This form will aide us in ensuring that we submit your claim to your insurance company promptly and accurately. If your plan requires a referral, please provide it to the receptionist or advise us so that so we may check to be sure we have received it. THANK YOU.
Payment for services or copay is expected at time of service.
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Patient's Full Name:
i.e. John J. Smith |
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| Sex: |
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Date of Birth:
i.e. xx/xx/xxxx |
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Social Security Number:
i.e. xxx-xx-xxxx |
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| Marital Status: |
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| Street Address: |
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| City: |
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| State: |
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| Zip: |
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| Home Phone # |
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| Email Address: |
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| Primary Physician:: |
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| Patient's Employer: |
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| Employer Address:: |
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| Employer City: |
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| Employer State: |
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| Employer Zip: |
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| Business Phone #: |
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Guarantor's Name:
*Guarantor is person responsible for payment. |
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| Guarantor's Address |
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| Guarantor's City: |
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| Guarantor's State: |
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| Guarantor's Zip: |
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| Guarantor's Phone #: |
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Guarantor's
Social Security #: |
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Guarantor's
Date of Birth:
i.e. xx/xx/xxxx |
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Guarantor's
Employer |
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In Case of an
Emergency Contact: |
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| Emergency Phone#: |
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*Insurance: Please list the subscriber of the policy, if other than the patient. |
Primary:
List your primary insurance. |
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| Policy Number: |
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| Group Number: |
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| *Subscriber: |
Please list the subscriber of the policy,
if other than the patient. |
*Subscriber's
Date of Birth: |
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*Subscriber's
Employer: |
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Secondary:
List your secondary insurance. (if applicable) |
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| Policy Number: |
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| Group Number: |
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| *Subscriber: |
Please list the subscriber of the policy,
if other than the patient. |
*Subscriber's
Date of Birth: |
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*Subscriber's
Employer: |
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If you have any individuals who may be assisting you in your care or payment, such as: your spouse, other family members, or aide, may we disclose information to them?
Do you have a home answering machine?
If so, may we leave messages to verify your upcoming appointments and to report normal test results?
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Who referred you to us?
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