New Patient Forms

Patient Information

First Name(Required)

Middle Name

Last Name(Required)

Sex(Required)

Male

Female

Date of Birth(Required)

Age(Required)

Patient Address(Required)

Street Address Address Line 2 City State ZIP Code

Home Phone(Required)

Cell Phone(Required)

Patient's Email(Required)

Social Security Number(Required)

Patient Employer

Job Title

Employer's Address

Street Address Address Line 2 City State ZIP Code

Employer's Phone Number

Emergency Contact Information

Emergency Contact Name(Required)

Emergency Contact Phone Number(Required)

Responsible Party

Responsible Party Name(Required)

Responsible Party Social Security Number(Required)

Responsible Party Address(Required)

Street Address Address Line 2 City State ZIP Code

Responsible Party Phone(Required)

Responsible Party Employer

Responsible Party Occupation

Employer's Address

Street Address Address Line 2 City State ZIP Code

Health Insurance Information

Insurance

Policy Holder Name

Policy Holder SSN

Policy Holder DOB

Policy Number

Group Number

Are you claiming this as an on-the-job injury?

Yes

No

Date of Injury(Required)

Was this problem caused by an accident?

Yes

No

Date of Accident(Required)

Do you have an attorney handling this claim?

Yes

No

Name of Attorney(Required)

Were you referred to our office?

Yes

No

Name of Referral(Required)

Primary Physician Name

Physician Phone Number

Required Authorizations

Please take a moment to complete all of the following required consents.

I hereby authorize payments directly to Infectious Diseases Consultants of Oklahoma City of the surgical and/or medical benefits. I understand that I am responsible for any portion of my bill not covered by my insurance company within the terms of its contract.

Benefits to Physician Signature(Required)

Signed by patient or parent of minor

I hereby authorize release of information necessary for filing my insurance claim or filing a payment review.

Release of Information Signature(Required)

Signed by patient or parent of minor

Please review our notice of privacy practices carefully and save to your records. By signing, you agree that you have received a Notice of Privacy Practices from the office of David Chansolme, MD.

Notice of Privacy Practices Signature(Required)

Signed by patient or parent of minor

Date(Required)

Please review the patient consent information for use and disclosure of protected health information carefully. By signing, you agree you have signed the patient consent for use and disclosure of protected health information from the office of David Chansolme, MD.

Patient Consent Signature(Required)

Signed by patient or parent of minor

Date(Required)

I authorize practice/billing company to contact me about my bill by reaching me via:(Required)

Phone

Cell Phone

Work Phone

Mail

None

NOTE: If "none" is checked we will require prepayment on all services.

You may speak with the following person/s about my bill regarding medical services provided:

Provide name, relationship and phone number.

You may NOT speak with the following person/s about my bill regarding medical services provided:

Provide name and relationship.

New Patient Forms

Patient Information

Emergency Contact Information

Responsible Party

Health Insurance Information

Required Authorizations

Health History Form

Symptoms

Family History