Your Federal Quarterly Tax Payments are due April 15th Get Help Now >>

Patient Information - Download Now DOC by 755Z5YH

VIEWS: 0 PAGES: 2

									                         Patient Information - Confidential
What is the Reason for your visit today? ________________________________________Date______________

How were you referred to our office?    Internet
                                        Insurance book
                                        Friend / Relative _________________________________
                                        Primary Care Physician

Who is your Primary Care Physician?_________________________________________________

Patient Name________________________________________________ Check appropriate box:  Male  Female

SSN_________________________________ Birthdate__________________________ Age: ______________________

Address____________________________________ City________________________ State________ Zip___________

Home Phone______________________________ Email Address___________________________________________

Cell Phone_________________________________ Other Phone____________________________________________

Check appropriate box:        Minor     Single      Married    Separated       Divorced      Widowed

Patient’s employer___________________________________________________ Work phone_____________________

Occupation______________________________________ Driver’s license #___________________________________

Spouse name_______________________ Employer________________________ Work phone____________________

Person to contact in case of emergency_______________________________________ Phone____________________

                             Responsible Party (if patient is a minor)
Person responsible for this account___________________________________ Relationship to patient_______________

Address___________________________________ City________________________ State_________ Zip___________

Home phone_____________________________ Driver’s license #___________________________________________

Birthdate________________________________ Social Security #___________________________________________

Employer_____________________________________________________ Work phone__________________________


                            Insured Party Information (policy holder)

Name of insured_________________________________________ Relationship to patient________________________

Birthdate_________________ Social Security #__________________________ Date employed____________________

Name of employer__________________________________________________ Work phone______________________

Insurance company_____________________________ ID #__________________________ Group #_______________

Insurance co. address________________________________ City___________________ State________ Zip_________

How much is your office visit co-pay/co-insurance? _________________________ Group name ____________________

                                        Pharmacy Information
Name of your Pharmacy__________________________          Address / Location_____________________________

Phone Number _________________________________          Fax Number __________________________________
Patient Name_______________________ Birthdate_________________ Patient #_____________


Do you have additional insurance? ⃞ Yes ⃞ No                    If yes, complete the following:

Name of insured_________________________________________ Relationship to patient________________________

Birthdate_________________ Social Security #__________________________ Date employed____________________

Name of employer__________________________________________________ Work phone______________________

Address of employer_________________________________ City___________________ State________ Zip_________

Insurance company_____________________________ ID #__________________________ Group #_______________

Insurance co. address________________________________ City___________________ State________ Zip_________

How much is your office visit co-pay/co-insurance? _________________________ Group name ____________________

                                      Worker’s compensation information

Is this a worker’s compensation claim? □ Yes □ No                   If yes, complete the following:

Employer contact_____________________________________ Employer phone #_______________________________

Worker’s Comp contact ________________________________ Worker’s Comp phone #__________________________

Date of Injury _______________________ Description of Injury_____________________________________________

_________________________________________________________________________________________________

[Office Use Only]        Claim #______________________ Worker’s Comp Carrier _______________________________

Worker’s Comp Carrier Address_______________________________________________________________________

                                    _______________________________________________________________________

Procedure for Filing Claims___________________________________________________________________________




Authorization & Release                          With this signature, I hereby authorize Northeast Atlanta Ear, Nose and Throat, P.C., to
release any information concerning my (or my child’s) health care, advice and treatment provided for the purpose of evaluating and
administering claims for insurance benefits. I also hereby authorize payment of insurance benefits otherwise payable to me directly to
the doctor. Furthermore, I understand that regardless of insurance, I am ultimately responsible for payment of fees for professional
services rendered, including non-covered services. If my insurance company (ies) changes at any time, I am responsible to notify this
office and provide a written copy or will be ultimately responsible for payment of professional service fees rendered at that time.

__________________________________________________________________                      _______________________________________
Signature of patient (or parent or legal guardian)                                      Date

Late Charges                                     In accordance with the Truth In Lending Act: All payments for services provided by this
practice are due and payable at the time services are rendered, or within 30 days of the patient receiving the invoice for such services.
In the event payment is not received as described above, a late payment fee of 1.5% per month will be charged. In addition, in the
event that any bill goes to collection, patients will be charged all costs associated with collection, including reasonable attorney fees.

__________________________________________________________________                      _______________________________________
Signature of patient (or parent or legal guardian                                       Date

								
To top