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| PRACTICE | ACCOUNT # | LAST NAME | FIRST NAME | MI |
| STREET ADDRESS | APT. # | City & State | ZIP CODE |
| SEX | BIRTH DATE | SSN |
HOME TEL. # | DRIVER"S LIC. | TYPE |
| ( ) |
| DEPENDENT NAME | BIRTH DATE | REL. | DEPENDENT'S NAME | BIRTH DATE | REL. |
| 1. | 2. |
| INSURANCE COMPANY (PRIMARY) | INSURANCE COMPANY (SECONDARY) |
| Code | Name | Code | Name |
| Address | Address | ||
| Member of Medicare # | Group # | Member of Medicare # | Group # |
| Subscriber's Name (If not Patient) | REL | Subscriber's Name (If not Patient) | REL |
| EMPLOYMENT INFORMATION | THIRD PARTY BILLING (OR REMARKS) |
| Employer Name | Work Phone | Third Party Name |
| Street Address | OCCUPATION | Street Address |
| City and State | ZIP CODE | City and State | ZIP CODE |
| REFERRED BY | TELEPHONE | REF. CODE | DR. |
EMERGENCY NOTIFICATION |
| NAME | RELATIONSHIP | |
| TELEPHONE | STREET ADDRESS, CITY, STATE | ZIP CODE |
As a courtesy to our patients, we bill your insurance. However, this office cannot accept responsibility for collecting payments or negotiating settlements on disputed claims. Patients are expected to pay toward their deductible and Co-Payments at the time of the visit. PATIENT'S SIGNATURE ___________________________ DATE ______________