|
PATIENT
INFORMATION RECORD
| DATE |
|
| NAME |
|
|
(LAST)
(FIRST) |
|
| ADDRESS |
|
|
(STREET) |
|
| CITY |
|
| STATE |
|
| TELEPHONE: |
|
| (H)
(W) |
|
| BIRTH DATE |
|
| MARITAL STATUS |
|
| IF MINOR, PARENTS FIRST NAME |
|
| |
|
| IF MARRIED, SPOUSES FIRST NAME |
|
| |
|
| HEALTH INSURANCE (SECRETARY
WILL NEED TO COPY YOUR CARD) |
|
| NAME OF COMPANY |
|
| ID #
GR # |
|
| COPAY
(DUE EACH VISIT) |
|
| SUBSCRIBER |
|
| IF MORE THAN ONE INSURANCE,
LIST COMPANY |
|
| NAME |
|
| ID
# |
|
|
|
| NAME OF REFERRING
PHYSICIAN |
|
| SUBSCRIBER'S EMPLOYER |
|
| NAME |
|
| ADDRESS |
|
| TELEPHONE: |
|
| OCCUPATION: |
|
| SOCIAL SECURITY # |
|
| DID INJURY OCCUR AT WORK? YES /
NO |
|
| DATE OF ACCIDENT / INJURY |
|
| INSURANCE CARRIER |
|
| ADDRESS |
|
| |
|
| CARRIER CASE NO. |
|
| NAME OF ATTORNEY |
|
| DID INJURY OCCUR IN AN AUTO
ACCIDENT? YES / NO |
|
| IS THIS COVERED UNDER
NO-FAULT? YES / NO |
|
| INSURANCE CARRIER |
|
| ADDRESS |
|
| |
|
| LIST ALLERGIES TO
MEDICATIONS |
|
| |
|
I authorize my insurance to be paid directly
to the Center For Sports Medicine realizing I am responsible to pay
non-covered services or any balance due after my insurance has paid. I
authorize the release of pertinent medical information to insurance
carriers.
I realize The Center For Sports Medicine
is not a department of Ellis Hospital and it is my responsibility to
determine if the medical services I am receiving are covered by my
insurance policy. If a school is involved, I realize that my own
insurance must be billed first. Once my insurance has paid, I am then
responsible for resubmitting this balance to the school's insurance.
| |
|
| PATIENT'S OR PARENTS SIGNATURE |
DATE |
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