New Patient Form

 

 

Marital Status
Single
Married
Divorced
Widowed

Language
Arabic
Chinese
English
French
German
Mandarin
Spanish
Vietnamese
Decline
Other
Other Language

 

Race
African American
American Indian or
      Alaska Native
Asian
Caucasian
Hispanic/Latino
Native Hawaiian or
      other Pacific islander
Declined
 

Ethnicity
Hispanic or Latino
Non-Hispanic or Latino
Declined

Preferred Phone Contact    
Home
Work
Mobile

Okay to Receive Text Messages
Yes
No

Justin W. Roberts, DO
Samuel Medaris, MD
Glen Mohan, NP
Unknown

How did you hear about us?
Flyer
Insurance
Radio
Facebook
Patient
Other

Do you have healthcare insurance?
Yes
No

I certify this information is true and correct to the best of my knowledge. I will notify you of any changes to the above information. I authorize the release of any medical information necessary to process an insurance claim and request payment of benefits be made to the physician unless my account has been paid in full. I have received Sound Health Services, P.C. Notice of Privacy Practices.

Responsible Party Signature* – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

 

We are committed to providing you with the best possible care and are pleased to discuss our professional fees with you at any time. Your clear understanding of our Financial Policy is important to our professional relationship. Please ask if you have any questions about our fees, financial policy or your financial responsibility.

PATIENTS MUST FILL OUT PATIENT INFORMATION FORMS PRIOR TO SEEING THE DOCTOR. WE WILL REQUEST TO PHOTOCOPY YOUR INSURANCE CARD(S) AND A PHOTO I.D. FOR YOUR FILE.

• APPOINTMENTS - 24 hours notice must be provided in the event you cannot keep an appointment. Should you not provide this notice, a cancellation fee of $35 may then be added to your account. Cancellations for Ancillary Services will have a higher fee.
• REFERRALS - If your plan requires a referral from your primary care physician, it is YOUR responsibility to obtain it prior to your appointment and have it with you at the time of your visit. If you do not have your referral, YOU WILL BE REQUESTED TO SIGN A FINANCIAL WAIVER to be set up as a "Self-Pay" patient. It is then your responsibility to provide us with the referral within 48 hours or you will be personally responsible for that day’s services.
• CO-PAYMENTS - By law we MUST collect your carrier-designated co-pay. This payment is expected at the time of service. Please be prepared to pay the co-pay at each visit. Should you not pay at the time of service, and we subsequently send you a statement, an administrative fee of $5 may be added to your account. Any procedure performed in this office could be deemed surgical by your insurance company and all copays and deductibles will apply.
• FMLA AND/OR WORKMANS’ COMP - There is a $25.00 charge for completion of FMLA or Workmans’ Comp forms.
• SURGERY DEPOSITS - If you and your physician determine that your course of care requires surgery, a surgical deposit will be collected at time of scheduling. Our scheduling coordinators will work with you to determine estimated insurance payment and estimated patient responsibility.
• OUT OF NETWORK PLANS - You will be responsible for any balance your plan indicates as due on their explanation of benefits form. We will adjust the charges to coincide with your plan’ s UCR (Usual, Customary and Reasonable) charges. All patients will be responsible for their co-insurance and deductible. If we do not "participate" with your plan, we will send a courtesy bill to that carrier on your behalf. However, should they not pay your claim within 45 days, you will be responsible for the full amount. Should you receive payment from your insurance carrier, please forward it to the physician’ s office.
  • Private Insurance Authorization of Benefits/Information Release: I, the undersigned, authorize payment of medical benefits to Sound Health Services, P.C. for any service furnished. I understand that I am financially responsible for any amount not covered by my contract. I also authorize any holder of information about me to release to my insurance company (or the agent) information concerning health care, advice, treatment or supplies provided to me. This information will be used for the purpose of evaluating and administering claims of benefits.
• SELF-PAY PATIENTS - Payment is expected at the time of service unless other financial arrangements have been made prior to your visit.
• MEDICARE - We will submit claims to Medicare. The patient will be responsible for the deductible and the 20% co-insurance, which can be billed to a secondary insurance if you have one.
  • Medicare Lifetime Signature on File: I request that payment of authorized Medicare benefits to be made on my behalf to Sound Health Services, P.C. for any services furnished to me. I authorize any holder of medical information about me to release to the CMS (and its agents) any information to determine these benefits payable for related services. This information will be used for the purpose of evaluation and administering claims of benefits.
• DIVORCED/SEPARATED PARENTS OF MINOR PATIENTS - The parent who consents to the treatment of a minor child is responsible for payment of services rendered. Sound Health Services, P.C. will not be involved with separation or divorce disputes.
• INSUFFICIENT FUND CHECKS - A $25.00 fee will be charged to patient’ s account for checks returned due to non-sufficient funds
• You are responsible for the timely payment on your account. Should it become necessary for us to use an outside agency to collect payment from you, you will be obligated to pay to us, to cover the costs of using a collection agency, an additional 30% of your total unpaid balance at the time a collection agency is brought in to collect your account. WE ACCEPT CASH, CHECKS, MASTERCARD, VISA, AMERICAN EXPRESS, DISCOVER OR CARE CREDIT. THANK YOU for taking the time to review our policies. Please feel free to ask any questions or share with us special concerns.

