PATIENT INSURANCE FORM Insurance knowledge

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PATIENT INSURANCE FORM Insurance knowledge Powered By Docstoc
					                                               PATIENT INSURANCE FORM
                                                FOR BILLING PURPOSES
                                               Please use insurance cards to fill out entire form

Date:                                                                                              PCP:

                                                        PATIENT INFORMATION

Last Name:                                               First:                                    Middle:

Birth Date:           Age:                               Sex:
        /     /                                          M       F
Street Address:                                                            Social Security no.:                    Home phone no.:
                                                                                                                   (           )
P.O. Box:                              City:                                                 State:                      ZIP Code:



                                                    INSURANCE INFORMATION
Person Responsible for Bill:      Birth Date:           Address (if different from above):                         Home Phone:
                                       /       /                                                                   (       )



Insurance?                                  Yes                   No




Primary Insurance:                                       Claims Mailing Address:

                                                         Subscriber’s        Subscriber’s Birth
Subscriber’s Name:                                       S.S. no.:           Date:
                                                                                                   Group no.:      ID no.:

                                                                                  /     /
                                                                                                 
Patient’s Relationship to Subscriber:                    Self     Spouse
                                                                              Child
                                                                                                   Other:




Secondary Insurance:                  (if applicable)    Claims Mailing Address:

                                                         Subscriber’s        Subscriber’s Birth
Subscriber’s Name:                                       S.S. no.:           Date:
                                                                                                   Group no.:      ID no.:

                                                                                  /     /
                                                                                                 
Patient’s Relationship to Subscriber:                    Self     Spouse
                                                                              Child
                                                                                                   Other:




The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I
am financially responsible for any balance. I also authorize LSUHSCS/Surgery Billing or insurance company to release any information required to
process my claims.


  Patient/Guardian signature:                                                                           Date:

				
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