Phone Numbers : Home ___________________ Work _________________ Emergency ________________________
Date of Birth : ___/___/_______ Social Security No.: ____________ Sex: M F Marital Status S M D W Seperated
How did you learn about our office : ___________________________________________________________________
EMERGENCY INFORMATION :
Name of Person to notify :
_______________________________
Relationship :
_______________________________
Address :
_______________________________
_______________________________
Phone No : _____________________
(Does this match the above emergency number?)
EMPLOYMENT INFORMATION :
Employer :
________________________________
Employer's Address :
________________________________
Telephone : ______________________
Occupation : _____________________
Job Title : ________________________
Employed : Full-time
Part-time
Family Members Living at Home/Age:
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
RESPONSIBLE BILLING PARTY :
Relationship to patient : Same
Spouse
parent
others
Name :
_______________________________
Address :
_______________________________
_______________________________
Social Security # : _________________
Birth Date : ______________________
Home Phone # : (____)_____________
Occupation : _____________________
Employer : ______________________
Employer' Address :
_______________________________
_______________________________
Employer's Phone # : ______________
PRIMARY INSURANCE INFORMATION :
Medicine
Medicare
Insurance
Self- Pay
Insurance Company :
________________________________
Certificate/ID # :
________________________________
Group/Policy # :
________________________________
Claim Mailing Address :
________________________________
________________________________
________________________________
________________________________
________________________________
PerCert Phone # : _________________
SECONDARY INSURANCE INFORMATION :
Insurance Company :
_______________________________
Certificate/ID # :
_______________________________
Group/Policy :
_______________________________
Claim Mailing Address :
_______________________________
_______________________________
_______________________________
ASSIGNMENT OF INSURANCE BENEFITS/RELEASE OF MEDICAL INFORMATION :
1: Authorization to Pay Benefits to Physician: I hereby authorize payment to Tapan K. Chaudhuri, M.D. for the surgical and/or medical benefits, if any, for his services.
2: Authorization to Release Information : I hereby authorize Tapan K. Chaudhuri, M.D. to release any information acquired in the course of my examination or treatment neccessary to establish a health insurance claim for payment.
I understand that occasionally my insurance company will deny payment for services that my physician and/or I feel are necessary for my good health. I hereby agree to pay for such services in a proper and timely manner.