PATIENT INFORMATION

Patient First Name

Please complete this field.

Middle Name

Please complete this field.

Patient Last Name

Please complete this field.

Mailing Address

Please complete this field.

City:

Please complete this field.

State:

Please complete this field.

Zip Code

Please complete this field.

Date of Birth

Please complete this field.

Home Phone:

Please complete this field.

Work Phone:

Please complete this field.

Cell Phone:

Please complete this field.

Marital Status

Please complete this field.

Sex:*

Male

Female

Please select an option.

Primary Care Physician:

Please complete this field.

List Physician(s) seen for problem seeing us for today(i.e. Surgeon, Pain Management, Chiropractor, Physical Therapy, etc

Please complete this field.

How did you hear about us?

REFERRAL INFORMATION:

Person to contact in case of emergency:

Please complete this field.

Phone:

Please complete this field.

To better serve our patients, we will automatically fax all prescriptions to the pharmacy for you:

Pharmacy:

Please complete this field.

Phone:

Please complete this field.

Fax:

Please complete this field.

Pharmacy Location

Please complete this field.

AUTHORIZATION AND FINANCIAL POLICY

I, the undersigned, certify that I (or my dependent) assign directly to CCSRM/Ahmed Khan, M.D., all insurance benefits for services rendered. Medicare and/or other insurance carriers will only pay for services that it determines to be “reasonable and necessary.” If my insurance company determines that a particular service, although it would otherwise be covered, is not “reasonable and necessary” under my policy with my insurance carrier, they may deny payment for these services and I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize release of all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions. My signature below shows that I understand that all copayments, coinsurance, deductibles, non-par insurance and self pay are due at the time services are rendered. I understand that CCSRM/Ahmed Khan, M.D. has the right to charge me $35 for any returned check and $50 for any office appointments and $150 for any procedures I fail to reschedule (No-Show Appointments).

CANCELLATION FEE POLICY-My signature below shows that I understand the cancellation policy: $95 Fee for less than 24 hours notice of cancellation for consult and follow up office visits or not showing for the appointment. $200 Fee for less than 7 days notice for scheduled procedures or not showing for the appointment. I also understand that payment of these fees must be made prior to any future appointments being scheduled.

I, the undersigned, certify that I (or my dependent) understand that All PRP deposits are non-refundable.

For HIPAA Compliance, please answer the following questions:

I authorize you to leave appointment messages or send information to me via:

Answering Machine

Please complete this field.

With another person

Please complete this field.

Mail

Please complete this field.

My signature below also indicates that I have been provided, CCSRM/Ahmed Khan, M.D.’s Notice of Privacy Practices.

My signature below authorizes CCSRM/Ahmed Khan, M.D., general consent for evaluation, treatment and the understanding of CCSRM/Ahmed Khan, M.D. Financial and Cancellation Policy.

If Guardian, state relation:

Please complete this field.

I give CCSRM/Ahmed Khan, M.D., permission to release medical information to the above referring and/or Primary Care Physician

We gladly accept Cash, Checks, MC, VISA, AMEX, DISCOVER.

Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Subscribe to updates from Columbus Center for Sports & Regenerative Medicine