Patient Profile

Patient Information

Patient Last Name

First Name

M.I.

Physical Address

City

State

Zip

Mailing Address

City

State

Zip

Email field

SSN#

Sex

M F

Date of Birth

Marital Status

M S D O W

Spouse’s Name

Employer

Occupation

Preferred Pharmacy & Location

Preferred Hospital

Referring Physician

Primary Care Provider -if Different (Full Name)

How did you hear about our office?

Were you directed to our website, AKCRS.COM, to submit your paperwork on line?

Emergency Contact

Name

Relationship

Phone

Insurance Information Please fill out completely even if cards have been scanned in

Primary Insurance

Full ID -Include Any Letters

Group

Subscriber Name (If Different)

Subscriber Employer

D.O.B.

Patient Relationship to Insured

Subscriber’s SSN

Secondary Insurance

ID Number

Group

Subscriber Name (If Different)

Subscriber Employer

D.O.B.

Patient Relationship to Insured

Subscriber's SSN

Confidential Communication

I wish to be contacted in the following manner (Check All That Apply):

Home Telephone

Work Telephone

Cell Telephone

Leave detailed message

Leave call back number only

Please initial the following items and sign at the bottom:

All Patients: 18 years and older must present with valid photo identification. Children under the age of 18 must have a parent or legal guardian present during their appointment. By signing below, I give my consent for examination, and the performance of any necessary tests and/or procedures. If patient is a minor: As the above patient’s legal guardian, I give consent for examination and treatment, to include necessary tests and/or procedures.

Financial Policy: We are preferred with most major insurance plans, however, you may have balances due after insurance pays- these are expected within 10 days. Should you need a payment plan, we do offer Care Credit

Non-Covered Services /Low-Claim Payments: Our role is to provide you with medical specialty care. If your insurance does not pay as you expect, you will need to handle this matter directly with your insurance carrier.

Personal Injury Cases: This office does not bill for auto accidents, liability, or lawsuit-related cases. You are responsible for cash or credit card payment at the time of service. We do not accept liens.

Missed Appointments: In fairness to other patients and the doctor, we require at least 24 hours notice to cancel appointments. If you miss three appointments, you will be dismissed from the practice. There may be a charge of $100.00 for no-show appointments.

Release, Assignment and Statement of Responsibility

I authorize release of any information necessary to process my insurance claims, and assign/request payment to be made directly to the provider(s). I understand that I may revoke this consent at anytime in writing to this office. I further understand that I am responsible for payment for all services rendered to me, or any patient for which I am listed as the responsible billing party.

Signature

Date

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