MARSHALL SURGICAL ASSOCIATES
DATE: _______________________
PATIENT=S NAME: ________________________________ BIRTHDATE:
___________________________
ADDRESS:
_________________________________________________________________________
CITY, STATE, ZIP:
PHONE: (__________)_________________
S.S. NO. _____________________________
MAIDEN NAME:
_________________________________________________________________
Single9 Married9
Widowed9
Separated9
Divorced9
Male9
Female9 Race ________________ Religion
___________________
FAMILY PHYSICIAN
_______________________________________________________________
PATIENT EMPLOYER
Name: ________________________________________
Address: _______________________________________________
Phone:
________________________________________
Employment
Status: Full-time 9 Part-Time 9 Retired 9 Unemployed 9
PERSON TO NOTIFY
Name:
________________________________________ Address:
_______________________________________________
Phone:
________________________________________Relationship:
___________________________________________
NEXT OF KIN (If same as person to notify, leave blank)
Name: ________________________________________Address:
_______________________________________________
Phone:
________________________________________Relationship:
___________________________________________
GUARANTOR (Who is responsible for bill: self, spouse, etc.)
Name: ________________________________________Address:
_______________________________________________
Phone:
________________________________________Social Security Number: __________________________________
GUARANTOR EMPLOYER
Name: ________________________________________Address:
_______________________________________________
Employee
Status: _______________________________Guarantor Employer Phone:
__________________________
Reason for Visit
______________________________________________________________________
Type
of Accident related to this
visit___________________________________________________
READ AND SIGN
I hereby authorize payment
directly to Marshall Surgical Associates, of any insurance coverage for surgery
or hospital charges, and authorize them to release any information necessary to
process these insurance claims.
I understand that I am fully
responsible for all social services and charges, including any balance due
after payment of insurance and that insurance coverage does not necessarily pay
all charges.
I also understand that any
co-pays and deductibles are due and payable when services are rendered.
I, the undersigned, authorize treatment by the doctor in this office.
Signature:
_________________________________________________
(IF
MINOR, PARENT OR GUARDIAN SIGNATURE)
Date:
(A photocopy of the above authorization will be accepted as valid.)
