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Gordin Medical
Patient Information Form
"This form is Copyright © 2011 Gordin Medical Center, S.C. All rights reserved.
No part of this form, either text or image, may be used for any purpose other than by patients or prospective patients of Gordin Medical Center for the purpose of providing demographics and health history to the practice. Reproduction, modfication, storage in a retrieval system, or retransmission, in any form or by any means, electronic, mechanical, or otherwise, for commercial or personal reasons, is strictly prohibited without prior written permission."
No part of this form, either text or image, may be used for any purpose other than by patients or prospective patients of Gordin Medical Center for the purpose of providing demographics and health history to the practice. Reproduction, modfication, storage in a retrieval system, or retransmission, in any form or by any means, electronic, mechanical, or otherwise, for commercial or personal reasons, is strictly prohibited without prior written permission."
When scheduling appointments for New Patients for Chiropractic Consultations, patients should be advised to:
Fax their insurance card before appointment or bring it with them in order to verify their benefits.
If faxing card, take down:
- Patient name
- Patient date of birth
- Policy holder name (if different from patient)
- Policy holder date of birth (if different from patient)
- Zip code
- Phone number where the patient can be reached once the benefits are verified.
If bringing card with them patients should be advised that the verification can not be completed after 3pm until the next business day morning.
ALL NEW PATIENTS SHOULD BE ADVISED THAT HAVING INSURANCE DOES NOT GUARANTEE COVERAGE.
When scheduling appointments for all New Patients, patients should be advised to:
- Bring a driver's license or picture ID.
- Fill out the paperwork ahead of time and bring it with them, if they so choose. Paperwork can be mailed to the patient if their appointment time allows, at least 3 business days for delivery. Paperwork can also be faxed to the patient.
- Have payment (or co-payment) ready at the time of appointment. Payment can be accepted in the form of cash, credit card and/or check. All major credit cards accepted. No debit transactions.
ALL PATIENTS SHOULD BE MADE AWARE OF THE APPOINTMENT COSTS WITH THE ADMINISTRATIVE DISCOUNT (THE CASH PRICES).
- Cancel the scheduled appointment 24 hours or more ahead of time if possible.
