Last Name: First Name: Middle: Date of Birth: Patient Email: Address

**Please review and update the information below to the best of your ability **
Patient Information
CURRENT PATIENT INFORMATION – PLEASE PRINT
Guarantor information (to whom statements are sent)
Last Name:
First Name:
Middle:
Date of Birth:
Patient Email:
Address:
City:
Zip:
Home #:
Work #:
Cell #:
Sex:
Social Security #:
Patient Language:
Race:
Patient Ethnicity:
Last Name:
First Name:
Date of Birth:
Relationship to patient:
Phone:
Email:
Address:
City:
Zip:
State:
State:
Emergency Contact Information
Are you living in an assisted
/nursing facility? Yes/No
If yes, which facility?
Name:
Address:
Name:
Relationship:
Phone #:
Mobile Phone #:
Email:
Power of Attorney:
POA Phone #:
DNR: Yes / No (please
circle)
Living Will: Yes / No (please circle)
**If you have a POA and/or answered “yes” to either DNR or
Living Will, our office will need a copy of the legal document
for your medical record. **
PERSONAL INDIVIDUALS WE CAN SHARE YOUR MEDICAL INFORMATION WITH:
Please initial if you do not wish to share any of your medical information: ____
__________________________________________________________________________________________________
Name
Relationship
Cell/Home Phone
Work Phone
__________________________________________________________________________________________________
Name
Relationship
Cell/Home Phone
Work Phone
__________________________________________________________________________________________________
Name
Relationship
Cell/Home Phone
Work Phone
POLICIES, RELEASES AND FINANCIAL RESPONSIBILITY
Payment is due at the time of service unless we are contracted with your insurance company, or you make other arrangements for
payment prior to your visit.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
All patients must complete the patient registration and health history questionnaire prior to being seen by the our
providers.
All patients are required to provide a current copy of their insurance card and driver’s license at each visit. Patients are also
required to notify DCND of any changes to their insurance, demographics and whom we can share information with. DCND
will not be responsible for any denials for inaccurate insurance information given or omitted by the patient.
I authorize the release of medical record information to the referring physician, other documented physicians, my
insurance carrier(s) and the above named in accordance with HIPAA.
I consent to treatment necessary for the care of the above named.
Co-payments/unpaid balances are to be paid at the time of service, unless DCND is contracted with your insurance company.
If you are not able to pay your balance in full, you must contact the DCND billing office to discuss a payment schedule. If you
fail to make payments as agreed upon, your account may be referred to a professional collection agency.
Your insurance policy is a contract between you, your insurance carrier and your employer. It is the patient’s responsibility
to know and understand your insurance policy.
I authorize my insurance carrier(s) to make payments directly to DCND, if appropriate.
If DCND is not contracted with your insurance company and/or in network, it is your responsibility to make payment in full
at the time of service. DCND will help you file your claim, but your insurance company will reimburse you directly. If you
have a secondary or tertiary policy, you will need to forward a copy of your Explanation of Benefits (E.0.8.) for further
billing. Patients are responsible for payment of annual deductibles and co-insurance. DCND is unable to process any third
party claims (i.e.: personal injury).
If you do not have medical insurance, payment for any DCND service is required at the time of appointment unless prior
arrangements have been made with the DCND billing office.
If a check is returned unpaid from the bank, a charge of $50.00 will be applied to your account.
If your insurance requires that you have a referral from your primary care physician, it is your responsibility to ensure that
our office receives the referral prior to your appointment date. If we do not receive that referral, you will be responsible for
payment of services provided or your appointment may be rescheduled.
Our DCND staff will try their best to pre-certify any testing that your physician might order. However, it is ultimately the
patient's responsibility to check with their insurance company to see if the test needs pre-certification prior to the test
being done.
If you are unable to make your scheduled appointment, and we are not notified at least 24 hours in advance, you may be
charged a $50 cancellation fee. (Please refer to our Appointment policy for further explanation, by visiting
www.dcndinc.com.) ___________Initial
I understand I have certain patient rights regarding my protected health information and I authorize DCND to disclose
that information to carry out treatment, payment, and health care operations. Please refer to our Notice of Privacy
Practices for more information. It can be found at www.dcndinc.com. ___________Initial
I have read and fully understand the above consent for treatment, financial responsibility, release of information and insurance
authorization. I have read the above information regarding my address, insurance and personal representative and certify that it is
correct and accurate. I agree to the terms outlined in this policy and understand my obligations regarding any charges incurred.
PATIENT SIGNATURE _____________________________________Date ____________________________
REPRESENTATIVE SIGNATURE __________________________________ Date ____________________________