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Patient Name:*
Social Security:*
Home Phone:*
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Date Of Birth:*
/ /
ex:01/02/1965		 Sex:*
Male Female
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Additional Patient Information
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ex:01/02/1965
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Policy Holder General Information
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Second Insurance Information
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ex:01/02/1965
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Medical Information
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Nature Of Complaint:
Accident Related:?
yes no		 Work Related:?
yes no
Explain How Injury Occured:
PATIENT IS RESPONSIBLE FOR OBTAINING ALL REFERRALS*
I HEREBY AUTHORIZE ASSIGNMENT OF BENEFITS TO BE PAID DIRECTLY TO DOCTORS; NATTIS, NUDELMAN, YOUNG, MARCUS, GOTLIB. THIS ASSIGNMENT WILL REMAIN IN EFFECT UNTILL REVOKED BY ME IN WRITING. A PHOTOCOPY OF THIS AGREEMENT IS TO BE CONSIDERED VALID AS AN ORIGINAL. THE PATIENT IS RESPONSIBLE FOR ALL FEES REGARDLESS OF INSURANCE COVERAGE. IT IS ALSO CUSTOMARY TO PAY FOR SERVICE WHEN RENDERED UNLESS OTHER ARRANGEMENTS HAVE BEEN MADE IN ADVANCE. I UNDERSTAND THAT I AM RESPONSIBLE FOR PAYMENT IN FULL FOR ALL COINSURANCE AND DEDUCTIBLE COSTS, AS WELL AS ANY DOCTOR’S SERVICES WHICH ARE DETERMINED TO BE NON-COVERED OR DENIED. I AUTHORIZE MY PHYSICIAN TO RELEASE ANY MEDICAL INFORMATION NECESSARY TO PROCESS MY BILL.

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