Raguel Healthcare, LLC. Intake Form (Adult)

Preferred Pharmacy Information

Insurance Information (Primary Insurance)

Insurance Information (Secondary Insurance)

Reason for visit

Medical History

Emergency Contact Information

Please provide the person that you would like to list as an EmergencyContact situation in the event an emergency situation was to take place while in our office(s):

Thank you for choosing Raguel Healthcare as your physician and as one of our patients, we would like you to be aware of our financial policies. Once you have carefully read the following, please sign this document and return to our office staff.

• Most plans have deductibles, coinsurances, and/or copayments that are solely your responsibility at the time of your visit. Copayments are due at the time services are rendered. The patient is responsible for full payment at the time of service. Copayments not collected at the time of visit will be charged a $10.00 fee plus the amount of the co-pay.
• On arrival, you must present your most current insurance card at each appointment. If the insurance company that you present is incorrect, you will be responsible for payment of the full cost of the visit and will be required to submit the charges to the correct plan.
• Certain insurances require you to select a Primary Care Physician or a PCP. Please call your insurance prior to the visit and to select our Practice as your PCP. If they have not been notified you may be financially responsible for this visit and/or your appointment will need to be rescheduled.
• If our physicians are not on your insurance panel or you do not have insurance, then payment in full for services provided are required at the time of visit. For appointments that have already been scheduled, all prior balances must be paid prior to being seen.
• Patient balances are billed immediately once your insurance plan’s explanation of benefits (EOB) has been received by our office. Your payment is due within 10 business days of your receipt of your bill.
• If you are unable to keep your scheduled appointment, we require you to contact our office within 24 hours before your appointment to reschedule or cancel. This will allow us to have another patient who needs that appointment to come in. If you do not contact us within 24 hours, we will charge a fee of $50.00 for each patient that was scheduled to be seen.
• We reserve the right to discharge any patient or family from the practice after 3 no show appointments.
• If you are more than 15 minutes late, you may be required to reschedule your appointment.
• Any balance over 60 days will be forwarded to a collection agency.
• Please call our office if you have a question about your bill. We are happy to review your bill with you to prevent any misunderstandings.

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