Patient Information

Name:

Date of Birth:

Social Security Number:

Home Phone:

Cell Phone:

Email:

Street Address:

City:

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Zip:

Employer Name:

Occupation:

Telephone:

Emergency Contacts:

Name:

Relationship:

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Insurance Information

Primary Insurance

Insurance Member ID

Secondary Insurance

Insurance Member ID

Medical Info Release and Assignment of Benefits

I authorize the release of any medical information necessary to process this claim. I permit a copy of this authorization to be used in place of the original.

I hereby Authorize Dr.

to apply for benefits on my behalf or covered services rendered by him or by his order. I request that payment from my insurance be made directly to Valencia Pulmonary Medical Group(or to the party who accepts assignment)

I certify that the information I have reported with regards to my insurance coverage is correct. I permit a copy of this authorization to be used in place of the original. This authorization may be revoked at any time in writing.

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

Signature:

Date:

Reason for today's visit:

Referred by:

Previous Surgeries and Hospitalizations:

Are you nursing, pregnant or planning to become pregnant?

Yes No N/A

Do you regularly drink alcohol?

Yes No

If yes, Amount:

Frequency:

Personal Medical History

Other medical Conditions:

Immunization:

Valencia Pulmonary Medical Group

Pharmacy Name:

Location:

Pharmacy Phone Number:

Drug Allergy:

Reaction:

Severity:

Add additional drug allergies.

Current medications, dosages, and frequency of use:

If other, Please specify:

If yes, Number of Years:

PATIENT RECORD OF DISCLOSURES

In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual's office instead of the individual's home.

I wish to be contacted in the following manner (check all that apply):

Other, Please specify

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

Patient Signature:

Date:

Birthdate:

The Privacy Rule generally requires healthcare providers to take reasonable steps to limit the use or disclosure of, and requests for PHI to the minimum necessary to accomplish the intended purpose. These provisions do not apply to uses or disclosures made pursuant to an authorization requested by the individual.

Healthcare entities must keep records of PHI disclosures. Information provided below. if completed properly, will constitute an adequate record.

( Note: Uses and disclosures for TPO may be permitted without prior consent In an emergency. )

Valencia Pulmonary Medical Group

23928 Lyons Ave. Suite # 203, Newhall, Ca 91321
Charanjit Saroa, MD
Himanshu Wickramasinghe, MD
Rami El-Yousef, MD

Dear Patient,

Please note that we bill your insurance company as a courtesy to you. It is the policy of this office to allow 60 days for insurance payment, at which time payment is expected. If we do not receive payment in 60 days, the amount outstanding for services rendered will become your responsibility and you would have to contact your insurance company for any inquiries regarding payment for services rendered.

I hereby authorize payment of insurance benefits directly to the above provider. I realize that this may not represent the full payment for services, and I will be responsible for the balance due.

I hereby authorize the above provider to bill Medicare for services provided to me.

I am not currently covered by any insurances and understand that I am responsible for the charges for services rendered.

All co-pays and existing balances are due prior to seeing the doctor we will not bill you for your co-payment.

Additionally, due to an increased number of "No Shows" if you are an established patient a $70.00 fee will be applied if an appointment is not cancelled within 24 hours.

If you are a new patient the "No Show" fee will be $80.00.

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

Signed / Name: (Insured or Authorized Person)

Date:

Your information will be encrypted.