as applicable. I understand that a refund will not be issued to me until all visits are paid in full and my account retains a credit balance.

I understand that it is my responsibility to know the requirements of my insurance policy and to comply with them. If Dr. Linder does not participate in my plan, I agree to be responsible for any costs not paid by my insurance company. Furthermore, if my insurance plan does not pay Dr. Linder, for any reason, I agree to be responsible for the costs of my treatment.
Consent For Financial Responsibility*

I specifically give Dr. Linder the authority to release my medical records to any medical provider who needs access to them to provide appropriate medical care. Furthermore, Dr. Linder may release my medical records to those who perform Dr. Linder's billing services and to any third-party payors who are responsible for my bill. I acknowledge receipt of Dr. Linder's privacy guidelines and have been given the opportunity to object to other listed reasons for release. These authorizations and releases remain in effect until I choose to revoke them by delivering a written statement to James S. Linder, M.D., P.C.
Signature of Patient/Responsible Party
Date
In the event we cannot contact you, please list any family members or other persons, if any, who we may inform about your general medical conditions and diagnosis and/or appointment information.
Name
Relationship
Phone
Name
Relationship
Phone
Name
Relationship
Phone

Patient Information

Insurance Information

Primary

Secondary

Patient History Form

Past Medical History

Current Medications

Family History

Social History

Immunization History

Ocular History

Other Surgical History

Systems Review

Consent For Medical Treatment

Consent For Electronic Prescribing

Consent For Student Participation

Acknowledgement of Receipt of Privacy Practices Notice

Consent For Financial Responsibility