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Las Vegas House Call Doctor
3750 S Jones Blvd. Ste. 110 *Las Vegas, NV 89103
Tel: (702) 876-0350 Fax: (702) 847-7437* Email: [email protected]
Patient Information
Referred by
E-mail
Last Name
First Name
SS#
DOB
Address
Gender
City
Male
Group Home
Female
Major Cross Streets
Gate Code
Home Phone
Cell Phone
Secondary Contact
Phone number
Emergency Contact
Phone
Insurance Information
Primary Insurance
Ins ID
Secondary Insurance
Ins ID
Pharmacy Name
Number
Please Have Insurance Card(s) and ID Available for Copying
I hereby authorize my insurance carrier to pay medical benefits directly to Dr. Regalado. I further authorize Dr. Regalado to release any medical
information, including information related to psychiatric care, drug and alcohol abuse and HIV/ Aids confidential information, acquired in the course of
my treatment necessary to process insurance claims or any medical information that is required for any health care related utilization review or quality
assurance activities. A photocopy of this authorization is to be considered as valid as the original, until revoked by me in writing.
I understand that I am financially responsible for all charges made to my account whether or not an insurance company is involved in payment. I am
further responsible for all co-payment, co-insurance amounts, non covered supplies and services, and yearly deductibles. I am also responsible for
collection fees incurred by Dr. Regalado in efforts to receive payment of my financial obligations for services rendered. Payment for these services is
expected at the time services are rendered. If Dr. Regalado is a contracted provider for your insurance carrier, we are required by your insurance company
to collect your financial portion at the time services are rendered.
Patient Signature
Date