PATIENT PAPERWORK

Please correct the errors described below.

Patient Information Record

AUTHORIZATION FOR MEDICAL TREATMENT & MEDICATION HISTORY

Office Practice/Clinic personnel at this facility are hereby authorized to administer any medical, diagnostic or therapeutic treatment as may be deemed necessary or advisable. I have the right to consent or refuse consent to any proposed procedure or therapeutic course, absent emergency or extraordinary circumstances.

RELEASE OF PROTECTED HEALTH INFORMATION

Information may be released to the following individual(s)

Add Name

AUTHORIZATION TO PAY BENEFITS TO PHYSICIAN:

I hereby assign payment directly to the Physician for the Surgical and/or Medical benefits, if any, otherwise payable to me for services as described but not to exceed my indebtedness to Physician for those services. I understand I’m financially responsible for charges not covered by my insurance. I further authorize:

AUTHORIZATION TO RELEASE INFORMATION:

I hereby authorize the Physician to release any information acquired in the course of my examination or treatment to my referring physician and/or to my insurance carrier information needed to determine benefits.

I further agree that all information submitted is true, correct and complete as of the date of my signature.

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.

Please present your insurance card(s) and a photo ID to the receptionist along with completed form(s). Thank you.

    Please upload a file

    Please check if you or your family had/has any of the following:

    Please Indicate: (M) Mother (F) Father (B) Brother (S) Sister

    MED HX

    ROS

    SKIN HX

    Please list all previous surgeries and dates:

    Add Surgery

    Please list all medications (include birth control, over the counter and herbal medications you routinely take; or provide list):

    Add Medication

    ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

    I may refuse to sign this acknowledgement.
    I have received a copy of Jeff Alexander, MD, PC Notice of Privacy Practices.

    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.

    OFFICE USE ONLY

    We attempted to obtain written acknowledgment of receipt of our Notice of Privacy Practices, but acknowledgment could not be obtained because:

    Your information will be encrypted.

    Jeff Alexander, MD, PC

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