NEW PATIENT INFORMATION (Medicare)

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

RESPONSIBLE PARTY – IF DIFFERENT FROM PATIENT

INSURANCE INFORMATION

MEDICARE QUESTIONNAIRE

MEDICARE AUTHORIZATION

I authorize any holder of medical or other information about me to release to the Social Security Administration and Center for Medicare and Medicaid services, or it’s intermediaries or carriers, any information needed for this or a related Medicare claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or the party who accepts assignment. Regulations pertaining to Medicare assignment of benefits apply.

General Authorization to Release Medical Information

I authorize the release of medical information to my primary care physician, referring physician, and consultants if needed, and as necessary to process any non-Medicare insurance claim, application or prescription.

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.

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 Allergies

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