How did you hear about us? __________________________________________________________________ PATIENT INFORMATION Las t Name __________________________________ Firs t ____________________________________ Middle______________________ Address ________________________________________________________________________________________________________ Ci ty_________________________________________________________ State ________________ Zip Code ______________________ Home Phone _____________________________ Cell Phone ___________________________ Work Phone ________________________ Soc. Sec. _______________________________ D.O.B _____/______/_____ Age ______ Sex ______Ma rital Sta tus ___________________ Email Address _________________________________________ Referri ng Physi cian___________________________________________ Spouse Name _____________________________________________ Social Securi ty #_________________________________________ Phone #_______________________________________________ Spouse Employer ___________________________________________ IN CASE OF EMERGENCY (PERSON NOT RESIDING WITH PATIENT) Name _________________________________________________ Relationship to Pa tient ___________________________________ Phone # _______________________________________________ PAYMENT OPTIONS (Please check mark the payment option you are using):
HEALTH INSURANCE Pri ma ry Insurance ___________________________________________________________Phone ________________________________ Poli cy # ________________________________________ Group# __________________Subs criber’s Na me _________________________ Rela tionship to Subs criber _______________________________Social Securi ty # _______________________D.O.B._________________ Secondary Insurance ____________________________________________________ Phone____________________________________ Poli cy #_____________________________Subs criber’s Name ________________________ Rela tionship to Subs criber_______________ Were you involved in an accident: ____Yes____ No Date of Injury: _____/_____/_____ Please circle one Auto / WC / Miscellaneous Which State: ___VA____DC____ MD or _____ Other___________
WORKERS COMPENSATION OR PERSONAL INJURY INFORMATION Insura nce Name_____________________________________________ Phone#: __________________________________ Adjus tor/ Case Manager Name: ________________________________________Phone #: _________________________ Claim #: _____________________________________ Da te of Injury: ___________________________________________ 3rd Pa rty Insura nce Na me: ____________________________________Phone #: __________________________________ Adjus tor/ Case Manager Name: ____________________________________Phone #: ______________________________ Claim #:_____________________________________________________________________________________________
AUTO INSURANCE/ MED PAY Auto Ins./Medpa y Company: ____________________________________________________ Phone #: ___________________________ OR Auto Ins ./Lien Company: _______________________________________________________ Phone #: ________________________ Claim Number: ____________________________________ Name of Adjus ter: ______________________________________________ Adjus ter Phone #: _____________________________________ Da te of Injury: ____________________________________ ATTORNEY INFORMATION Name: ______________________________________________ Phone #___________________________ Fa x#_____________________ Please rememb er that Insurance is considered a method of reimbu rsing the pati ent for fees paid to the doctor and is not a sub stitute for payment. Some compani es may p ay fixed allowances for c ertain proc edures; th ey someti mes ref er to as “R easonable and customary fees.” We do not accept this as pay ment in full (unless oth erwise restricted by law or agreement we may hav e with your insurer). Also some of the insuranc e compani es only pay a p ercent age of the charge. It is your responsibility to pay any deductibl e amount, co-insurance or any other bal ance not paid for by your insuranc e. IN ORD ER TO C ONTROL YO UR CO ST OF BILL INGS, WE D O R EQU EST THAT O UR CH ARGE FO R OFFIC E VISITS B E P AID AT THE IN ITIATION OF EACH VISIT . In the ev ent th e account is turn ed ov er for coll ections, th e coll ection f ees and /o r l egal fees, including attorn ey f ees, s hall b e your responsibility. I hereby assign all medical and /or surgical benefits to include major medical benefits to which I am entitl ed, M edicare, pri vat e insurance and oth er health plans to the facilit y list ed in th e top h ead er of this page. This assignment will remain in eff ect until revoked by me in wri ting. A photocopy of this assign ment is to b e considered as valid as an ori ginal . I h ereby autho rize said assignee to rel eas e al l information nec essary to secure the pay ment , vi a fax t ransmitt al or h ard copy.
Pa tient/Pa rent or Legal Gua rdian Si gna ture ____________________________________________ Da te ________________________