Please PRINT neatly and in BLACK ink. Please fill out COMPLETELY.
LAST NAME______DOB ___/___/______Male/Female
First______Middle______SSN (last 4)______
Street Address ______Apt______P.O.Box ______
PRIMARY Phone # (_____) ______SECONDARY # (_____)______
EMAIL______Marital Status: ______
EMERGENCY CONTACT Name ______
Relationship to Patient______Phone (______)______
Were you referred to our office? Y / N
Name of patient who referred you: ______
Other referral source: ______
Occupation/Type of Work______Insurance thru WORK Y / N
Are you SELF PAY Y/N Have a Deductible Y/N Copay Y/N Co Ins Y / N
Name of Pharmacy______Phone #______
PRIMARY INSURANCE COMPANY______
Name of Subscriber______Relationship to pt ______
Policy #______Group # ______DOB______
Employer (if different from above) ______
SECONDARY INSURANCE COMPANY______
Policy #______Group #______
RESPONSIBLE PARTY/Guarantor (if patient is a minor)______
Is this person the legal guardian? Y/N Address______
PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY as they apply to the submission of insurance claims and payment to the physicians for their services.
Payment to Dr. Gent will be expected on the date of service. We will accept cash, check and debit or credit cards. Payment may include any unmet DEDUCTIBLES, CO-INSURANCE, CO-PAYMENTS or other NON- COVERED services. It is the patient’s responsibility to know his or her insurance benefits and coverage for services provided by this office.
It is only as a courtesy that this office tries to confirm benefits and any such verification is NOT a guarantee of payment by the insurance company. We will make every attempt to verify your benefits prior to your office visit, however if we are unable to do so, you will pay the allowable amount and your insurance company will be notified when the claim is filed.
If, in any event the undersigned patient’s account is more than 30 days past due, the patient will be charged 2.0% monthly (24% annually) on the outstanding balance. Absolutely no appointments will be made or prescriptions given, until the account is paid in full. In addition, if the account is turned over to collections, the undersigned patient agrees to pay all attorney fees, court fees and related expenses.
We expect all patients to arrive on time and we try to keep the doctors on schedule. Please understand that from time to time they may run behind if there is an emergency. We ask for your patience. Likewise, we understand that patients have emergencies too and should you need to cancel or reschedule an appointment we will be happy to do that for you. We provide voicemail after office hours if you need to cancel an appointment. There is a $40.00 fee for cancellations with less than 48 hours notice.
All appointments are confirmed in advance by our office staff. This effort is provided as a courtesy to you. We will leave you a message and this is considered your reminder. If you do not get the message or don’t check your voicemail this should not be considered a reason to avoid the charge stated above and in accordance with our policy.
The undersigned patient agrees that we may release any medical information to the insurance company on their behalf.
He/She is responsible for all charges for services by our physicians as stated above and that all information is correct.
Live healthy and well.
Please read the following carefully and if you have any questions please ask us for help. We need all information to be accurate and up to date so we may contact you or your insurance company. This page and all others will be kept in your permanent record.
As a patient of Dr. Gent I agree to the following:
(Please initial next to each item then sign and date the bottom)
____ I will provide accurate information (to the best of my knowledge) and when my insurance, address, or phone number changes, I will let the office know immediately.
____When I make my appointments for lab draws and for any appointments with the doctor, I will keep the appointment as scheduled, unless I have an emergency and must re-schedule. I understand that in order to treat me medically and with the best accuracy, the doctor may need lab work done before my appointment.
____ If it is necessary for me to reschedule I will provide at least two business days notice. I understand that should I not provide this notice I will be charged the sum of $40.00. This applies to “no-shows” for labs as well.
____ If I need a prescription refill I will call my pharmacy and ask them to FAX a refill request to the office. I will allow 48 hours for this refill and I further understand that if this request occurs on a holiday or weekend the refill will be completed on the next business day. If I am due for an office visit and I do not have enough medication I may get an “OK” for a small quantity from this office and I should not expect my full prescription.
____ I will call the office if I have a question and I understand that the office staff /nurses may not dispense medical advice. They will take a message and give it to the doctor. The doctor will then decide to answer the question and have a staff member call back or request the patient come in for an office visit. Our doctor does not call patients with routine information.