Forms

11%

Basic Information
Name
Date
SSN
Birth date
Sex
- Male
- Female
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Marital Status
- Minor
- Married
- Widowed
- Divorced
- Separated
Email
Employer
Work Phone
If a student, name of school and address
Age
Height
Weight
Shoe Size
Emergency Contact
Phone

Insurance Information
We will need a copy of your insurance cards before being seen by the physician
Name of person responsible for this account
Relationship to Patient
Policy Number
Group Number
SSN
Birth Date
Phone
List the name of each of your insurance carriers

MED
Which Pharmacy do you use?
Please list all the medications you are currently taking (include birth control pills, insuline, aspirin, and all over the counter medicines)
I am allergic to (include medicines, foods, pollens, latex, etc.), and what type of reaction you had:

Notice of Privacy
Electronic Signature - Please type your full name below to indicate your agreement:*
I understand that under the Health Insurance Portability and Accountability Act (HIPAA), I have certain rights to privacy regarding my protected health information. I acknowledge that I have received or have been given the opportunity to receive a copy of your Notice of Privacy Practices. I also understand that this practice has the right to change its Notice of Privacy Practices and that I may contact the practice at any time to obtain a current copy of the Notice of Privacy Practices.
Date
Information and assignment of Benefits
Electronic Signature - Please type your full name below to indicate your agreement:*
I authorize the release of any medical information necessary to process any of my claims. I permit a copy of this authorization to be used in place of the original.
Electronic Signature - Please type your full name below to indicate your agreement:*
I hereby authorize the physicians of this company to apply for benefits on my behalf for covered services rendered by them or by their order. I request that payment from my insurance company be made directly to the physician. I certify that the information I have reported with regard to my insurance coverage is correct. I permit a copy of this authorization to be used in place of the original. This authorization may be revoked be either me or my insurance company at any time.

Basic Information

Operation	Date	Hospital	Surgeon