Patient Information

Emergency Assistance

If this is an emergency, call:

911
Visit your nearest hospital Emergency Room

Client Information

First name

Last name

Date of birth

Age

Marital Status

Partner's Name, if applicable

Partner's Date of Birth

Partner's Cell Phone

Partner's Employer

Contact Information

Cell Phone

Home Phone

Work Phone

Email address

Address

City

State

Zip Code

What is your preferred method of communication?

Text/SMS

Phone

Employer or School Information

Employer or School Name

Employer or School Address

Insurance Information

I would like you to file on my health insurance.

Insurance Company

Subscriber ID

Group Number

I am the primary insured person.

Primary Insured's Name

Primary Insured's Date of Birth

Relationship to Insured

Primary Insured's Address is the same as mine.

Primary Insured's Address

If patient is under the age of 18 or residing with parents, please complete:

Mother's Name

Mother's Cell Phone

Mother's Employer

Mother's Work Phone

Mother's Date of Birth

Father's Name

Father's Cell Phone

Father's Employer

Father's Work Phone

Father's Date of Birth

If either parent's address is different from patient, please provide address and specify which parent:

Address

Emergency Contact

Add another emergency contact

In case of an emergency, do we have permissions to contact this person?

Yes No

Financial Policy

PAYMENT IS EXPECTED AT THE TIME OF SERVICE, UNLESS PRIOR ARRANGEMENTS HAVE BEEN MADE.

Regarding In-Network Insurance

Initials

As a courtesy, we will be glad to assist you in filing your insurance. The following Assignment of Benefits and Release of Information Authorization must be signed for this office to file insurance claims on your behalf.

Assignment of Benefits

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I hereby authorize direct payment of benefits to Dawn L. Shogren, M.D. for services rendered by her. I understand that I am financially responsible for any balance not covered by insurance.

Regarding Out of Network Insurance

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As a courtesy, we will file your out of network insurance, as unassigned. This means payment will come directly to you based on your out of network benefits. Payment is expected at the time of service unless prior arrangements have been made.

Release of Information Authorization

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I authorize the release of my medical or other information to my insurance company, which is necessary to process a claim.

UCR (Usual and Customary Rates)

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My practice is committed to providing the best treatment possible for my patients, and my charge is based on what is usual and customary in this area. You are responsible for payment in full, regardless of any insurance company’s arbitrary determination of usual and customary rates. For those patients with managed health care, for whom I am a provider, you will be responsible for the amount determined by your plan. If I am an out-of-network provider for your plan, you will be responsible for my UCR rate.

Insurance Disclaimer

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Every effort is made to be sure that the benefit information given to you is accurate. If a conflict exists between the information provided to you and the terms of the plan, the terms of the plan govern. Final determination of coverage and patient responsibility is made at the time your claim is received and processed by your insurance company.

Additional Fees

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Prescription refills are given at the time of the appointment. Any interim refills are subject to the following: Controlled substances are subject to $50 fee per interim refill. Other routine medications are subject to a $25 fee per interim refill.

There will be a fee for a completion of paperwork/forms beyond the usual scope of practice. This includes, but is not limited to: FMLA Paperwork, Life Insurance, Disability, Affidavits and Extensive Records Record Requests. These fees are based on the amount of time it takes for completion by the doctor.

Cancellation Policy

Please read carefully!

Unless canceled 48 hours in advance, my policy is to charge for missed or late canceled appointments at the rate of $290, (the standard rate for an office visit) and will be billed to the card on file the same business day of the appointment. Insurance companies do not reimburse for missed or late canceled appointments. Help me serve you better by keeping scheduled appointments. Appointments must be canceled by calling the office directly and leaving a message. Appointments may not be canceled via email or text.

If you have any questions or concerns regarding this Financial Policy, please discuss it with me or my office manager. I have read the Financial Policy. I understand and agree to this Financial Policy.

Initials

Credit Card Authorization

I authorize Dawn L. Shogren, M.D. to charge my credit card for any missed appointments or appointments canceled less than 48 hours prior to the appointment time, at the rate of $290.

I further authorize Dawn L. Shogren, M.D. to charge my credit card for any unpaid balance on my account that is beyond 45 days past due.

Credit Card Number

Expiration Date

CVV (3 or 4 digits)

Billing Zip Code

Your information will be encrypted.

Patient Information

Emergency Assistance

Client Information

Contact Information

Employer or School Information

Insurance Information

If patient is under the age of 18 or residing with parents, please complete:

Emergency Contact

Financial Policy

Regarding In-Network Insurance

Assignment of Benefits

Regarding Out of Network Insurance

Release of Information Authorization

UCR (Usual and Customary Rates)

Insurance Disclaimer

Additional Fees

Cancellation Policy

Credit Card Authorization

Emergency Assistance

Dawn L. Shogren M.D., P.A.