New Patient Questionnaire

Premier Heart & Vascular

Board Certified, Interventional Cardiology, Cardiovascular Disease & Nuclear Cardiology

Pranav Doshi DO | 10240 W Indian School Rd Suie 140, Phoenix AZ 85037 | Phone 602-922-1020

New Patient Questionnaire

Name

DOB

Address

Home Phone

Cell phone

Email

Gender

Male

Female

Social Security #

Referring Physician

Primary Care Physician

Emergency Contact(Required)

I authorize PHV to release health information to my Emergency contact

Name

Relationship

Phone

Insurance Information

Primary Insurance Company

Relation to Subscriber

ID#

Group#

Subscriber Name

Birth Date

SSN

Secondary Insurance Company

Relation to Subscriber

ID#

Group#

Subscriber Name

Birth Date

SSN

Authorization

AUTHORIZATION: I assign all medical/surgical benefits to and understand if eligibility of insurance cannot be verified or if deducible has not been met, I will be responsible for the cost of all medical services rendered. I hereby authorize payment directly to Premier Heart and Vascular for the surgical and and/or medical benefits, if any, otherwise payable under terms of my insurance.

Authorization

PATIENT WAVIER: I hereby authorize Premier Heart and Vascular to release any information acquired in the course of my examination or treatment. I hereby authorize the physician, hospital, or medical facility to provide all information on my medical history and treatment to Premier Heart and Vascular. I hereby authorize photocopies of this form and my signature to be as valid as the original.

Authorization

REFERRALS: If you are an HMO or managed care patient, you will need to obtain a referral form from your primary care doctor. It is the patient’s responsibility to obtain the referral prior to your visit. Please initial even if you do NOT have an HMO policy. This states you acknowledge our policy if your insurance changes in the future.

Authorization

MEDICARE PATIENTS ONLY: I request payment of authorize Medicare benefits be made on behalf of Premier Heart and Vascular for any services furnished to me by the physician. I authorize any holder of medical information about me to release to Health Care Financing Administration and its agents any information needed to determine these benefits payable to related services.

Authorization

I have read and understand the information on this form.

Signature(Required)

Date(Required)