Patient InformationReferring PhysicianFamily PhysicianPatient First Name(Required)Patient Last Name(Required)Middle InitialDate of Birth Month Day YearAgeAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code SSNSex Male FemaleMarital Status Single Married Divorced WidowedHome PhoneWork PhoneCell PhonePlease check which number(s) we may call you at? Home Work CellAnd/or which number(s) we may leave a message at? Home Work CellEmployment Status Employed Unemployed RetiredEmployerEmployer AddressSpouse Name First Middle Initial Last Spouse Date of Birth Month Day YearSpouse EmployerSpouse Employer Phone NumberWho can we contact for you in the event of an emergency?Emergency ContactRelationshipPhoneEmergency ContactRelationshipPhoneInsurance Policy Holder InformationPrimary CompanySecondary CompanyPrimary Subscriber's NameSecondary Subscriber's NamePrimary Subscriber's Date of Birth Month Day YearSecondary Subscriber's Date of Birth Month Day YearPlease provide a copy of your card upon check-in or your account will be entered as self-pay/uninsured.Please confirm if your insurance requires a referral so your claim is not unnecessarily denied, causing you to be responsible for the full bill. You will need to contact your primary care physician or referring physician to obtain your referral. You can provide them our fax number (316-685-1273).Guarantor (Responsible Party - if different from patient)Responsible PartyResponsible Party Date of BirthAddress Same as patient Different addressPlease Add the Address of The Garauntor Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Relation To PatientSSNCell PhoneResponsible Party EmployerWork PhonePatient DemographicsIf you would like a written summary of today’s visit (clinical summary), please inform the receptionist. Please answer the following questions so we may comply with the Meaningful Use regulations:Race White, Not Hispanic or Latino Black or African American, Not Hispanic or Latino Asian Native Hawaiian Other Pacific Islander American Indian or Alaskan Native Hispanic or Latino (all races)Ethnicity Hispanic or Latino Not Hispanic or LatinoPreferred Gender Male Female Male-to-female transgender Female-to-male transgender Non-comforming / other genderPreferred Language English Spanish OtherWhat is your preferred language?Preferred Method of Communication Email US Post Office Home Telephone Cell PhoneEmail Address (to be used for secure patient communication only)(Required) Assignment and Financial Responsibility Please check this box if you agree to the terms belowI hereby assign payment directly to Kansas Surgical Consultants, L.L.P. for surgical and/or medical benefits. I acknowledge that I accept full responsibility for any medical service rendered to me or anyone for whom I am legally responsible for. I understand that I am financially responsible for charges even when insurance should provide coverage and does not pay a valid claim within 60 days, or for non-covered services. I will be legally responsible for all collection costs involved with this account including all return check fees, court costs, attorney fees and other expenses incurred with collection if I default on this agreement. I have received a copy of the KSC Financial Policy and agree to its terms. I acknowledge that the Notice of Privacy Practices of Kansas Surgical Consultants have been offered to me and are available upon request at any time.SignaturePlease type your name
