This form must be completed and signed before you will be allowed to see the doctor. Last Patient’s Full Name Social Security # First MI Driver’s License No. Address Date of Birth / Street Home Phone Ethnicity City Name Address Phone # Referred by: Primary Insurance Coverage Self Spouse Policy Holder’s DOB / / Copay Amount Insurance Claims Street Address City Policy Number State Zip Business / / Copay Amount Insurance Claims Street Address City Policy Number Yes No Parent Other_________ State Group Number Company Name Zip Policy Holder SS# Self Spouse Policy Holder’s DOB Parent Other_________ State Group Number Secondary Insurance Coverage Insurance Carrier Name Policy Holder Name Policy Holder’s Employer: Any Other Insurance Coverage Name of Spouse Primary Care Physician: Insurance Carrier Name Policy Holder Name Policy Holder’s Employer: Insurance Phone# Zip Relationship Street Insurance Phone# State Marital Status pM pS pW pD Phone # Employer City Phone Number Language Responsible Party Sex p Male p Female Alternate Phone Name Address Nickname Age / Cell Phone Emergency Contact Email Address Race Maiden Name Zip Policy Holder SS# Phone # FISCAL POLICY: 1) Payment is expected at time of service. A receipt will be provided for you to file with your insurance company. 2) All accounts not paid within a reasonable time may be referred to a collection agency. 3) We do not get involved in any way with disputes between divorced parents of a child we are treating. If you bring the child for treatments you are responsible for payment in full for services rendered. We do not bill the other parent. We will, however, provide additional copies of your child’s bill should you need it. I AUTHORIZE THE RELEASE OF ANY MEDICAL RECORDS OR OTHER INFORMATION TO PROCESS INSURANCE CLAIMS OR ANY BENEFITS DUE MY PROVIDER. I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO THE PROVIDER AT THIS OFFICE FOR SERVICES RENDERED TO ME. I UNDERSTAND THAT IF THE PHYSICIAN IS NOT PAID IN FULL BY PROCEEDS OF ANY BENEFITS, THEN THIS ASSIGNMENT DOES NOT RELEASE MY OBLIGATION AND LIABILITY TO THE PHYSICIAN FOR PAYMENT OF ALL SERVICES AND ITEM PROVIDED TO ME. Signature of Patient OR Patient’s Authorized Representative Date