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Date:
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Patient #
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Doctor Provider
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Primary Phone
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Correo electrónico
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City
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State
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Zip
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Alternative Phone
MAY WE: Select all that apply
CALL CELL
CALL HOME
CALL WORK
E-MAIL
Age
Birth Date
Race
Martial ( M S W D )
Occupation
Employer
Employer's Adress
Office Phone
How many children?
Names and Ages of children
Name of Nearest relative
Adress
Phone
How were you referred to our office
Please check any of and all insurance coverage that may be applicable in this case
Major Medical
Worker's Compensation
Medicaid
Medicare
Auto Accident
Medical Savings Account & Flex Plans
Other/Non Insured/Cash
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.
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English
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