Patient Information

PATIENT INFORMATION
   
First Name: Middle: Last:
Mailing Address: City: State/Zip: /
Home Phone: Work Phone: Cell Phone:
Date of Birth: Age/Gender: / Marital Status:
SSN: Occupation:
Employer: Employer's Phone: Employer's Fax:
Primary Physician: Referred By:

Responsible Party Information Patient is Responsible Party
First Name Last Name Relationship to Patient
Mailing Address: City: State/Zip: /
Home Phone: Date of Birth: Age/Gender: /
SSN: Occupation:
Insured Party Information Patient is Insured Party
First Name: Last Name: Relationship to Patient:
Mailing Address: City: State/Zip: /
Home Phone: Date of Birth: Age/Gender: /
SSN: Occupation:
Insurance Company: Referral Needed: Referral No.
# of Visits: Expiration Date:
Claim Address: City: State/Zip: /
Policy: Group: Effective Date:
Eligibility/Benefit/ Cust.Service #: Precert #:
 
Emergency Contact: Relationship:
Home Phone: Work Phone: Cell Phone:
Injured at work? Yes   No In Auto Accident? Yes   No Date of Injury:
Attorney Involved: Yes   No Attorney Name:
How did you hear about us?
Our Office will file insurance claims for you; however, office visit, co-pays, and deductibles are payable on the day you are seen. Please remember you are responsible for all fees regardless of insurance coverage. All HMO's, IPA's, and EPI's require authorization. This is your responsibility. If we do not receive the authorization, payment is due at the time of service. I authorize the release of medical information necessary to process this claim and to Health Care Professionals requesting consultation and third party payers responsible for all or part of the physician's fee. I authorize payment of medical and surgical benefits to Atlanta ENT, Sinus and Allergy Associates, P.C.
Method of Payment: Cash Check   Visa   MC   Discover
Cardholder Name: Card Number: Expiration Date:
Send my history form to: