Adult friend Peterson

Added: Shealene Miser - Date: 10.09.2021 03:54 - Views: 30898 - Clicks: 2125

Chris M. Peterson, MD, PA. Greenville, SC Welcome, and thank you for choosing us to serve your dermatology and surgery needs.

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We ask that you please arrive 15 minutes PRIOR to your appointment so that we can prepare your chart and process all insurance information prior to your appointment time. We are a participating provider with several Managed Care Insurance Programs as listed below. If you belong to one of these programs, we will handle the insurance filing for you. We send out patient statements at the beginning of each month. If you have any questions regarding your insurance, please feel free to call our office ahead of time and we will be happy to assist you.

We look forward to seeing you in the office. We are participating provider with many insurance companies. As a part of our contracts, we are required to file your claims to these companies. If you have insurance through your employer that insurance is primary and must be filed first. Insurance through your spouse's employer is secondary and will be filed after we hear from the primary insurance. We are a participating provider with many insurance companies.

As a part of our contracts we are required to file your claims to these companies. I do not have insurance coverage. I will not file to any insurance company for reimbursement. I understand that I am responsible for my bill at the time of service. I authorize Chris M. Peterson, MD, PA to release to my insurance companies any information required for service provided. I permit a copy of the authorization to be used to place of the original and request that payment of insurance benefits be ased to Chris M.

I agree to pay all copays, deductibles and balance of allowable fees.

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As a professional courtesy, we will file your insurance. We cannot assume responsibility of your payment by your insurance carrier, nor can we accept their payment as payment in full. I understand that my insurance is a contractual agreement between myself and my insurance company.

I agree to pay any amount not paid by my insurance companies. I permit a copy of the authorization to be used in place of the original and request that payment of insurance benefits be ased to Chris M. Peterson, MD, PA to forward my insurance information to such labs. I authorize Dermatology Consultation Service, LabCorp, Quest, Miraca or Pathology Consultants to release to my insurance companies any information required for services provided. I permit a copy of this authorization to be used in place of the original and request that payment of insurance benefits be ased to them.

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Patients with managed care insurance are billed after insurance processes their claim. Unpaid patient balances over 90 days old are subject to collection proceedings and dismissal from the practice. I understand that the purpose of this notice is to inform me of my rights in regard to my Protected Health Information and also the way in which Chris M. Required by Federal Government.

Please indicate which family member has a history of condition by checking. Authorization to Disclose Information. Subscriber name as it appears on card. Subscriber DOB. Subscriber relationship to patient. Are you on Medicare?

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Do you have Medicare Replacement Plan? Are you currently enrolled in Hospice? Patient Name. Sex M. Full Time? Part Time? Home Phone. address. Date of birth. Father's name. City, State, Zip. Date of Birth.

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Place of Employment. Work Phone. Mother's name. Father's Ins. Mother's Ins. Is this patient covered under any other insurance?

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Insured Name. Relationship to patient. Insurance Co. Patient's ature. Free Text We send out patient statements at the beginning of each month. Preferred Phone. May we leave a detailed message?

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Referred by Dr. Family Physician Dr. May we obtain your medication history from other providers? Preferred pharmacy Preferred pharmacy. Preferred Language. Race African American. Alaska Native. American Indian. Native Hawaiian. Pacific Islander. Other Race. Declined to Specify. Non-Hispanic or Latino. State briefly the problem s for which you were referred here. Have you received your flu vaccine? Have you received your pneumonia vaccine? Past Medical History Please check all that apply Anxiety. Artificial ts.

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Atrial fibrillation. Bone Marrow Transplantation.

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email: [email protected] - phone:(896) 375-9580 x 6682

PATIENT FORMS