Patient Information Form

PATIENT INFORMATION

Responsible Party

Name of person responsible for this account*

Address

Occupation

Do you prefer to receive reminder calls at:

May we leave a message on your answering machine?

Patient Marital Status

Whom may we thank for referring you to us?

Person to contact in case of emergency

INSURANCE INFORMATION

Primary Insurance

Secondary Insurance

If insurance is in the name other than the patient, please provide primary insured's:

Name

Address

CERTIFICATION AND ASSIGNMENT

To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health.

I certify that I, and/or my dependent(s), have insurance coverage with:

and assign directly to Dr. Wanda Batson, Dr. Amy Riggs, Dr. Wes Mayes, Dr. Chelsea Evans and/or Dr. Jane Purdy all insurance benefits, if any, otherwise payable to me form services rendered, 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(s) may use my health care information and may disclose such information to the above-named insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits payable for related services.