BLANCO & CANTU FAMILY PRACTICE, P.A.
Date:______Home Phone: ______
Cell Phone: ______
Work Phone: ______
Patient Information Form
Please print all information in the spaces provides
Name: (Last)______(First)______(M.I.)____
Home Address, City, State, Zip Code ______
Email: ______Marital Status:______Sex ( )F / ( )M
Employer Name and Address: ______
Social Security # : ______
Date of Birth: ______
Pharmacy of choice and location: ______
(For Insurance Purposes):
Race:______Ethnicity: ______Language Spoken: ______
Emergency Contact or Responsible Party (if minor)
Name: / Ph #:Address: / Relation to Insured:
Please give your Insurance Information card to front desk personnel
PATIENT FINANCIAL/DISCLOSURE AGREEMENT
( ) I give permission / ( ) I do not give permission for the office of BLANCO AND CANTU to leave message on my answering machine regarding:
( ) Test results, ( ) appointments, ( ) account information.
( ) I give permission / ( ) I do not give permission for the office to speak to a family member regarding:
( ) Test results, ( ) appointments, ( ) account information.
( ) I give permission / ( ) I do not give permission to fax/email my personal information, and/or test/lab results to another doctor office upon
my request.
PERMISSION FOR TREATMENT
I, the undersigned, hereby voluntarily consent to medical care/diagnostic treatment and/or minor surgical treatment by Blanco and Cantu Family Practice deemed advisable and necessary in the diagnosis and treatment of my condition. I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made to me as a result of treatment or examination in the office. I authorize the release of any of my past / current medical records that are needed for my treatment from any prior healthcare providers.
AUTHORIZATION AND ASSIGNMENT
I hereby authorized (assign) my Insurance Carrier (s) / Medicare to make payment directly to Blanco and Cantu Family Practice for medical / diagnostic / surgical benefits payable for the services rendered. I understand that any unpaid balance not covered by this policy will be billed to me. I understand and agree (regardless of my insurance status) that I am ultimately responsible for the balance of any professional services rendered. In the event that I fail to pay the balance of my account to Blanco & Cantu Family Practice within sixty (60) days of the date of service, my account will be turned to collections. In the event that it is necessary to turn my account over to collections I will also be responsible for any and all costs of collection, including attorney fees and interest charges. I understand that Medicare and / or insurance carriers do not cover all office services / procedures. I agree to take full responsibility for any unpaid balances and that such payment will be made to this physician’s office for services rendered. I certify that the information given here is true and correct to the best of my knowledge. I will also notify you of any changes in my status or changes in the above information.
I authorize any holder of medical information about me to release to CMS / Insurance Carries and its agents any information needed to determine these benefits or benefits related to services. I hereby authorize Blanco and Cantu Family Practice to furnish information to Medicare / Insurance carriers concerning my medical condition, illness and treatment determine the benefits for related services.
Dr. Alex Blanco and Dr. Cynthia Cantu are required by law to disclose that they have an ownership interest in Doctor’s Hospital of Laredo and its affiliated clinics and outpatient services. I acknowledge that I have received full disclosure of any ownership interest from Blanco and Cantu Family Practice.
I have read and fully understand the Patient Financial/Disclosure Agreement as outlined above. I understand that this Authorization shall apply to all services provided to me, my dependents, or any other person for which I have assumed responsibility by signing below, from this date forward until it has been revoked in writing.
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Signature of patient/Patient’s RepresentativeDate
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Printed name of patient / representativeRelationship to patient
HIPAA PRIVACY NOTICE
I have been informed of and given an opportunity to review the poster of Blanco and Cantu Family Practice Privacy Notice.
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Signature of patient/ Patient’s RepresentativeDate
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Printed name of patient / Patient’s RepresentativeDate
OFFICE POLICY – EXTRA CHARGES (not paid by insurances)
______(initial) We reserve the right that physicians may charge after hour telephone consultations for assessing and managing medical problems over the phone in lieu of an office visit. Fee starting at $20.00 for the first 5-10 minutes and $20.00 every 10 minutes thereafter.
______(initial) We reserve the right to charge $25.00 for missed appointments not cancelled within 24 hours
10410 Medical Loop Unit 3B
Laredo, Texas 78045
Phone: (956) 523-8900 Fax: (956) 523-8903