Responsible Party Signature* – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

I understand that Sound Health Services, P.C. (the “Practice) has certain rights and obligations with regard to my protected health information (information regarding my health and treatment that the Practice may have in its possession). I also understand that I have certain rights with regard to my protected health information.

I authorize the Practice to provide informational reminders regarding upcoming appointments I may have to me or anyone who may answer the telephone, or to leave such reminders on any telephone answering device or service, at the telephone number(s) I have provided the Practice as telephone numbers at which I may be contacted (other than the telephone number of my place of employment) or at any of the following telephone numbers.

I authorize the Practice to report any test results on any telephone answering device or service which may answer the telephone number I inserted in the preceding paragraph.

I authorize the Practice to disclose my protected health information to any of the following persons (state name of person and relationship to you):

I understand that I may revoke any authorization granted above by written notice signed by me delivered to the Practice’s Privacy Official at the address stated below. My authorization remains valid until revoked by me in writing.

I acknowledge receipt of the Practice’s Privacy Practices Notice effective September 23, 2013 regarding the Practice’s rights and obligations and my rights regarding my Protected Health Information. I acknowledge that I understand that I have the right to request and receive clarifications, explanations or further information with regard to the Practice’s Privacy Practices through written request signed by me addressed to the Practice’s Privacy Official.

Sound Health Services, P.C.
Attn: Privacy Officer
1010 Old Des Peres Road
St. Louis, MO 63131

Patient/Patient’s Representative Signature* – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button I understand and agree that this is a legal representation of my signature.

 

Have you been diagnosed with any of the following - check all that apply     None apply

Check all that apply     None apply

Do you currently take ANY medication?*
Yes - enter name, dosage and frequency
No

Drug Allergies?*
Yes - enter name and reaction
No

Latex Allergy*
Yes
No

Pet Allergies?*
Yes
No

History of Anesthesia Problems?*
Yes
No

Flu Shot
Yes
No

Pneumonia Shot
Yes
No

COVID-19 Vaccine
Yes
No

Tobacco Use*
Yes
No

Do you use alcohol?*
Yes
No
Quit

Do any family members have any of the medical problems below?     None apply

Check any of the following that apply to you today

 

Allergies
Cough

Dizziness
Ear Drainage
Ear Pain
Hearing Loss
Tinnitus
Vertigo

Loss of Smell
Nasal Congestion
Nasal Drainage
Nosebleeds

Hoarseness
Reflux/GERD
Sore Throat

Fatigue
Sleep Apnea
Snoring

Signature of Patient or Responsible Party* – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.