New Patient Forms - Point Pleasant

PATRICIA C. MCCORMACK, M.D, F.A.A.D

407 Richmond Ave.

Point Pleasant Beach, NJ 08742

Phone: 732-295-1331

Today's Date:

Date of Birth

Sex

Male Female

Last Name, First Name

Address

City

State

Zip

Home

Work

Cell

Age

S.S. #

Person responsible for bill

D.O.B.

Relationship to patient

S.S. #

Employer name & address

Phone #

IN CASE OF EMERGENCY NOTIFY

Relationship

Phone #

Primary Care Physician

Phone #

Address

Town

Pharmacy

Address

Phone #

ALL PATIENTS MUST PROVIDE THE FOLLOWING INFORMATION

Reason for visit

Do you have allergies?

Yes

if so, please explain

Are you allergic to lidocaine?

Yes

Latex?

Yes

Heart condition?

Yes

Please list all medications you are currently taking. Include OTC and prescriptions, herbal supplements, cough medicines, laxatives, and suppositories. If attached please check here

File attachments

Add file

Please upload a file

Medications

Have you had any operations?

Yes

If so, please describe

Have you ever been hospitalized?

Yes

If so, please list year and medical condition

Have you ever been diagnosed or treated for any of the following:

High blood pressure

Seizures

Acne

Diabetes

Migraines or headaches

Psoriasis

Heart disease

Excessive bleeding

Eczema

Lung disease

Blood disorder

Hives/Uticaria

Gastro-intestinal disease

Lupus/Anemia

Hypertrophic/Keloid scars

Kidney disease

Arthritis

Herpes

Liver disease

Eye disease

AIDS risk

Endocrine disease

Hay fever

Cancer

Thyroid disease

Please list any other medical condition that you would like the doctor to be aware of:

HABITS

Do you consume alcohol?

Other substances?

Do you smoke?

Do you exercise?

FOR WOMEN

Are you on birth control?

Which type

Last menstrual period?

Are you pregnant?

Are you breastfeeding?

If so, when do you anticipate you will stop breastfeeding?

Assignment of insurance benefitsAuthorization to release information:

I hereby authorize direct payment of surgical/medical benefits to Patricia McCormack, M.D. for services rendered by her in person or under her supervision. I understand that I am financially responsible for any balance not covered by insurance. I also authorize Dr. McCormack to release any medical or incidental information that may be necessary for either medical care or in processing applications for financial benefit. I certify that the information given by me in applying for payment is correct. I authorize release of all records on request. I request that payments of authorized benefit be made on my behalf. If the co-pay is not paid at the time of the visit, there will be a $10.00 surcharge. *It is your responsibility to obtain a referral, if required, from your primary care physician. If a referral is not obtained, you will be responsible for all charges pertaining to your visit.

Name

Signature

Parent/guardian

Signature

REQUEST FOR LIMITATIONS AND RESTRICTIONS OF PROTECTED HEALTH INFORMATION

PATIENTS PLEASE NOTE: The practice is not required to agree to your request. Please see our notice of privacy practices for more information regarding such requests.

Patient Name

DOB

Patient Address

City

State

Zip

Please mark where you DO NOT want us to contact you:

(If no restrictions, please check “NO RESTRICTIONS” and sign below)

Home phone

Home address

Work phone

Work address

Spouse’s work

NO RESTRICTIONS

Other

Please mark any information that may not be shared with your other physicians, pharmacy and/or your insurance company:

Occupation

Name of employer

Visit notes/hospital notes

Prescription information

Patient history

NO RESTRICTIONS

Other

PAYMENT AND/OR CLAIMS MAY BE DENIED IF CERTAIN INFORMATION IS RESTRICTED TO YOUR INSURANCE COMPANY

Do you have any special instructions or requests concerning your personal health information? Are we allowed to speak to anyone on your behalf? If so, please write their name below.

Signature of Patient or Legal Guardian

Date

ACKNOWLEDGEMENT OF PRIVACY PRACTICES

I ACKNOWLEDGE THAT I WAS PROVIDED OR OFFERED A COPY OF THE NOTICE OF PRIVACY PRACTICES AND THAT I READ (OR HAD THE OPPORTUNITY TO READ IF I SO CHOSE) AND UNDERSTAND THE NOTICE

Print Name

Date

Parent or Authorized Representative

Date

Signature

Date

**Note**

This acknowledgement shall remain valid for a period of six (6) years from date of signing. If you would like to review, read, or take a copy of the notice of privacy practices, please ask a member of Dr. McCormack’s staff.

Your information will be encrypted.

New Patient Forms - Point Pleasant

PATRICIA C. MCCORMACK, M.D, F.A.A.D

407 Richmond Ave.

Point Pleasant Beach, NJ 08742

Phone: 732-295-1331

ALL PATIENTS MUST PROVIDE THE FOLLOWING INFORMATION

Assignment of insurance benefits***Authorization to release information***:

REQUEST FOR LIMITATIONS AND RESTRICTIONS OF PROTECTED HEALTH INFORMATION

**PAYMENT AND/OR CLAIMS MAY BE DENIED IF CERTAIN INFORMATION IS RESTRICTED TO YOUR INSURANCE COMPANY**

ACKNOWLEDGEMENT OF PRIVACY PRACTICES

I ACKNOWLEDGE THAT I WAS PROVIDED OR OFFERED A COPY OF THE NOTICE OF PRIVACY PRACTICES AND THAT I READ (OR HAD THE OPPORTUNITY TO READ IF I SO CHOSE) AND UNDERSTAND THE NOTICE

Assignment of insurance benefitsAuthorization to release information:

PAYMENT AND/OR CLAIMS MAY BE DENIED IF CERTAIN INFORMATION IS RESTRICTED TO YOUR INSURANCE COMPANY