Patient Signature definition

Patient Signature. Date: Time:

Patient Signature. Name in Print: Date:

Patient Signature. Date: (Parent or Legal Guardian if patient is a minor) Date Last Name___________________ First Name___________________ Age_____ Date ___________ Who is your healthcare professional (physician, chiropractor, therapist, etc)? Name/Clinic Phone Fax When was your last visit to a healthcare provider etc.? What did you see this provider for? Have you talked to your primary care doctor about medical cannabis? Yes No If you haven’t, why not? Do you have health insurance? Yes No If yes, what kind? Chronic Pain Muscle Spasm Anorexia Insomnia Anxiety/Depression Glaucoma Headache Nausea Other Work Never Sometimes Often Relationships Never Sometimes Often Sleep Never Sometimes Often Physical activity Never Sometimes Often Mood Never Sometimes Often Enjoyment of life Never Sometimes Often Are you currently pregnant? Yes No Are you currently breastfeeding? Yes No

Examples of Patient Signature in a sentence

• 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.

• Patient Print Name Patient Signature Date Responsible Party Print Name (if not patient) Responsible Party Signature (if not patient) Date Important Note Regarding After Hours/Weekend Services Relievus provides care for chronic problems.

• Patient Full Name (please print) Patient Signature Date Signed (YYYY/MM/DD) FOR PATIENTS OVER THE AGE OF 65 OR THOSE RESIDING IN BC, MB, AND SK:Certain drugs require prior approval from Provincial or Pharmacare Programs before they are eligible for coverage.ALL INITIAL AND RENEWAL SUBMISSIONS FOR PROVINCIALLY ELIGIBLE DRUGS MUST BE SUBMITTED TO THE PROVINCIAL PLAN FIRST.

• 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.

• Patient Signature Date: Relationship to patient if not patient Authorized Witness: *Mark Malone MD PA includes Advanced Pain Care and it's sub‐specialties, Round Rock Surgery Center, or Advanced Surgical Center.

More Definitions of Patient Signature

Patient Signature. DATE: GUARANTOR SIGNATURE: DATE:

Patient Signature. Date: / / Authorized Representative Signature (if applicable): Date: / / If signed by Authorized Representative, please confirm the nature of your relationship with Patient:

Patient Signature. Date: 3rd Party Guarantor (Organization & Authorized Agent): 3rd Party Guarantor Authorized Signature: Date:

Patient Signature. Date: For minors:

Patient Signature. Date: GP Signature: Date:

Patient Signature. Date: Patient Name (Printed): Pain Doctor Name:

Patient Signature. Date: Signature: Date: Xxxxxxx X. Xxxxxxxx, MD If the Patient is a minor, the Patient’s parent or legal guardian must sign below indicating the parent or guardian’s acceptance of the above terms and agreement to pay the Membership Fee on behalf of the Patient: Signature of Parent/Guardian: Date: I AGREE, UNDERSTAND AND EXPRESSLY ACKNOWLEDGE THE FOLLOWING: ● The Practitioners listed below (the “Practitioners”) have all opted out of the Medicare program effective on dates indicated after their names for a period of at least two years. ● Neither Evolve nor any Practitioner is involuntarily excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or any other section of the Social Security Act. ● I accept full responsibility for payment of Evolve’s and Practitioners’ charges for all items and services furnished to me by Evolve. ● Medicare fee limitations do not apply to what Evolve and the Practitioners may charge for the items or services they provide to me. ● I will not submit a claim (or request that Evolve or any Practitioner submit a claim) to the Medicare program for payment for any items or services provided to me by Evolve or any Practitioner, even if the items or services are covered by Medicare Part B. ● Neither Evolve nor any Practitioner will submit a Medicare claim for items or services they furnish to me, and no Medicare reimbursement will be provided for such items or services. ● Medicare payment will not be made for any items or services provided to me by Evolve or any Practitioner even if those items or services would have otherwise been covered by Medicare if I had not signed this Patient Agreement and this Attachment B, and a proper Medicare claim had been submitted. ● I enter into this Patient Agreement with the knowledge that I have the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted out of Medicare, and that I am not compelled to enter into private contracts that apply to other Medicare-covered items and services furnished by other physicians or practitioners who have not opted out of Medicare. ● Medigap plans do not provide payment or reimbursement for items and services (such as any Services provided to me by Evolve or the Practitioners) not paid for by Medicare, and other supplemental plans may likewise deny payment or reimbursement for such items and services. ● I am not currently in an emergency or urgent health care situation, and do not currently requ...