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New Patient Registration

(RECOMMENDED)
Print the complete registration form, fill out, print and
bring to our office on your appointment date.

PRINT NEW PATIENT REGISTRATION FORM
New Patient Registration

ALLERGY, ASTHMA, SINUS & IMMUNOLOGY CENTER
Shawky A Hassan, M.D., Ph. D.
Phone: (239) 261-5599

PATIENT REGISTRATION

GUARANTOR INFORMATION

Name
Name
First
Last

GUARANTOR INFORMATION TO BE PROVIDED IN OFFICE

  • Last 4 digits of social security number
  • Driver's license number
  • Employer Information

PATIENT INFORMATION

PATIENT INFORMATION TO BE PROVIDED IN OFFICE

  • Patient name
  • Patient address
  • Birthdate
  • Referring physician or other source of referral
  • Family physician
  • Gender and Marital status

INSURANCE INFORMATION

INSURANCE INFORMATION TO BE PROVIDED IN OFFICE

  • Primary/Secondary Insurance Carrier | Address
  • Group #
  • Contract #
  • Name of insured
  • Birthdate
  • Relation to patient

FEES & BILLING INFORMATION

Our billing procedures are clear. Please take a few moments and acquaint yourself with our credit policy:

  1. Payment is expected at the time of service by cash, check or credit card (Visa/Master Card).
  2. You will receive an itemized statement for all services rendered to you on the same day of service.
  3. All accounts past due over 60 days are to be paid by the patient prior to the next visit.
  4. A rebilling charge of 1 ½% per month will be added to any unpaid balance over 60 days from the day of service.
  5. All accounts 90 days or older are handled exclusively by a collection agency and a collection fee will be added to the balance.

AUTHORIZATION

SIGNED AUTHORIZATION TO BE REQUIRED IN OFFICE