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956-292-0100
EDINBURG, JACKSON, SOUTH MCALLEN
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ASAS HEALTH. Monzer H Yazji, M.D
Welcome to the value based healthcare family
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Home
About Us
Patient Orientation
Service Policies
Forms
Worker’s Comp
After Hours Care
House Calls/Home Visits
Hospital Care
Community Resources
Emergencies
Survey
Our Medical Staff
Quality Improvement
Medical Home
Preceptorship
The Star Program
Contact Us
WORKERS COMP FORMS
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WORKERS COMP FORMS
WELCOME TO OUR PRACTICE
Last Name:
*
First Name:
*
M.I.:
*
Street Address:
*
Apt. #
*
City:
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State:
*
ZIP Code:
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Home Phone:
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Cell:
*
S.S # :
*
Date of Birth:
*
Marital Status
*
Age:
*
Is this visit due to a work related injury ?
Yes
No
Date of Injury:
*
Body Part Injured:
*
Name of Employer:
*
Address:
*
Street Address
Apt, Suite, Bldg. (optional)
City
State / Province / Region
Postal / Zip Code
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo (Brazzaville)
Congo
Costa Rica
Cote d\'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor (Timor Timur)
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia, The
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palestinian Territory
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Western Sahara
Western Samoa
Yemen
Zambia
Zimbabwe
Country
City:
*
State:
*
ZIP Code:
*
Employer’ s Phone #:
*
Contact Person:
*
Description of Injury/ Accident:
*
Worker’ s Compensation Insurance Name:
*
Phone #
*
Address
*
City:
*
State:
*
ZIP Code:
*
Adjuster:
*
Claim #:
*
Emergency Contact Name & Relationship:
*
Phone #:
*
VOICE MESSAGE CONSENT FORM
*
, hereby Authorize / Refuse(circle one) Monzer H. Y azji, M.D. & Associates
to utilize my voice answering service to transmit information related to my health care needs.
Patient’ s Signature
*
Date of Birth
*
Print Name
*
Date
*
Witness Signature
*
Print Name
*
Date
*
CONSENT FOR MEDICAL TREATMENT PHYSICIAN ASSIST ANT SERVICES
*
, hereby acknowledge that I have been given the right opportunity to choose my health care provider . I fully understand that this office uƟlizes or employs both Medical Doctors and Physician Assistants
Patient’ s Signature
*
Date
Print Name
*
Date
*
Witness Signature
*
Print Name
*
Date
*
NULL/VOID INFORMATION
*
Patient’ s Signature
*
Print Name
*
Date
*
ACKNOWLEDGMENT OF REVIEW OF NOTICE OF PRIVACY PRACTICE
I have reviewed this practice’ s Notice of Privacy Practices, Which explains how my medical information will be used and
Patient’ s Signature or Personal Representative
*
Date
*
Name of Patient or Personal Representative
*
Personal Representative Relationship to Patient
*
Please CIRCLE one per question. Than You
*
American
Anglo-Saxon
Arab
Asian
Black
Black Non-Hispanic
Caucasian
East India
Hispanic
White Non- Hispanic
Patient Refuses
Other Race or Ethnicity
What is your ETHNIC background?
American
American Indian
Anglo
Buddist
Caucasian
Czeck
Egyptian
French
German
German-American
Greek
Hispanic
India
Latin American
Latino
Mexican
Mexican American
Northern European
Pakistani
Phillipino
Polish-American
Puerto Rican
White
Not Reported/Refused
Other
Patient Refused
What is your language of choice ?
English
Spanish
Other
your signature below indicates your consent for treatment of/as patient and the release of medical information to your insurance company for claim purposes.
Patient’ s Signature
*
Date
*
Verification
Please enter any two digits
*
Example: 12
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