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 ▇▇. ▇▇▇▇▇▇▇▇ or ▇▇. ▇▇▇▇▇▇▇, 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. Date: Responsible Party: Relationship to patient: Signature: Witness Initials:
Examples of Patient Name in a sentence
Patient Name / / Patient/Health Care Agent/Guardian/Relative Signature Date It is the policy of Women’s Health Associates of Southern Nevada to inform patients of the availability of an Advance Directive form.
Patient Name Birth Date • Any other providers involved in my medical care to release my records to Pelorus Elder & Behavioral Health.
Patient Name (printed): Date of Birth: / / Signature of Patient (or representative): Date: / / Relationship (If other than patient): Consent Denied: Date: / / We provide an online Patient Portal to make managing your health care simple and convenient.
Patient Name / / Patient/Health Care Agent/Guardian/Relative Signature Date THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
Patient Name: _ _ Patient Signature: _ __ _Date: _ Signature: _Date: ▇▇▇▇▇▇▇ ▇.
More Definitions of Patient Name
Patient Name. DOB: Address: Social Security#: You Should Know the Following • Psychotherapy evaluation and treatment work best when you and your doctor work cooperatively. • During the course of your evaluation/treatment, you may discuss things that will be upsetting but necessary to help you resolve your psychological difficulties. • What you and your doctor discuss and all records will be held in the strictest confidence. Information can only be released with your written consent, except where stated and/or federal law directs otherwise. • State law requires that your doctor report all cases of abuse or neglect of minors and, in some states, abuse of vulnerable adults as well. • Your doctor has a legal duty to take action and break confidentiality if you are a danger to yourself or others. • Please ask your doctor any questions you may have about your psychological services.
Patient Name. Patient Signature: E-mail Address: Date: State of residence: _
Patient Name. Signature: Date: Parent or Guardian: Signature: Date: Witness Name: Signature: Date:
Patient Name. DOB: Insurance Company: ID #: Dates of service: In-Network / Out-of-Network Deductible: Met: Out of Pocket Max: Met: Deductible Applies Y / N Co-Pay: $ Co-Insurance: % Chiro Visits: $ Amount:
Patient Name. Signature:
Patient Name. Diagnosis: Admission Dates: Length of Stay: Discharge destination: Home
Patient Name. [PatientFirstname] [PatientLastname] Consultant: …………………………………….