Dr. Kreitmann's Practice  
     
 
 
     
DEMOGRAPHIC DOCUMENT  
Oliver Kreitmann,M.D.                (2/2/06)

Your Name:
(First, Last)    
Date of Birth/Age:                                                                            
Social Security Number:    
Home Address:

    
Home phone:    
Work phone:    
Cell phone:    
Best way to reach you?    
Occupation:    
Workplace:    
Spouse /emergency contact:    
Primary care physician:    
    
INSURANCE INFORMATION: Bring your insurance card with you.

PATIENT AUTHORIZATION:
By signing below, I authorize Oliver Kreitmann M.D. to provide for benefits on my behalf for covered services rendered.  I request payments by my insurance company be made directly to Dr. Kreitmann .  I certify that the information I have reported with regard to my insurance coverage is correct and further authorize the release of any necessary information, including medical information for this or any related claim, to the above named billing agent, or the insurance company named above.  I permit a copy of this authorization to be used in place of the original.  This authorization may be revoked by either me or the above named carrier at any time in writing.  
I authorize any holder of medical information about me to be released to my insurance company  to determine appropriate payments for covered services.
OFFICE CONFIDENTIALITY POLICIES:
This office is HIPAA compliant. Documents to that effect are available upon request or on the office website www.laclinic.medem.com
APPOINTMENT POLICIES:
Making an appointment in a physician's office is a commitment that requires the most serious consideration.  Each appointment must be written on one's own calendar at the time it is established.  Time management in a medical office is a challenge that requires accuracy and reliability.  For any appointment made, a reminder call will be given 2 days prior.  This is why we need to know what is the best way to reach you.  Any missed appointment or any late cancellation for no good reason will generate a charge of $25 as a compensation for office time lost and disruption.  In the event of a repetitive pattern of disrespect, the patient will be advised to seek medical care in another practice.  Appointments involving procedures and requiring more than 30 minutes of time may be secured by a down-payment equivalent to 25% of the expected billing for the procedure.  
By signing below I accept the general terms of this patient-physician relationship and accept to abide by them.
Your signature: __________________________________
 



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