Marshall Orthopedic & Sports Medicine
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 Orthopedic & Sports Medicine, 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.)