PATIENT INFORMATION
Patient Name Last
First
Middle
Account Number
Date of Birth (XX/XX/XXXX)
Home Address
City
StateState/Prov.AlabamaAlaskaAlbertaArizonaArkansasBritish ColumbiaCaliforniaColoradoConnecticutD.C.DelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineManitobaMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew BrunswickNew HampshireNew JerseyNew MexicoNew YorkNewfoundlandNorth CarolinaNorth DakotaNorthwest Terr.Nova ScotiaOhioOklahomaOntarioOregonPennsylvaniaPrince Edward Isl.QuebecRhode IslandSaskatchewanSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingYukon
Zip
Mailing Address (if different from above)
Daytime phone
Evening phone
Sex
MaleFemale
Marital Status: Single MarriedWidowed Divorced Separated
Spouse's name:
Healthcare ProxyYes No
Social Security Number (SSN)
Driver's License #
E-mail address (optional)
Who Referred You? If a physician, give full name and phone number, also.
EMPLOYMENT INFORMATION
Employed
YesNo
Employer (Parent's employer if minor)
Occupation
Employer Address
Spouse's Employer
height=25>RESPONSIBLE PARTY INFORMATION
Person Responsible for Medical Expenses
Relationship to patient
Home Phone
Social Security Number
Work Phone
Address
Payment for Today's Visit Select PaymentCashCheckVisaMasterCardAmerican ExpressDiscover
Name on Card
ExpiresMonth010203040506070809101112 Year2001200220032004200520062007200820092010
PRIMARY INSURANCE INFORMATION
Insurance Company
Policy Number
Medicare Number
Medicaid Number
Subscriber's Name
Sinaia kempinski hotelSubscriber's Relationship to Patient:Self Spouse Parent Other
Address of Insurance Company
height=25>SECONDARY INSURANCE INFORMATION
Subscriber's Relationship to Patient:Self Spouse Parent Other
EMERGENCY INFORMATION
cheap hotels in TurinPerson to Contact in Case of Emergency, Other than Spouse
Relationship to Patient
Phone
AUTHORIZATION
All professional services rendered are charged to the patient and remain the patient's responsibility regardless of insurance coverage. It is customary to pay for services when rendered unless other arrangements have been made in advance. HMO & PPO PATIENTS: It is the patient's responsibility to have any required referral from the primary care doctor and to furnish complete insurance information for this office. If the insurance information or referral is not available, the patient will be responsible for the charges and payment in full will be collected.
AUTHORIZATION AND ASSIGNMENT (PLEASE READ AND SIGN) I authorize you to give me reasonable and proper medical care by today's standards. I authorize Accredited Foot Clinic to obtain any X-ray films or laboratory results needed for my treatment. I authorize Accredited Foot Clinic to release all medical information required by my insurance company and others to file for medical benefits or otherwise collect on my account. I also authorize Accredited Foot Clinic to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services. I authorize payment of all benefits to the physician(s).
Patient's Signature
Patient Signature Date
Legally Responsible Person's Signature
Date
After submitting this form to our office electronically with the button below, you will see a page with the information you submitted. Please also PRINT OUT the completed page and bring it to your appointment.