New Patient Form
Patient Information
Last Name
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First Name
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MI
Soc. Sec. No.
Birthdate
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Sex
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Address
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City
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State
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Zip
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Home Phone
Cell Phone
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Email
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Employer Name
Employer Address
City
State
Zip
Responsible Party Information
Different than Patient?
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Yes
No
Last Name
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First Name
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MI
Soc. Sec. No.
Birthdate
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Sex
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Address
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City
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State
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Zip
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Home Phone
Cell Phone
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Email
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Employer Name
Employer Address
City
State
Zip
Primary Insurance
Do you have healthcare insurance?
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Yes
No
Insurance Company
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Policy/ID No.
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Group No.
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Copay
Deductible
Name of Insured
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Date of Birth
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Address
City
State
Zip
Relationship to Patient
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Please provide a copy of insurance card(s) (front)
Please provide a copy of insurance card(s) (back)
Please provide a copy of driver’s license (front)
Other Information
Pharmacy Name
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Phone
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Fax
Pharmacy Address
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City
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State
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Zip
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Who referred you?
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ALL SCHEDULED APPOINTMENTS MUST BE CANCELLED 24 HOURS PRIOR TO THE APPOINTMENT DATE.
APPOINTMENTS NOT CANCELLED WILL BE BILLED AT FULL RATE TO THE PATIENT OR/GUARANTOR.
I authorize the release of any medical information or other information to process claims, including information related to Mental Health and Substance Abuse. I authorize payment of medical benefits to the physician or supplier for all services rendered. I understand and agree that regardless of my insurance status, I am ultimately responsible for the balance of my account for any professional services rendered.
Signature of Patient or Legal Guardian
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– 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.
Date
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Office Policy and Procedure Agreement
Thank you for choosing Dr. Kut's practice. Please read this agreement in full, ask us any questions you may have, and then sign in the space provided. A copy will be provided to you upon request.
Payments, Co-Payments and Deductibles.
All payments, co-payments and deductibles and any balances must be paid at the time of service.
Non-Payment.
If your account is over 90 days past due, you will receive a letter from our billing company to inform you of the status of your account and inform you that you have 10 days to pay your balance in full. Partial payments will not be accepted unless otherwise negotiated. Please be aware if your balance remains unpaid, your account is automatically referred to a collection agency and you will be responsible for the additional agency fee, which is 30% of the principal portion.
In addition, you may be discharged from the practice. If this is to occur, you will be notified by certified mail that you have 30 days to find alternative medical care. During that 30 day period, our physician will only be available to treat you on an emergency basis.
Cancellation Policy.
Please help us serve you better by keeping your scheduled appointments.
A) If you are unable to make it to an appointment, you must call 24 hours in advance to notify the office staff.
B) If you call within the 24 hour timeframe, you are subject to a $100 no-show fee. Exceptions can be made for emergencies.
C) If you do not call to cancel your appointment, a $100 no-show fee will be charged to your account.
D) Recurrent no-shows are subject to discharge from the practice. If this is to occur, you will be notified by certified mail that you have 30 days to find alternative medical care. During that 30 day period, our physician will only be available to treat you on an emergency basis.
Lost/Stolen Medications
A)
Lost Medications
. Please be aware that any early refills are not likely to be covered by insurance and you may have to pay out of pocket for the early refill. The physician will only fill the prescription until your next appointment. Repeatedly lost medications may not be covered and you may be asked to go to the Emergency Room for refill. Controlled substances typically will not be filled early.
B)
Stolen Medications
. It is office policy to have a police report on file for any suspected stolen medications. Refills may not be provided until the office has received a copy of the police report. It is your responsibility to keep your medications safe.
Prior Authorizations.
If your medication is not covered by your insurance, the pharmacy will send a prior authorization request. There is a $30 fee for all prior authorizations.
Additional Letters or Forms.
There will be a fee for any additional documentation the doctor needs to write or fill out. This includes disability forms, school forms, insurance forms, etc. Fees may vary. The doctor has the right to refuse to sign off on anything he does not feel comfortable signing. The doctor does not write letters for emotional support animals or medical marijuana.
I have fully read and understand the Policy and Procedure Agreement from the office of Dr. Kut and agree to abide by its guidelines.
Signature of Patient or Legal Guardian
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– 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.
Date
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