Patient Name definition

Patient Name. DOB: Please initial each clause and sign below to indicate you have read and understand the fee agreement. Pacific Center for Plastic Surgery requires all medical services to be paid in advance. A $500.00 administration fee is required at the time of scheduling for all surgical procedures. This fee is applied towards your surgery. The remaining surgery balance must be paid in full at the pre-op or the pre-op appointment will be rescheduled. If the pre-op appointment is rescheduled, the surgery date may have to be rescheduled also. Surgery cancellations require notice to our office in writing. If the cancellation request is after the pre-op appointment and prescriptions have been issued, no refunds will be made until the prescriptions are returned to the office. We will not reimburse prescription fees if prescriptions have been filled. If surgery is cancelled, the administration fee will be retained by the Pacific Center for Plastic Surgery. The work of our staff on behalf of our patient intensifies when the patient elects for surgery. In an effort to provide the best possible service to all patients, the administrative fee is necessary to offset some of the expenses of a cancelled surgery. Cancelled surgeries financed through one of our office finance plans will be held to the cancellation policies of the financing company. If surgery must be cancelled due to illness or any other circumstance, the standard fees as listed above will be assessed if surgery is not rescheduled. The patient shall be liable for 50% of the Surgeon’s Fee and 100% of Supply Charges if a scheduled surgery is cancelled within less than 5 business days of the surgery. Required lab work, prescriptions, garments, and pathology, if needed, are the financial responsibility of the patient. This document outlines the cancellation policies of the Pacific Center for Plastic Surgery; patients are advised to review the cancellation policies for the selected surgery center, regarding operating room and anesthesia fees, as they may differ from our office policy. As explained in the initial office visit with Xx. Xxxxxxxx or Xx. Xxxxxxx, there are risks associated with all surgeries. While the risks are low, they must be addressed before surgery so misunderstandings are avoided post-operatively. Should a revision become necessary, there will be an extra financial obligation on your part. If a revision is needed and the patient has remained compliant, i.e.: followed recommended follow-up schedule, f...

Patient Name. Patient Signature: Date: Relationship: Guardian Signature (if patient is a minor):

Patient Name. Signature: Date: Parent or Guardian: Signature: Date: Witness Name: Signature: Date:

Examples of Patient Name in a sentence

• Example: Patient Module includes Patient Name, Patient ID, Patient Birth Date, and Patient Sex.

• Patient Name (printed) Date Patient Signature (18yrs and older) Parent/Guardian Signature (if applicable) Patient Responsibility Agreement & Therapy Terms/Conditions I, as myself, or as a representative for my child would like to pursue all means necessary to obtain speech/language/feeding services for myself/my child.

• Signature of Patient or Parent/Guardian Date Patient Name Patient’s Date of Birth I authorize the release of any medical or other information to the insurance company that is necessary to process my insurance claim(s).

• X Patient Name Signature DatePATIENT INFORMATION Last Name: First Name: SEX: M F If patient is a minor, name of parent or guardian accompanying patient: Relationship to patient: Phone # (if different): Address: City: State: Zip Code: Home Phone: 2nd Phone: Email: Date of Birth: SS#: married single divorced widowed (circle one)Referred by: Phone: Location: Family Doctor: Phone: Location: INSURANCEDate of accident:(If applicable): Type of Accident: Please briefly describe the accident.

• Patient Name Patient Signature Insurance Company Date No Insurance: If you do not have health insurance, have out-of-network coverage, or decide to OPT OUT of using your health insurance policy, you will be responsible for payment of our regular office fees at time of service.

More Definitions of Patient Name

Patient Name. DOB: Patient Signature: Date: Legal Representative: Date: Relationship:

Patient Name. Date: Responsible Party: Relationship to patient: Signature: Witness Initials:

Patient Name. Diagnosis: Admission Dates: Length of Stay: Discharge destination: Home

Patient Name. Address: City: State: Zip: Home Phone: Employer: Work Phone: Social Security #: Birth Date: Sex: M F (circle one) Primary Insurance Company: Group #: Address: Phone #: Subscriber Name: Co-Pay Amount: Secondary Insurance Company: Group #: Address: Phone #: Subscriber Name: Co-Pay Amount: Physician: Phone #: Address: City: State: Zip: Responsible Party: Relationship: Address: City: State: Zip: Home Phone: Work Phone:

Patient Name. [PatientFirstname] [PatientLastname] Consultant: …………………………………….

Patient Name. Date: As a participant in buprenorphine treatment for opioid addiction, I freely and voluntarily agree and understand this treatment agreement, in its entirety, as follows:

Patient Name. Date: Patient Signature: (or legal representative or guardian, if applicable) Medicare Patient Acknowledgements