Lake Rheumatology: Dr. K. Stark & Dr. N. Blum

Available Forms

#1 New Patient Information #2 Medication List & Drug Allergy List #3 Consent for Non-Face to face "Virtual" Visits #4 Comprehensive Patient History Questionnaire #5 Labs And Prescription Policy #6 Patient Call List #7 No Show Fee Financial Agreement #8 Rapid Questionnaire-Only if instructed #9 Osteoporosis Questionnaire

#1 New Patient Information

Kenneth Stark, MD, PA

Date *

Name *

Title *

Mrs

Date Of Birth *

Age *

Ethnicity *

Social Security Number

Mailing Address *

Home Phone *

Wk Phone

Cell Phone

Email Address *

Marital Status *

Single

Married

Widowed

Divorced

Other

Emergency Contact *

Emergency Ph Number *

Employer/Occupation

Business Address

Referring Physician

I Agree *

I hereby authorize Dr. Kenneth Stark to furnish my information to the insurance carriers concerning my illness and condition. I understand that Dr. Stark's office will file Medicare and Primary Private Insurance claims for dexas. I understand that Secondary Insurance will NOT be filed if not crossovered by Medicare. I am financially responsible for any deductibles, copays, coinsurance, and any other amounts not covered by my insurance. I understand any payment I am responsible for is due at the time services are rendered. I further understand that should collection procedures become necessary all interest charges up to 7%, collection charges up to 50% of the debt, and attorney fees (varying according to debt) can be charged to my account. By clicking the above box I certify that I understand and agree to the above statement and all the information provided including any and all Insurance is accurate.

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