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Patient Infomation

Name
Address
City
State
 Zip
Home Phone
Work Phone
Social Security
Date of Birth
 Sex M F
Marital Status
 Single Married Divorced Widowed Separated

Parent, Spouse, or Responsible Party (if different from patient)
Name
Address
City
State
 Zip
Home Phone
Work Phone
Social Security
Date of Birth

Insurance Information (Please present insurance card at time of check in.)
Primary Insurance Name
Secondary Insurance Name
Ins. Address
Ins. Address
Name of Insured
Name of Insured
Insured's ID#
Insured's ID#
Group #
Group #
Employer Name
Employer Name
Employer Address
Employer Address
Employer Phone
Employer Phone
Relationship of patient to the Insured
Relationship of patient to the Insured

Other family members who are patients
Pharmacy of choice
 Phone
Emergency contact
 Phone
Referred by
Primary Care Physician

I authorize the release of medical information to my primary care or referring physician, to consultants if needed and as necessary ro process insurance claims, insurance applications and prescriptions. I also authorize payment of medical benefits to the physician.
In order to establish optimal relations with our patients and avoid misunderstanding and confusion regarding our payment policies, our staff is trained to consistently inform you of the financial payment policies of this office. Payment is required for all services at the time they are rendered unless you are in a prepaid plan in which we can participate. For those patients, applicable copayments and deductibles will be collected. We accept payment in the form of cash, check, or credit card. In the event of hospitalization or major procedures, our office may file with the appropriate insurance. However, before such claims are filed, coverage will be preverified and you will be asked to pay any unmet deductible, non-covered services and copayments. In the event that your account must be turned over to collections, a $10.00 collection fee will be added to your account. Your signature below signifies your understanding and willingness to comply with this policy.
Recheck to make sure all above information is correct, then press submit.

 
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