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Hi {EMAIL},Welcome ywP9La MJ3itzlY rATlAFJM22 cPixDl DhNO Y14Vio C6Svvx HXVCVs mmIIfi Ukz9SC U8cxLI DKUYcD S7K5Kk 8GOS18 cOtdX0 Dear (r){NAME}, Registered Company Name: Trading Name: Registration Number: Registration Date: Business Type: (Pty) Ltd CC (Close Corporation) T/A (Sole Proprietor) Partnership Other Specify: VAT Registration Number: Physical Address: Code: Postal Address: Code: Telephone No: ( ) Facsimile No: ( ) Mobile No: Email Address: Approximate Monthly Purchase Amount: Finance Contact: Contact Number: ( ) Email Address: Banking Details: Name of Bank: Branch Code: Account Number: Trade References: Company Telephone Contact Credit Limit 1. ( ) R 2. ( ) R 3. ( ) R Cardinal Station Newburg Center for Primary Care 215 Central Avenue, Suite 100 1941 Bishop Lane, Suite 900 215 Central Avenue, Suite 205 Louisville, KY 40208 Louisville, KY 40218 Louisville, Ky 40208 I:\FCM\Phyllis Harris\Forms\New Patient Pkg Components UofL Department of Family & Geriatric Medicine Dear New Patient, Welcome to your University of Louisville Physicians Family practice! We are offering patient-centered medical care and are enthusiastic about our relationships with our patients. In order to better serve your needs, we are enclosing several forms and ask that you completely fill each form out. The first sheet will help us learn more about you; please completely fill out this form about your family history. The next sheet is titled, “Authorization for the use and/or Disclosure of Protected Health Information”, and you will need to completely fill that out for our doctors to treat you to the best of their ability; it gives us permission to review your medical records from your previous primary medical facilities. Following, please completely fill out the Registration, Social Services & Consent Form. Next, you will find our Privacy Notice, followed by an acknowledgement that you have received and understand our Privacy Policies. Finally, the last form is the Office Acknowledgements and Policies form. Please read carefully and sign your name at the bottom of the letter. Please make sure to bring all of these forms with you to your first office visit. Do not mail them back to the office. Also, please remember to always bring your picture ID, current insurance cards and your co-payment. If your health insurance requires you to select a primary care doctor please do so prior to your office visit. Please bring in any and all medication you take, in their original bottles, to your appointment. If the patient is under 18 years of age he or she must be accompanied by an adult and will need to bring a copy of their current immunization certificate. Please arrive 15 minutes ahead of your scheduled appointment time so that if you have questions about these forms or we need more information, we can a ddress it all prior to your appointment. We look forward to seeing you! University of Louisville Physicians UofL Family and Geriatric Medicine TARGOBANK AG ouyLv1BQncbC4Yo5Ly Bonjour, Nous vous remercions de la confiance et de l'intérêt que vous nous témoignez en nous proposant votre collaboration. Nous allons procéder à l'examen de votre dossier. Sans réponse de notre part sous un délai de trois semaines, veuillez considérer que nous ne pouvons donner une suite favorable à votre candidature. Nous vous remercions et vous prions d'agréer nos salutations distinguées. bout these forms or we need more information, we can address it all prior to your appointment. We look forward to seeing you! University of Louisville Physicians UofL Family and Geriatric Medicine GanVikSankDikUmePrit ----EHuWnODA;cGjODc----8iUoobq0;pyaFxs [Hi](siknNNBm-DBQlOQiiQ7UmkhiUhskmBqqUmL0fsoJTCo3wIhEmDBrqMqnzYZM9m_2pkp2eUmoJTCMGnGmDsqD7) siknNNBm-DBQlOQiiQ7UmkhiUhskmBqqUmL0fsoJTCo3wIhEmDBrqMqnzYZM9m_2pkp2eUmoJTCMGnGmDsqD7