NEW PATIENT INFORMATION (Non Medicare)

Please correct the errors described below.
(Required if you want access to patient portal)

RESPONSIBLE PARTY – IF DIFFERENT FROM PATIENT

INSURANCE INFORMATION

Financial Policy and Release of Medical Information

  1. The adult/guardian who brings a child in is responsible for all out of pocket expenses, including copayments, deductibles, and non-covered services. We will not forward bills to another party regardless of court ruling or divorce decrees.
  2. I authorize the release of medical information to my primary care physician, referring physician, and to consultants if needed. In addition, I authorize the release of my medical information as necessary to process insurance claims, prescriptions and for payment and collection purposes.
  3. I authorize payment of medical benefits/payments to Rudolf Strnot Jr MD.
  4. I understand I am responsible for any copayments, deductibles, and any other charges deemed to be my responsibility by my insurance company.
  5. I understand if I do not have health insurance, payment is due at the time of service unless other arrangements have been made
  6. I understand there will be a $30.00 charge for any appointment that is missed or cancelled with less than 24 hours’ notice. This will not be submitted to my insurance and must be paid prior to scheduling another appointment.

By signing below, you acknowledge your understanding and acceptance of the Information listed above.

DISCLAIMER: 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.

NOTICE OF PRIVACY PRACTICES - HIPAA Notice

A printed copy of Dr. Strnot’s Notice of Privacy Practices is available upon request.

History and Intake Form

PAST SURGERIES (Please list and give approximate date)

Add Surgery

MEDICATIONS – If you brought a list, we will take a copy of it, otherwise please list below and include the dosage.

Add Medication

ALLERGIES TO MEDICATIONS – INCLUDE REACTION

Add new row

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