MAY WE: Select all that apply
Martial ( M S W D )
How many children?
Names and Ages of children
Name of Nearest relative
How were you referred to our office
Please check any of and all insurance coverage that may be applicable in this case
Medical Savings Account & Flex Plans
Name of Primary Insurance Company
Name of Secondary Insurance Company (if any)
AUTHORIZATION AND RELEASE:
I authorize payment of insurance benefits directly to the provider or clinic. I authorize my provider to release all information's necessary to communicate with personal physicians and other healthcare providers and payors and to secure the payment of benefits. I understand that i am responsible at all cost of medical care, regardless of insurance coverage. I also understand that if i suspend or terminate the schedule of care as determined by my treating doctor, any fees for professional services will be immediately due and payable.