Patient Information Sheet - Robert G Saieg Md printable pdf download

PATIENT INFORMATION SHEET

TODAYS DATE___________________________

ROBERT G SAIEG MD

YOUR PRIMARY

ALLERGIES____________________________

CARE PHYSICIAN______________________

____________________________

NAME_______________________ _________DOB ________________SS #______________________________

ADDRESS________________________________CITY_________________STATE______ ZIP______________

WINTER/SUMMER ADDRESS__________________________________________________________________

EMAIL ADDRESS_____________________________________________________________________________

MARITAL STATUS: S W D M

PHONE: H #_______________________ CELL #______________________

YOUR EMPLOYER______________________OCCUPATION___________________WORK #______________

SPOUSE’S NAME___________________________ __________________________SS# ____________________

SPOUSE’S EMPLOYER____________________________________WORK #____________________________

EMERGENCY CONTACT: NAME_____________________________PHONE # _________________________

I CONSENT TO TREATMENT NECESSARY FOR THE CARE OF THE ABOVE NAMED PATIENT. I AUTHORIZE THE RELEASE OF MY

MEDICAL RECORDS TO THE REFERRING, AND FAMILY PHYSICIANS, AND TO MY INSURANCE COMPANY IF APPLICABLE. I ALLOW

FAX TRANSMITTAL OF MY MEDICAL RECORDS, IF NECESSARY. I ACKNOWLEDGE FULL RESPONSIBILITY FOR SERVICES

RENDERED BY DR. SAIEG. I UNDERSTAND THAT PAYMENT FOR THOSE SERVICES IS DUE AT THAT TIME, UNLESS OTHER

DEFINITE FINANCIAL ARRANGEMENTS HAVE BEEN MADE. INSURANCE CLAIMS WILL BE SUBMITTED FOR ME FOR COVERED

SERVICES ONLY, AND ONLY TO THOSE COMPANIES WITH WHICH DR. SAIEG PARTICIPATES. WE RESERVE THE RIGHT TO SEND

YOUR ACCOUNT TO A COLLECTION AGENCY FOR ANY DELIQUENT BALANCE, INCLUDING FEES INCURRED BECAUSE OF THIS

ACTION, AND INCLUDING BUT NOT LIMITED TO COURT COSTS, AND COLLECTION TRANSFER FEES. MY SIGNATURE REPRESENTS

MY AGREEMENT TO THESE TERMS. I HAVE READ AND FULLY UNDERSTAND THE ABOVE CONSENT. THIS ASSIGNMENT IS TO BE

CONSIDERED AS VALID AS AN ORIGINAL.

DATE____________________________ SIGNATURE____________________________________________

MICHIGAN LAW REQUIRES PHYSICIANS TO ADVISE PATIENTS ABOUT THEIR RIGHT TO CREATE AN

ADVANCE DIRECTIVE.

YES

I WOULD LIKE A COPY OF THE ADVANCE DIRECTIVE. INITIALS__________________

I WOULD LIKE TO REQUEST THAT THE FOLLOWING DESIGNATED PERSON BE GIVEN ACCESS TO MY

RECORDS AND/OR MEDICAL CONDITION, ALLOWING THE PHYSICIAN AND STAFF TO DISCUSS PERSONAL,

FINANCIAL, MEDICAL AND/OR CHANGES IN MEDICATION OR TREATMENT IF I AM UNABLE TO BE

REACHED.

NAME AND RELATIONSHIP_______________________________________________________________

PATIENT SIGNATURE__________________________________________________ DATE_____________

MAY WE LEAVE A MESSAGE REGARDING BILLING OR RESULTS? _________________________

Patient Information Sheet - Robert G Saieg Md