Rittenhouse Women's Wellness Center

Available Forms

A.) Internal Medicine Authorization to Release Healthcare Information A.) Internal Medicine Health History Form A.) Internal Medicine HIPAA : Notice of Privacy Practices A.) Patient Registration B.) Dermacenter Client Information and History C.) Nutrition 3 Day Food Diary C.) Nutrition History D.) Dr. Perilstein: Emotional Well-being Authorization to Release Protected Health Information D.) Dr. Perilstein: Emotional Wellbeing Consent for Treatment D.) Dr. Perilstein: Emotional Wellbeing Receipt of Privacy Information E.) Dr. Liggera's Patient Registration Form F.) Payment and Cancellation Policy G.) Email Agreement

A.) Patient Registration

Patient Registration

Today's Date *

Last Name *

First Name *

Date Of Birth *

Mailing Address

Apt#<br/>City <br/>State<br/>Zip

Marital Status

Social Security

Best Telephone Number to Reach You: *

Phone Number: *

Email Address *

Preferred Pharmacy *

Please include Pharmacy name, address, phone number and zip code.

Occupation

Employer

Referred By

Insurance Information

Primary Insurance *

Member ID# *

Subscriber *

If you are not the subscriber, please list the subscriber's last name, first name and date of birth

Secondary Insurance (if applicable)

Member ID#

Secondary Subscriber

If you are not the subscriber, please list the subscriber's last name, first name and date of birth

May we leave messages regarding appointments at your *

May we leave messages for test results at *

Emergency Contact Information

Name of local friend or relative *

Relationship to patient *

Telephone Number *

Consent

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Rittenhouse Internal Medicine, P.C. or insurance company to release any information required to process my claims. If Medicare is my only insurance carrier, I understand that I am fully responsible for my 20% co-insurance due after Medicare payment.

Acknowledging Consent *

I understand

* Required field