Patient Registration Form

Please complete the form and submit it before your appointment with Dr. Rastogi. All patients must complete this form.

Patient Registration

Let us know your personal and insurance details.

Patient First Name

Sex (Male or Female)

Select Male or Female

Last Name

Driver License #

Patient D.O.B.

mm/dd/yyyy

Patient Social Security #

xxx-xx-xxxx

Cell #

Home Phone #

Patient Home Address

City

Emergency Contact Name

Name of Phramacy

State

Relationship

Pharmacy City

Zipcode

Contact Phone #

Pharmacy State

Name of Primary Health Insurance Company

if no insurance, write self insured.

Name of Person Insured

If self, write self

Patient's Relationship to Person Insured

if self or no insurance, write self.

Member ID #

If self pay, write None

Group #

If self pay, write None

Insurance Co Phone #

Secondary Health Insurance if any

Name of secondary Person Insured

if none, write none

Relationship to Patient secondary

Secondary Member #

Secondary Group #

Medicare Y/N

select Yes or No

Medicaid Y/N

Select Yes or No

By signing below, I authorize the use of my health information to my Insurance company for benefit and payment information. I authorize the use of this form on all my insurance submissions. I authorize release of information to all my insurance companies. I understand that I am responsible for my bills, coinsurance, co-pays and deductibles. I understand that it is patient's responsibility to obtain verification for services requested by my Physician including but not limited to ;abs, radiology, referrals, and any other medical related services. I authorize direct payment to my physician. I permit a copy of this authorization to be used in place of the original.

write your name

If patient is less than 18 years of age, Name of Parent

patient is 18 years or older write NA.

If patient is less than 18 years of age, Signature of parent for payment Guarantee

if patient is 18 years old or over write NA.

Family Physician Name

Referring Physician Name

Family Physician Phone #

Referring Physician Phone #

Welcome to Family Internal Medicine, the office of Dr. Nita Rastogi, MD. She is here to offer her patients primary care services for the diagnosis and treatment of medical diseases. Dr. Rastogi is a board-certified physician in Internal Medicine. Dr. Rastogi can help her patients in providing medical services for treating all health-related diseases. She can also help patients having addiction problems with alcohol and opioid. Besides these medical treatments, Dr. Nita Rastogi also provides aesthetic laser treatment to her patients for spider vein removal, photo facial, acne & acne scars, and permanent hair removal. Dr. Nita Rastogi works hard to make sure that her patients stay healthy and are compliant with their medical treatment.

You can contact Dr. Rastogi’s Office at:

Tel. (717) 540 – 1920 Fax. (717) 540 – 1927

Email. office@mdfim.com

https://bizgrouplink.com

Bizgrouplink is a free online platform to.

Connect, network, and discuss in business groups under different Topics.
Everyone gets BizTokens by posting comments on discussions platform. BizTokens can be used to get discounts on the Market and Hotels. BizTokens can also be converted to Biz units of Bizgrouplink.
Online MARKET – to buy supplies. Vendors can sell to businesses in bulk.
Buy – Sell Business online. Buyers and Sellers can do all transactions online including checking financials, communicating, negotiating and closing.
FACILITATOR – A Facilitator helps buyers and sellers in communicating and meetings. The Facilitators get 1/3 of the fee earned in closing a sale of a business. Anyone can enroll to become a Facilitator on Buy-Sell Business.
Professional service providers, Accountants, Attorneys, Business Appraisers, Banks/Financing companies, and Environmental and Title companies can advertise to get new business from buyers and sellers of businesses.
Hotel owners can sell rooms to the users of Bizgrouplink by becoming a participating hotel with Bizgrouplink.
A salesperson can earn commission in bringing vendors to the Market and listing businesses for sale. Anyone can enroll to become a Salesperson on Bizgrouplink.

http://www.rastogitax.com

Contact Dr. Anil Rastogi for business tax preparation, bookkeeping, payroll, financial planning, and business savings.

Tel: (717) 889 – 1124

Welcome to RTFS LLC in Harrisburg, PA. We are here to advise you on Tax Savings Planning. We can also help you with tax preparation, e-filing your individual and business tax returns, bookkeeping, and payroll preparation. We can work with you in financial planning for retirement savings and implementing investment strategies for the growth of your wealth.

Tax Planning

RTFS LLC and Dr. Rastogi are experienced in tax planning to reduce taxes and increase profits for small business owners. Dr. Rastogi follows all guidelines of IRS’s internal revenue codes and finds the deductions which are best suitable for tax preparation of an individual client’s personal and business income taxes. It is important for a client to reduce taxes by intelligent planning to defer taxes to the later part of the years when individuals earned income shall be minimum.

Patient Registration Form

Patient Registration

Patient Portal

Welcome

Subscription

BIZGROUPLINK IS TO CONNECT – INTERACT – DISCUSS IN BUSINESS GROUPS UNDER TOPICS, ONLINE MARKET FOR BUYING SUPPLIES, and BUY-SELL BUSINESS ONLINE. EVERYONE GETS REWARDED BizTokens ON BIZGROUPLINK.

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RTFS LLC – Rastogi Tax and Financial Services

Tax Planning