Longevity Institute of Indiana
If you are a new patient please fill out the form below. If you would like to print the form, please click here to download a PDF version. A modern browser (Chrome, Firefox, Internet Explorer 10+, Opera, Safari, etc.) is required complete our online form.

Patient Information

Name



Sex



Address



Phone


Preferred phone to leave reminders and messages:






Email


Birth Date

Employment



Guarantor Information (Optional)

Guarantor Name



Relationship to Patient



Guarantor Address



Guarantor Phone


Preferred phone to leave reminders and messages:

Guarantor Email


Guarantor Birth Date

Guarantor Employment



Patient Consent for Use and Disclosure of Protected Health Information

I understand that as a part of my healthcare, Arthur Sumrall, M.A, M.D., and/or Longevity Institute of Indiana originates and maintains health records including history, exam, test results, diagnoses, treatment, and plans for care. This is a information serves to plan my care, to communicate to other healthcare professions, to provide diagnosis and procedure codes to my bill, to allow third-party payers to verify that services were performed, and to access quality and competence of healthcare professionals.

For my review is the Notice of Privacy Practices which provides a more complete description of information uses and disclosures; a copy is available to obtain from our records upon request. I understand that I have the right to review the notice prior to signing this consent and acknowledged receipt of the notice of privacy practices.

With this consents, Arthur Sumrall, M.A, M.D., may mail to my home or other designated location any items that assist in carrying out my treatment, payments, or healthcare operations such as appointment reminders, insurance items, and calls regarding clinical care including lab and pathology results.

By signing this form, I am consenting to Artur Sumrall, M.A, M.D. and/or Longevity Institute of Indiana to use and disclose my protected health information to carry out treatment, payment, or healthcare operations. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliane upon my prior consent. If i do not sign this consent, I understand the practice may decline to provide treatment to me.



Appointments

We strive to give all patients the earliest available appointment. If you have a very urgent problem, your primary care physician's office is welcome to call us with the details. We request 24 hours notice for cancellations, as this will enable us to fil the appointment time; there is a $25 fee for missed appointments without appropiate notice. There is also a $75 missed appointment fee for laser, surgery, or ANY procedure appointments. We reserve the right not to reschedule you if you repeatedly miss appointments. For your convenience our office is open the 3rd Saturday of every month until 1:00pm ET.



Payment For Services

By contract, we are required to collect co-pays at the time of service. We accept cash, check, Visa, MasterCard, Discover, and PayPal.



Deductable Policy

Most insurance policies have a deductable. If your deductable is not met we will collect money owed at the time of service. Our staff can check your policy to obtain the amount of your deductable and the amount you have met if you are uncertain of this information. Please ask our staff for assistance.

If you do not have insurance or do not have your card with you for your visit full payment will be necessary at the time of service.



Non-covered Services

Services that your insurance company considers cosmetic or not medically necessary will not be reimbursed by your insurance company. Payment in full is due at the time of service. Examples include: removal procedures (skin rags, milia cysts, normal moles, benign asymptomatic keratosis, oil glands, blood vessels, and some warts) and skin discoloration. Accounts referred to an attorney for collection will incur an additional charge that you will be responsible for.



Health History

Please check the conditions you have had in the past:





























Please check the conditions you currently have:



















Please check the following that your biological parent or grandparent have had:













Allergies



Habits




Are your pregnant or nursing?




Prescription Refills

Please call our office during regular business hours to request prescription refills. We try to accommodate the requests on the same day, though it is not always possible. When requestions a refill please leave your full name, date of birth, name of medication, and the phone number to your pharmacy.







Current Medications




Past Operation and Health Problems



General




Confirm

Thank you for taking the time to complete the paperwork needed to serve your needs better. The staff at Longevity Institute of Indiana would like to welcome you to our office. We are honored that you have chosen us for your healthcare needs and we promise to provide you with the best care available.

Please review all information above and type your name in the signature fields below: