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Patient Information

PATIENTS UPDATE


TO OUR CURRENT PATIENTS


We know that things change from year to year and in an effort to make sure all of our information is current, we ask that you bring the following information to your appointments:

  • Your Insurance Card. Due to HIPPA violations, our office can no longer look up your insurance information online. If your card does not contain the address and phone number of your carrier, please obtain this information and bring it with
    you. Failure to supply this information may result in your being billed for the visit.
  • If you have secondary insurance, we will also need this information in order to coordinate your benefits.
  • If your address or telephone numbers have changed, please give your updated information to the check-in desk.

ALL co-pays and unmet deductibles are due and payable at the time of your visit. If you do not have insurance or if we do not partictpate with your insurance company, you will be responsible for your entire bill ($75.00 for the office visit, additional charges for injections) at the time of services. If you have questions or concerns please contact our office before your appointment.

As always, if you need to cancel or change your appointment, please try give us at least a 24 hours notice. There is a $25.00 charge for all missed appointments.


Patient Update Form






Patient’s Name

City

Zip code
Date of Birth (mm-dd-yyyy)

State

Address


Phone Number
Cell Phone
Email Address


Billing Address (if different from above)

Name

City

Zip code
Phone Number

State

Address


Employment Information

Name

City

Zip code
Phone Number

State

Address


Pharmacy Information

Name

City

Zip code
Phone Number

State

Address


In Case Of Emergency

Name

Relationship

Home Phone
Cell Phone


Release of Information

Name

Relationship

Name

Relationship


I acknowledge that all information listed above is current if there happens to be any changes to this information at any time I will inform the office immediately of these changes


 
 
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Welcome to the website of Houston Primary Care an Internal Medicine and Wellness Center based in Warner Robins, Georgia. Dr. Shetty provides personalized and state-of-the-art primary care and consultation for adult patients.

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