SMA Patient Registration Form

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Patient Information

Please Check Preferred Contact Phone Number

Insurance Information

Assignment and Release

I, the undersigned certify that I (or my dependent) have insurance coverage with the above
stated insurer. I assign directly to Saluja Medical Associates all insurance benefits, if any,
otherwise payble to me for the services rendered. I understand that I am financially
responsible for all charges whether or not paid by insurance. I hereby authorize the
physician to release all necessary information to secure the payment of benefits. I authorize
the use of this signature on all insurance submissions.

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

Your information will be encrypted.