Notes

PLEASE PRINT & FILL OUT ALL INFORMATION PLEASE PRINT LEGIBLY
Referring Physician or PCP: Address: Phone:
PATIENT PERSONAL INFO Last Name: First Name: Address: City: State: Zip: Home Phone:(___) - Date of Birth / / Sex: M F Alternate Phone Contact: (___) - Email Address: Social Security Number: - - Marital Status: S M D W SEP Emergency Contact Name: Phone Number: (___) Pharmacy: Phone Number: (___) If a minor, PARENT NAME:___________________________Phone Number:( ) -
EMPLOYMENT: (if patient is a minor, please use information for parent or guardian) Employer: Address: City/State Zip: Business Phone Number ( )
PRIMARY INSURANCE: Insurance Company: Policy Number: Group Number: Insurance Address: Phone Number: (___) - Policy Holder: Policy Holder SSN: Policy Holder Address: Policy Holder Employer: Policy Holder Date of Birth: / / Relationship to Insured:
SECONDARY INSURANCE: Insurance Company: Policy Number: Group Number: Insurance Address: Phone Number: (___) - Policy Holder: Policy Holder SSN: Policy Holder Address: Policy Holder Employer: Policy Holder Date of Birth: / / Relationship to Insured:
Is this Visit covered by: Worker’s Comp? No Fault?
Authorization for Release of Information & Assignment of Benefits I hereby authorize and direct the above named clinical practice, having treated me, to release to governmental agencies, insurance carriers, or others who are financially liable for my medical care, all information needed to substantiate payment for such medical care and to permit representatives thereof to examine and make copies of all records relating to such treatment. Upon my written request for release of my medical records, I hereby authorize Nathan Monhian, M.D., P.C. to furnish all records and results to the parties I specify. I also hereby assign, transfer, and set over to the above named clinical practice sufficient monies and/or benefits to which I may be entitled from government agencies, insurance carriers or others who are financially liable for my medical costs of the care and treatment rendered to myself or my dependent in said practice. I understand I am responsible for any services not covered by my insurance. I accept responsibility for payment of my account. I further understand that any cancellations must be done 24 hours in advance to avoid a $35 missed appointment fee. The doctor reserves the right to release me from his practice after 3 no show appointments.
Signature: Date: