David Schechter, M.D.

Patient Intake Form

Please fill out this form completely. The following information will help us in providing you the best medical care and treatment possible. If you have any questions, please contact the office. Thank you and we look forward to seeing you!

Patient Information

First Name * Middle Initial Last Name * Date of Birth * Age: * Gender * SSN Mailing Address * City * State * Zip Code * Cell Phone * Home Phone Email Address *

Additional Information

Driver's License Number * Photo of Driver's License/ID Marital Status * Occupation * Employer * Work Address * Preferred Language Who is your Primary Care Provider (PCP)? Referral Source: If you chose "Patient," "Physician," or "Other," please specify here:

Emergency Contact or Next of Kin

Emergency Contact Name * Emergency Contact Number * Relationship with Emergency Contact: If minor, parent info:

Payment/Insurance Information

Insurance Type * Insurance Carrier's Name *

Attach photo of insurance card AND/OR fill out policy information below. No appointments will be confirmed without payment information.

INSURANCE CARD INSURANCE CARD Policy ID Group ID Policy Holder's Name Policy Holder's DOB Policy Holder's SSN Patient Relationship to Policy Holder

Secondary Insurance Information

INSURANCE CARD INSURANCE CARD Secondary Insurance Name Policy ID Group ID Policy Holder's Name Policy Holder's DOB Policy Holder's SSN Patient Relationship to Policy Holder

ASSIGNMENT OF BENEFITS/FINANCIAL RESPONSIBILITY:

I hereby authorize payment directly to the Physician. I understand that my insurance policy is a contract between myself and my insurance provider and I agree to be financially responsible for non-covered services. The Provider will file my insurance claim for some PPOs. I understand that if I fail to cancel an appointment with 24 hours (one business day s) notice that I will be charged a fee and that insurance companies do not pay this fee; it is my responsibility alone. The no-show or late cancellation fee will typically be $90 for each 15 minutes of appt time missed.. I understand that failure to pay my bills promptly may result in interest, penalty or collection fees, dating back to the first day the payment was due. Late payment: at 60 days add: $25. 90 days add $50. 120 days add $100. Payment expected at time of service including any copays or deductibles.

INITIALS: *

AUTHORIZATION TO RELEASE INFORMATION:

I hereby authorize the Provider to release any information to insurance companies required to process my claim. I have read the doctor's HIPAA notice and understand the priority the office places upon patient confidentiality.

GENERAL:

I understand the Physician is not an HMO nor Medi-Cal Provider.

MEDICARE FINANCIAL RESPONSIBILITY:

I understand that the Physician is not a Medicare Provider. I can sign a Private Contract to see him outside of Medicare and will not be reimbursed by Medicare or Secondary Insurance for his services. Labs that are sent out, imaging, etc. can be Medicare covered. I acknowledge by my signature below that any lab tests not covered by Medicare that are ordered by this office are my responsibility alone and will be billed directly to me. I understand that I may be charged for completion of forms by the doctor.

If I have Medicare, I will also initial here:

REFERRAL INFORMATION:

I understand that I am ultimately responsible for checking on any referral doctor or facility and determine if he/she/it is a provider for my PPO insurance and whether any preauthorization is required.

Questions? Ask our front office assistant as soon as possible for clarification.

Patient's Signature: * Date: *