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Patient Information

*Last Name *First Name Middle Initial

Street Address City State Zip

*Email Address *Home Phone Work Phone Social Security Number

Date of Birth Age Sex

Responsible Party

Last Name First Name Middle Initial

Street Address City State Zip

Home Phone Work Phone Social Security Number

Date of Birth Age Sex

INSURANCE INFORMATION (Please present insurance card at time of check in.)

Primary Insurance Name Insurance Address Name of Insured Insured's ID# Group# Relationship of patient to the insured Employer Name Employer Address Employer phone

Secondary Insurance Name Insurance Address Name of Insured Insured's ID# Group# Relationship of patient to the insured Employer Name Employer Address Employer phone

Other family members that are patients
Pharmacy of choice Phone
In case of Emergency, who should be notified? 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 to 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 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 pre-verified 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.
*Signature