Patient Demographics

Image

Patient's Name

Date of Birth

Street Address

City

State

Zip

SS Number

Email address

Ethnicity

Preferred Phone

Alternate Phone

Emergency Contact

Phone

Relationship

Pharmacy Name

Address

Referred By

PATIENT’S EMPLOYER INFORMATION

Employer Name

Telephone Number

Employer Address

City

State

Zip

Occupation

INSURED PERSON IF NOT PATIENT

Guarantor Name

Date of Birth

Street Address

City

State

Zip

Relationship to Patient

Employer Name

INSURANCE DETAIL

Medicaid #: (if applicable)

Medicare # :(if applicable)

Primary Plan

ID Number

Group Number

Phone Number

Secondary Plan

ID Number

Group Number

Phone Number

AUTHORIZATION TO RELEASE INFORMATION AND ASSIGNMENT OF BENEFIT

I authorize the release of any medical information necessary to process this claim. I permit a copy of this authorization to be used in the place of the original. I authorize Dr. Modi to obtain my medication history on-line. I hereby authorize Dr. Chintan Modi to apply for benefits on my behalf for covered services rendered by him/her or by his/her order. I request that payment from my insurance company be made directly to Dr. Chintan Modi (or to the party who accepts assignment).

I certify that the information I have reported with regards to my insurance coverage is correct. If at any time my insurance coverage changes, I must notify the office staff immediately. This authorization may be revoked by either me or the insurance company at any time in writing.

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's Name / Signature

Date

TO ALL PATIENTS

I understand that it is my responsibility to provide accurate and updated insurance information at each visit. I am aware that I am responsible for all charges if my insurance has expired (with or without my knowledge) or inaccurate insurance information was given by me.

I understand that, where required by my insurance company, it is my responsibility to bring updated referrals, Co-pays and deductibles. I understand that if I do not have the appropriate referral and I choose to receive treatment at that time, I will be solely responsible for the payment of any medical service charges to Dr. Modi.

I understand that if my insurance company denies payment to Dr. Modi for any of the reasons stated above (i.e. failure to provide accurate and/or updated insurance information, or failure to obtain a referral where required), it is my responsibility to pay Dr. Modi’s medical service charges although I may choose to follow up with the insurance company regarding getting personally reimbursed.

Dr. Modi has a financial ownership interest in Oak Tree Surgical Center, Union County Surgical Center and Pleasantdale Ambulatory Care Center. You have right to be treated at another health care facility of your choice. We are making this disclosure in accordance with federal regulation.

By signing this form I also acknowledge Dr. Modi’s office has offered or given me a copy of its Privacy Notice (HIPAA), which explains how my health information will be handled.

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's Name / Signature

Date

Your information will be encrypted.