Dr. randolphs ageless & wellness medical center c.w. randolph, jr., m.d. lori leaseburge, m.d. nicole thomas, arnp steven garces, arnp kristin byers, arnp general patient information (please print clearly) demographic date: name: first middle...
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Louis h. medved, m.d. brandon a. yehl, p.a. neurology electromyography and infusion suite 30 erie canal drive, suite g rochester, new york 14626 telephone (585) 2273950 fax (585) 2279047 .louismedvedmd.com infusion/injection referral form...
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Childrens medical group, p.a. new patient information form appointment date: time: chart #: patients full name: address: city state zip primary phone #: date of birth: sex: m f ethnic origin: birth hospital: birth wt: lgth: fathers name: ss#:...
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Children s medicine of rockdale 1765 parker road, suite b210, conyers, ga 30094 phone: 770.761.0672 fax: 770.761.0784 web: .rockdalekids.com new patient information patient s full name nickname street address gender city state zip date of birth...
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Patient information form 3504 cragmont dr. ste 100 tampa, fl 33619-8300 toll free nationwide: 800.588.8383 phone: 813.931.2369 toll free fax: 800.588.9282 patient soc. security no. date unit issued patient name: type of claim address q group...
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(409) 8330 phone (409) 8339039 fax .eyecentersofsetexas.compatient information form date: doctor: chart number: welcome to eye centers of southeast texas, l.l.p. so that we can effectively meet your needs, please print and complete all the...
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If you are a new patient, please bring to your office visit the following items: information form completed (found below); the nora medical group patient clinical
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Russell s. gornichec, md, pc, facs general & bariatric surgery 501 w. grand avenue hot springs ar 71901 5017787300 5017787301 fax weightlosscenterar.com patient information last name, first, middle initial date of birth sex marital status...
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Ultrasound whatisanultrasound? an ultrasound study is a test performed by a qualified health care professional called a sonographer or ultrasound technologist. most ultrasound examinations should be painless; it uses sound waves to image...
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Doh-4359 (2010) physician s order for personal care/consumer directed personal assistance services complete all items 1. incomplete forms will be returned to the physician patient identifying information (use additional paper if necessary) patient...
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Staple 2-hole 1/4 2 3/4 c-to-c intensive outpatient program 3-hole 1/4 4 1/4 c-to-c admission face sheet patient label patient name: last: first: middle: are you known by any other name? no yes: mother's maiden name: patient
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Name: date: 1 chart: university of washington school of dentistry - medical and dental history general information male c. weight: lbs. month day year female d. height: ft. inches e. highest grade of regular school that you have completed? f....
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Hipaa privacy authorization form **authorization for use or disclosure of protected health information (required by the health insurance portability and accountability act, 45 c.f.r. parts 160 and 164)** **1.authorization** iauthorize...
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Release of information - phone # 805-370-4895, fax # 805-370-4726 processing may take up to 15 working days and a fee of $.25 cents per page and shipping and handling will apply* healthport will be handling the release of the records. section a:...
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5-hole 1/4 1 3/8 c-to-c outpatient patient information sheet patient information patient name: sex: last first middle m f child's social security #: dob: religion: parent/legal guardian: relationship: ss#: parent/legal
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