3820 SW Hall Blvd.   Beaverton, OR 97005   (503) 644-5665

E-mail: __________________________________________________

Insurance Name: ____________________________ I.D. Number: _____________________ Group: ________________
Policy Holder: _______________________________ DOB: __________________ SSN: ___________________________

Insurance Name: ____________________________ I.D. Number: _____________________ Group: _______________
Policy Holder: _______________________________ DOB: __________________ SSN: __________________________

Name (Last, First, MI): _________________________________ SSN: _________________ DOB: __________________
Address: ____________________________________ City: __________________ State: _________ Zip: ___________
Cell Phone: ____________________________ Home/Work Phone: ________________________ Gender: M / F
Marital Status: ______________________
Occupation: _____________________________ Employer: _______________________________________________

Weight: _________Height:__________ Approximate Blood Pressure: ________

3820 SW Hall Blvd.   Beaverton, OR 97005   (503) 644-5665

Patient

I have received the notice of Privacy Practices (HIPAA) and have been provided an opportunity to review it. 
Name: __________________________________________ DOB: _________________ 
	Signature: _______________________________________ Date: _________________

	Personal Representative of Patient Signature: _______________________________________________
	(If Patient is under 18)

I certify that I assign directly to Remy Delplanche, PC all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. Remy Delplanche, PC may use my health care information and may disclose such information to Medicare or other insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.

Signature of patient/parent/guardian/personal representative: ______________________________ 
Printed name of patient/parent/guardian/personal representative: ___________________________ 
Relationship to patient: _______________________________________ 

3820 SW Hall Blvd.   Beaverton, OR 97005   (503) 644-5665

No Show and Cancellation Policy

•	Our Focus Is YOU ~ Dr. Delplanche has reserved this time exclusively for you. 

•	Please be aware of our requirements of a 48 hour notice should you be unable to keep your appointment time. 

•	Failure to cancel or reschedule your appointment will result in a $35.00 No show fee. Insurance will not pay for this fee. You will be responsible to pay at your next visit.

      _______________________           _____________
      Patient Signature:			    	    Date: