1. Please enter your information.
2. Employer / School Information
3. Emergency Contact Information
4. Accident Information ( Additional Forms Required )
5. Self Pay (Services paid by Cash, Check, Credit - Skip to #8 )
6. Primary Insurance
7. Secondary Insurance
8. Patient Current Condition
Name, address and phone number of other providers who have treated you for your condition:
9. Describe in which part you are having a problem!
10. Previous Condition(s)
11. Pharmaceutical
12. Information Provided by
Assignment and Release
I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.The above-named doctor may use my health care information and may disclose such information to the insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.
