Kamal H - Dr Kamal Artin, MD

Kamal H. Artin MD
62 Discovery, Irvine CA 92604 Tel (949) 451-1789, Fax (949) 451-1431
Last Name: ___________________________ First Name: ________________________ Middle Initial: _____
Address: ________________________________ City: ___________________ State: _______ Zip: _________
Home Phone: ___________________ Cell Phone: _____________________ Work Phone: ________________
DOB: _______________________ Age: _____ SS#: __________________________
Marital Status: ______ Gender: ____ Ethnicity: ___________ Referred by: ____________________________
Driver’s License #: ______________ Occupation: __________________ Years of Education: _____
Emergency Contact Name: ______________________ Home Phone: ___________ Cell Phone: ____________
Nearest relative not living with you (name, address, telephone): ______________________________________
__________________________________________________________________________________________
Reason for Visit: ___________________________________________________________________________
Have you been hospitalized? ______ If so, reason: _________________________________________________
Prior medical and surgical diagnosis: (Do you have a history of the following?) __________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Allergies: ____________________________ If so, describe reaction: _________________________________
Current medications: ________________________________________________________________________
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Primary Insurance Company __________________________________ Phone No: _______________________
Identification No ______________________________________ Group No: ____________________________
Name of Insured ______________________________ Relationship ___________________ DOB: __________
Secondary Insurance Company ________________________________ Phone No: _______________________
Identification No: ______________________________________ Group No: ___________________________
Name of Insured: ______________________________ Relationship: __________________ DOB: __________
Please sign and date below to indicate that you have received a copy of the NOTICE OF PRIVACY
PRACTICES. Your signature simply acknowledges that you received a copy of this notice.
Name ____________________________ Signature _______________________ Date ____________________
Kamal H. Artin MD
62 Discovery, Irvine CA 92604 Tel (949) 451-1789, Fax (949) 451-1431
FINANCIAL AGREEMENT AND ASSIGNMENT OF BENEFITS
The undersigned, whether he signs as agent or as patient, hereby agrees to pay the account in accordance with
regular rates and terms of the physician for services to render to the patient by Dr. Kamal H. Artin or his
associates. Usually insurance does not take responsibility for no shows, cancellations, and phone appointments
and therefore, the patient is responsible for such fees. An approximate hourly fee for services rendered is
$300.00. Cancellation fees within 48 to 24 hours before the appointment are $50.00. No show and cancellation
fees within 24 hours are $100.00. A clarification phone conversation between appointments is free. For more
than one interval phone conversation, phone appointment, and requests for copies of medical records there is a
fee of $50.00. Should the account be referred to an attorney and/or for collections, the undersigned hereby
agrees to pay reasonable attorney fees and /or collection expenses. The undersigned accepts terms hereof,
certifies that he or she has read the forgoing, and is the patient or is authorized to sign as the patients agent. I
authorize my credit card to be charged for the services that are not covered by my insurance.
Card type: _____Card Number: __________________________ Expiration Date: ________
Name and Address of card holder: ____________________________________________
________________________________________________________________________
Please help us serve you better by keeping scheduled appointments.
Thank you for honoring our Cancellation/Missed Appointment Policy.
Please let us know if you have any questions or concerns. I have read the Cancellation/Missed Appointment
Policy. I understand and agree with this policy.
Date: __________________
Patient Name: _________________________ Signature: __________________________
Name of Guardian
Or Responsible Person: __________________ Signature: _________________________