Name: COB: ColumbiaDoctors
Name: COB: ColumbiaDoctors
Adult New Patient Intake Form
Patient Information
Last Name:
Gender: M Home Phone)]
Preferred Phone: om a or Mobile (circle one)
Emergency Contact: tel12/•JA Sl-luLA AV, Relationship: Fg I 0-14.) Emergency Contact Phorl Patient Marital Status: $ Occupation: 'BM Kee Employer: a -
Primary Care Provider (PCP): DC eascif marn 011ie_ PCP. Phone:
Referring Provider: h1... M OSI4o,,, IT -2. Referring Ph
Preferred Pharmacy: VITA Ft GA 1-71-I Pharm Phone:
Preferred Pharmacy Address: /0 35 I st. Ave-First Name: Ter-F gel DOB:
Mobile Phone;
Email: e e s e a ebe nic6 L- win Page I of 4
Please list ALL active treating physicians (i.e. pulmonologist, oncologist, internist, cardiologist, etc...)
Doctor's Name: Dg • SI-1 m 01 Specialty: C4eDiet-DCIS -r
Doctor's Name: Specialty:
Doctor's Name: Specialty:
Doctor's Name: Specialty:
Collection of the following information is encouraged by federal health agencies. This information is used to
monitor and improve the quality of care provided to all patients.
Ethnicity: Race:
o Decline Response ❑ Dedine Response a Black or African American
o Hispanic or Latino erAmerican-Indian or Alaska Native o Native Hawaiian or Pacific Islander e-Not Hispanic or Latino a Asian ErWhite a Other
Preferred Language: o Decline Response
Patient Financial Obligation Agreement
I understand that all applicable copayments and deductibles are due at the time of service. I agree to be financially responsible and make full payment for all charges not covered by my Insurance company. I authorize my insurance benefits be paid directly to ColumbiaDoctors for services rendered. I authorize representatives of ColumbiaDoctors to release pertinent medical Information to my insurance company when requested or to facilitate payment of a claim.
Notice of Privacy Practices: Acknowledgement of Receipt
I acknowledge that I was provided with a copy of the ColumbiaDoctors Notice of Privacy Practices (NOPP).
o Received ❑ N/A (only if you received the notice from ColumbiaDoctors previously)
Information Disclosure and Consent
ColumbiaDoctors will provide you with the health plans that your provider(s) accepts*. If you decide to be treated by a provider who does not accept your health plan, you will be asked to sign a consent form agreeing that you accept treatment from that provider.
I read and agree to all of the above (Financial Agreement, Notice of Privacy, Insurance Information).
Patient or Legal Guardian Name (Print): —,relt---epey ftJ
Patient or Legal Guardian Signature:
*Please refer to our website: columbladoctors.org, for a list of insurances accepted by your provider.
Version 1.8 Updated: 642/2016 Date: MAY l P, QO I "4-
EFTA00313690