New Patient Information

I am here for my first appointment with: *

Internal Medicine - Preeti Rana, M.D.
Nephrology and/or Hypertension, - Irmindra (Inder) Rana, M.D.
Nephrology and/or Hypertension, - Waqas Memon, M.D.
Nurse Practitioner - Suh Yang, NP

Nephrology and/or Hypertension, *

I have a referral with me today.
My insurance requires no referral.

I was referred by: *

Name *

First

Middle

Last

Date of Birth *

SSN: *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Home Phone

Work Phone

Email *

Email

Confirm Email

Would you like to list an emergency contact? *

Yes
No

Emergency Contact Name *

Relationship

Phone *

Consent *

I DO consent to Text messaging from Dr. Rana's office.
I DO NOT consent to Text messaging from Dr. Rana's office.

Signature affirming the above selection: *

Messages may include but are not limited to appointment reminders, notifications, requests to contact the office, notifications about lab work but not actual lab results, cancellations or closures of the office due to extenuating circumstances or adverse weather conditions and other pertinent information. You have the right to change your consent selections at any time and without any questions asked or explanations needed. Confirmation of this change will be affirmed by completing a form stating your wish to opt-in or opt-out, mobile number associated with the request, date and your signature.

Insurance *

I have current/active health insurance.
I am currently uninsured and would like to pay for my visits in full, at the time of service.

Advanced Directive: *

I DO NOT have an advanced directive.
I have an advanced directive.
I'd like to discuss or get information regarding advanced directives.
I have no interest in advanced directives, thank you,

If at any time you change your mind, feel free to contact our office and/or make an appointment with the physician.

Pharmacy Name *

Pharmacy Address

Address Line 1

City

State

Pharmacy Phone

Medication *

I do not currently take any prescription medication
I currently take over the counter medication
I currently take prescription medication

I currently take prescription medication *

I have a list of medication of my medication with me
I have my medication with me for the physician's review
I take the medications indicated below

Please list all medications that you are currently taking. *

History (I, or a member of my family have/had)

Other information pertaining to me or my health:

Concerns I have about my health:

I'd like more information about:

Financial Policy

Thank you choosing us for you healthcare needs. Our goal is to provide and maintain a good physician-client relationship . The following is our Financial Policy, which we ask you to review and sign prior to your first visit.

General Information *

(Initial) Your co-payment, deductible, coinsurance, or payment in full is due at the time of service. We accept checks and cash at this time.

Regarding Insurance *

(Initial) We participate in a wide variety of managed care plans. We are happy to bill your insurance carrier as a courtesy to you. We suggest that all patients review their health coverage with their carrier prior to receiving services or treatment. It is the responsibility of the patient to notify us of any changes in the insurance policy. Your insurance policy is a contract between you and your insurance company and our staff will not know the therms of your insurance policy. Please be aware that some, perhaps all, of the services provide may be non-covered services and not considered reasonable and necessary under the Medicare program and/or other medical insurances. The patient/financial guardian will be responsible for any remaining balances,. Additionally, it is your responsibility to obtain and track referrals for your visits.

Self-Pay Patients *

(Initial) Patients without insurance are expected to pay at the time of service.

Worker's Compensation

(Initial) we will bill your employer's worker's compensation insurance carrier and follow all other procedures as required by the states worker's compensation laws. As the patient, it is your responsibility to notify us prior to the with appropriate worker's compensation policy information.

Automobile and Other Liability Cases

(Initial) Due to state laws surrounding auto insurance payments, as well as payments delays, we regret that we may not be able to bill third party administrators in liability cases. In addition, we cannot suspend our normal billing and collection process when services are rendered. Your health insurance carrier or the guarantor will be billed for services.

Returned Checks *

(Initial) There will be a $30.00 returned check fee on all returned checks. In the event that a check is returned for insufficient funds, we reserve the right to call your bank for any future checks that are presented for payment on your account.

Missed Appointments *

(Initial) Unless cancelled at least 24 hours in advance, your appointment could be considered a no-show. Our policy allows us to charge up to $25.00 for these types of missed appointments. Please help us serve you better by keeping your scheduled appointments.

Thank you understanding our Financial Policy. Pleases let us know if you have any questions or concerns. Please sign below to express your understanding and agreement to this financial policy.

Patient Name *

Date *

Patient/Responsible Party Members Signature *

Responsible Party Member's Name (Print)