Signature of Patient definition

Signature of Patient. Print please: Date:
Sample 1Sample 2Sample 3
Signature of Patient. Print please: Date: Signature of Health Professional Job Title Printed Name Date
Sample 1

Examples of Signature of Patient in a sentence

  • Signature of Patient or Parent/Guardian Date Late Cancellation and no-show policy:If for any reason, you are unable to keep this appointment, we request you call us 24 hours in advance at (864) 331- 1400 to cancel or reschedule.

  • Signature of Patient or Parent/Guardian Date If there are any changes to your or your child’s insurance between now and the time of yourappointment, please notify us because your new insurance my not cover your service.

  • 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 X Printed Name of Patient Printed Name of Guardian (if applicable)X X Signature of Patient or Guardian Date Waiver of Patient Authorizations****(ONLY SIGN IF YOU DO NOT WISH TO HAVE YOUR INSURANCE BILLED AND WILL PAY OUT OF POCKET AT THE TIME OF SERVICES) **** I do not wish to have information released and prefer to pay at the time of service and/or to be fully responsible for payment of charges and to submit claims to insurance at my discretion.

  • Print Patient’s Name Signature of Patient or Patient’s Representative Date 3.

  • Print Patient’s Name Signature of Patient or Patient’s Representative Date 4.

  • During this past year, IOM staff have been in close proximity to several terrorists bombings, have come under fire, and have been subjected to captivity, assault, threats and robbery.

  • Signature of Patient Date Signature of Parent, Guardian or Personal Representative* Date *If you are signing as a personal representative of an individual, please describe your legal authority to act for this individual- power of attorney, healthcare surrogate, etc.

  • Signature of Patient Printed Name Date Signature of Parent/Guardian Printed Name Date I, a mental health professional, have discussed the issues above with the patient and/or his or her parent or guardian.

  • Signature of Patient Date or Signature of Patient’s Representative & Relationship Date Office Representative Signature Date Patient Registration Last Name: First Name: MI: DOB: Social Security #: Address: City: State: Zip: Primary Phone Number: Secondary Phone Number: Driver’s License Number: Issuing State: Employer: Occupation: Email Address: Emergency Contacts:1.

Related to Signature of Patient

  • Manual brachytherapy means a type of brachytherapy in which the brachytherapy sources (e.g., seeds, ribbons) are manually placed topically on or inserted either into the body cavities that are in close proximity to a treatment site or directly into the tissue volume.

  • Signature means a tangible symbol or an electronic signature that evidences the signing of a record.

  • Diagnosis of autism spectrum disorder means medically necessary assessments, evaluations, or tests

  • Patient means a person who is undergoing medical or other treatment as an in-patient in any hospital or similar institution;

  • Hospice patient s family" means a hospice patient's immediate family members, including a spouse, brother, sister, child, or parent, and any other relative or individual who has significant personal ties to the patient and who is designated as a member of the patient's family by mutual agreement of the patient, the relative or individual, and the patient's interdisciplinary team.

  • Digital Signature means authentication of any electronic record by a subscriber by means of an electronic method or procedure in accordance with the provisions of section 3;

  • Behavioral health provider means a person licensed under 34 chapter 18.57, 18.57A, 18.71, 18.71A, 18.83, 18.205, 18.225, or 18.79

  • In-patient means a person admitted to a hospital as a resident or bed- patient and who is provided at least one day's room and board by the hospital.