DS9 Document EFTA00313690

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 ma r n 011i e_ 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 K 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 K 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