Christina M. Mcalpin, M.D. - Patient Forms

Please correct the errors described below.

Registration Form

In Case of Emergency

The above information is true to the best of my knowledge. I authorize my insurance benefits to paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Christina M. Mcalpin, M.D. or insurance company to release any information required to process claims.

Disclaimer: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient Financial Agreement Form

Dr. Mcalpin requires this form to be signed by her patients. We appreciate your cooperation. If you have any questions, please speak with Billing Department. We are pleased to assist you with your insurance.

  • Financial Responsibility: I understand that with the exceptions explained below, I am personally responsible for any medical fees I will incure with Dr. Christina M. Mcalpin.

I also understand that I will be responsible for any charges incurred by not providing the most current and correct insurance information to Dr. Christina M. Mcalpin. Exception to this policy is: those patients with current authorization with HMO, state or federally funded programs or PPO in which Dr. Christina M. Mcalpin is currently contracted with.

Disclaimer: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
  • Authorization to Pay Benefits to Physician: I hereby authorize payment for medical services provided directly to Dr. Christina M. Mcalpin.
Disclaimer: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Dr. Christina M. Mcalpin will be responsible for billing and collection on professional charts. Dr. Mcalpin is not responsible for any bills you may receive from the Hospital including Anesthesia, Pathology or Laboratory services when surgery is performed. Please be aware that most surgery cases performed may require and assistant to be present, not all assistance may be contracted with your insurance policy. We will do our best to acquire a contacted assistant but this is solely based on availability of the assistant. I understand and agree with the terms and conditions listed above.

Disclaimer: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Pharmacy Location

Patient History Form

Family History: What is the health status of your family?

Father

Mother

Brother

Sister

Other

Social History

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