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PATIENT INFORMATION
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| Patient Name (Last, first, middle initial) |
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Sex |
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DOB |
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Drivers License |
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| Address |
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City/State |
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Zip |
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Telephone |
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| Employed: |
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Student |
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Employer Name or School Name |
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Employer Telephone |
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| Marital Status |
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If visiting from out of state: |
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Local Contact Name |
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Local Telephone |
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RESPONSIBLE PARTY
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| Patient Name (Last, first, middle initial) |
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Sex |
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DOB |
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Drivers License |
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City/State |
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Zip |
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Telephone |
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INSURANCE POLICY HOLDER (IF DIFFERENT FROM ABOVE)
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| Patient Name (Last, first, middle initial) |
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Sex |
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DOB |
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Drivers License |
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| Address |
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City/State |
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Zip |
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Telephone |
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| Employed: |
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Employer Name |
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Employer Telephone |
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| Relationship to patient |
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This medical facility accepts insurance from many different health plans. A list of accepted
insurance plans can be obtained from the Patient Representative.
Without the following items, you will not be able to utilize your
insurance benefits for services rendered:
1) Valid Insurance Identification Card,
2) One form of Photo Identification (responsible party to provide),
3) Applicable copay, Deductible or Coinsurance at time of service
You will be responsible for all charges at time of visit.
We will attempt to verify eligibility for patients wishing to utilize insurance benefits
for today’s services. Payment for today’s services will be based on the “estimate of benefits”
information obtained from your insurance carrier. When your insurance carrier processes the claim
and a final determination regarding payment is made, if any additional payment is due from you,
we will send you a bill. Please understand that financial responsibility for medical services lies with the patient.
If you do not have insurance, you agree to pay for today’s visit in FULL.
I have read and understand my obligations and I acknowledge that I am fully responsible
for payment of any services not covered by insurance. I understand that I am financially
and legally responsible for all charges. I further agree that should I not pay the balance
within thirty (30) days after the statement due date, my account will be considered delinquent.
I agree to pay the costs of collection, including reasonable attorney’s fees and costs,
collection agency fees and costs and interest, which shall accrue at the maximum rate allowed by law.
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