Patient Information

Thank you for choosing our office. In order to serve you properly, we need the following information. All information will be confidential in accordance with HIPAA.

Patient's Name

Date of Birth

Chart Number

SSN

Home Phone

Cell Phone

Address

City

State

Zip Code

Email address

Patient’s or Parent’s Employer

Work Phone

Ext.

Business Address

City

State

Zip

Spouse's Name

Employer

Work Phone

Spouse’s SSN

Spouse’s Date of Birth

If patient is a student, name of school/college

Whom may we thank for referring you?

If not a physician, check how you got our name

Yellow pages

Internet

Insurance Plan

Friend/Family

Person to contact in case of an emergency

Phone Number

Responsible Party

Name of person responsible for this account

Relationship to Patient

Address if different from above

Home Phone

Driver’s License #

Birth Date

Social Security #

Employer

Work Phone

Ext.

Primary Insurance Information

Please provide a copy of current card

Add file

Please upload a file

Add new row

Secondary Insurance Information

Please provide copy of current card

Add file

Please upload a file

Add new row

If you have any other coverage, please advise the front desk.

Authorization and Release

I authorize the release of any information concerning my (or my child’s) health care, advice, and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I also hereby authorize payment of insurance benefits otherwise payable to me directly to the doctor.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient (or parent if minor)

Date

Authorization of Treatment

I hereby authorize that

has/have my permission to give authorization of treatment for the above named patient. The relationship(s) of this/these person(s) to the patient is

Signature of Parent or Legal Guardian

Date

Agreement to Pay for Non-Covered Services

I understand and agree that if my insurance is not in effect on the date of services rendered or if the insurance company determines that I am responsible for charges for which I have not previously rendered payment that I will pay in full for these services within 30 days of receiving a bill from James B. Maddox, M.D., P.A.

Signature of Patient or Responsible Party

Date

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