Premier Surgery Center Patient Info Form

Today's Date *

Date

Name *

First Name Middle Name Last Name

Sex

Male Female

Social Security #

Date of Birth *

Month Day Year

Race *

Language

Marital Status

Employment Status *

Employer

Occupation

Are you currently in a Skilled Nursing Facility (SNF)?

Yes No

If so, name of SNF

Patient Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

E-mail

Home Phone Number

Area Code Phone Number

Work Phone

Area Code Phone Number

Cell Phone

Area Code Phone Number

**By including your cell phone number, you give Premier Surgical consent to call your cell phone for automated appointment reminders.**

Referring Physician

Physician's Phone Number

Area Code Phone Number

Other current Physicians on Your Care Team

Primary Care (PCP)

PCP Phone Number

Area Code Phone Number

Cardiology

Cardiologist Phone Number

Area Code Phone Number

Pulmonary

Pulmonary Phone Number

Area Code Phone Number

Gastro

Gastro Phone Number

Area Code Phone Number

Endocrinology

Endocrinology Phone Number

Area Code Phone Number

Dialysis Center

Dialysis Center Phone Number

Area Code Phone Number

Other

Other Phone Number

Area Code Phone Number

Preferred Pharmacy

Pharmacy Phone Number

Area Code Phone Number

Pharmacy Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Emergency Contact:

First Name Last Name

Sex

Male Female

Relationship to Patient

Language

Home Phone:

Area Code Phone Number

Work Phone:

Area Code Phone Number

Cell Phone:

Area Code Phone Number

Is Contact a Parent/Guardian?

Yes No

If patient is under the age of 18, Emergeny Contact should be a Paretnt or Guardian unless patient is an emanicipated minor.

Insurance Company

Group No:

Member ID

Specialist Co-pay $

Subscriber Information below (if differs from patient)

Primary Insurance Subscriber Name

First Name Last Name

Relationship to Patient

Subscriber's SSN:

Subscriber's Date of Birth

Month Day Year

Subscriber's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Home Phone

Area Code Phone Number

Insurance Subscriber's Phone Number

Area Code Phone Number

Work Number

Area Code Phone Number

Cell Number

Area Code Phone Number

Marital Status

Sex

Male Female

Subscriber's Employment Status

Subscriber's Employer

Secondary Insurance Information

Insurance Company

Group No:

Member ID

Subscriber Full Name

First Name Last Name

Relationship to Patient

Subscriber SSN:

Date of Birth

Month Day Year

Address (if different from patient)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Subscriber's Home Phone

Area Code Phone Number

Work Number

Area Code Phone Number

Cell Number

Area Code Phone Number

Marital Status

Sex

Male Female

Subscriber's Employment Status

Subscriber's Employer

Your Supervisor

First Name Last Name

Supervisor's Phone Number

Area Code Phone Number

Workers Comp or Auto Insurance Phone Number

Area Code Phone Number

Claims Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Adjuster's Name

First Name Last Name

Adjuster's Phone Number

Area Code Phone Number

Claim No.

Approval No.

Date of Injury

Date

Did injury occur at work?

Yes No

Auto accident?

Yes No

Briefly describe injury or accident

Do you have any of the following? Check all that apply.

Living Will Do Not Resuscitate (DNR) Power of Attorney (POA) End of Life Decision No Cardio-Pulmonary Resuscitation (CPR) None

Notice of Privacy Practices Acknowledged:

I have been given an opportunity to review, ask questions about and understand Premier Surgical Associates' Notice of Privacy Practices for Protected Health Information. (Notice)

Patient's Signature: *

Clear

Today's Date *

Date

Premier Surgical Associates, PLLC

PLEASE READ

All charges are due at the time of service. If hospitalization or surgery is indicated, we will file your claim directly to your insurance company. Please remember that most insurance companies do not pay the full amount, and therefore, you are responsible for the balance. If there is a problem paying the balance in full, please let us know and we will be happy to work with you.

Financial Responsibility (Financial Policy is available in office UPON REQUEST)

I understand and commit to the following:

1. I have recieved a copy of Premier Surgical's financial policies and have read and understand these policies.

2. I will pay my cop-pay, deductible and co-insurance at the time of service.

3. I will provide the most current insurance information and immediately notify Premier Surgical of changes.

4. I surgery is required, all or a portion of my financial financial responsibility must be paid prior to surgery.

5. I will follow my insurance company's requirements for referrals and pre-authorizations and I understand that if I fail to do so, my insurance benefits will be reduced and I will be responsible for all denied balances.

6. I understand that I am responsible for all balances after insurance has paid.

7. If I have no insurance, I have informed Premier Surgical and I am responsible for 100% of all balances.

8. A collection fee of 30% will be added to all my accounts that are turned over to collection agencies.

Patient's Signature *

Clear

Today's Date *

Date

Insurance Authorization and Release:

I request that payment of authorized benefits - inclulding Medicare, and any other government sponsored program, private insurance, and any other health plans - be made to Premier Surgical Associates, PLLC, for any services furnished by that provider. I authorize any holder of medical information about me to release to those persons or companies presenting a legitimate request for such information needed to determine these benefits or the benefits payable for related services. I authorize Premier Surgical Associates, PLLC, to act as my agent to help me obtain any required precertification as well as acting as my agent to help me obtain payment from my insurance companies. I authorize my insurance companies to give Premier Surgical Associates, PLLC, any information they require to fulfill this function. This will remain in effect until revoked in writing. A photocopy of this assignment and release is to be considered as valid as the orginal.

Patient or Guardian's Signature: *

Clear

Today's Date *

Date

Missed Appointment Policy:

In order to provide the best care and service to our patients, we ask that you notify us 24 hours in advance to cancel and/or reschedule your office visit, surgical procedure, ultrasound or other diagnostic test appointment. A minimum of 30 and up to 90 minutes is set aside for each appointment and your communication and compliance is much appreciated by your physician and supporting staff.

Please be aware that if 24 hours notice is not recieved a fee may be charged to your account which must be settled before another appointment is scheduled. Please call us if you are unable to keep your scheduled appointment. This will provide us an opportunity to reschedule your appointment to a more convenient time and avoid any additional charges on your account.

Any No Shows will be charged as follows:

Surgery Consult - $25
Ultrasound Exam - $30
Cosmetic Consult - $50
Surgical Procedure - $100

Patient or Guardian's Signature: *

Clear

Today's Date *

Date

Premier Surgical Patient Info Form

Your Physicians

Your Local Pharmacy

Emergency Contact Information

Insurance Information

Workers Compensation

Patient's Past Medical History

Past Surgical History

Review of Symptoms

Current Medications

Allergies