Medical Office Forms

PLEASE PRINT NEATLY TODAY’S DATE:_________________

LAST NAME:__________________________________FIRST NAME:______________________MIDDLE INITIAL:______

STREET ADDRESS:_______________________________________________________APT. #_________________________

CITY/STATE/ZIP________________________________________________________________________________________

HOME PHONE:__________________________ CELL:__________________________EMAIL:_________________________

SS#:______________________________________DATE OF BIRTH:____________________________AGE:_____________ SEX: ____________MARITAL STATUS: Married__________Single__________Widowed__________Divorced___________

OCCUPATION:______________________________________EMPLOYER:________________________________________

WORK PHONE:______________________________WORK ADDRESS:___________________________________________

CITY/STATE/ZIP:________________________________________________________________________________________

SPOUSE NAME:_____________________________________________DATE OF BIRTH:_____________________________

EMPLOYER:________________________________________________WORK PHONE:_______________________________

INSURANCE PLAN:__________________________________NAME OF POLICYHOLDER:___________________________

POLICYHOLDER BIRTHDATE:_________________________RELATIONSHIP TO POLICYHOLDER:_________________

POLICYHOLDER ADDRESS (if different from the above address):_________________________________________________

CITY/STATE/ZIP:_______________________________________________PHONE:__________________________________

POLICYHOLDER EMPLOYER:___________________________________ POLICYHOLER SS#_______________________

SECONDARY PLAN (If applicable)________________________________POLICYHOLDER:__________________________

EMERGENCY CONTACT:________________________________________RELATIONSHIP:__________________________

(someone not living at your home as we will contact your immediate family members first if possible)

HOME PHONE:______________________________________CELL PHONE:_______________________________________

Release of Records:

I hereby authorize _______________ to release any information necessary for the completion of insurance claims for payment from third party payers, including but not limited to: insurance companies, health maintenance organizations government agencies and their representatives. I permit release of information concerning dates of treatment, condition, diagnosis, procedures or surgeries to my personal physician, referring physician, and/or the referring facility or for follow-up care.

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Date Patient Name Signature of Patient/Responsible Party

Assignments of Benefits:

I accept financial responsibility for all services rendered. I understand that the billing office will file my insurance claim if my physician/provider is a participating provider with my insurance carrier and I assign direct payment to the physician all payments made under the terms and provisions of my policy. I further understand I am responsible for payment for denied services regardless of the outcome of any dispute between myself and my insurance carrier. I understand that I am responsible for and will pay my portion of the unpaid balance due for services performed by the facility and physician/provider.

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Date Patient Name Signature of Patient/Responsible Party