PATIENT INFORMATION (PLEASE PRINT) - West Coast …
PATIENT INFORMATION (PLEASE PRINT)
PATIENT'S NAME___________________________________________ DATE__________________________
DATE OF BIRTH_______________SOC. SEC.#____________________ DRIVERS LIC#_________________
ADDRESS______________________________________________________________ TEL #________________
Number & street
city state
zip
CELL PHONE #___________________________________
E-MAIL ADDRESS__________________________________________________
PATIENTS/GUARANTOR'S EMPLOYER______________________________ TEL #________________
EMPLOYER ADDRESS________________________________________________________________________
Number & street
city state
zip
EMERGENCY CONTACT:____________________________________________ TEL#________________
HOW WERE YOU REFERRED TO OUR OFFICE_________________________________
INSURANCE INFORMATION (PLEASE LET US COPY YOUR INS. CARDS)
PRIMARY INSURANCE:
SECONDARY INSURANCE:
INS. CO. NAME_______________________________ INS. CO. NAME_______________________________________
INSURED ID#________________________________ INSURED ID#_________________________________________
GROUP#_____________________________________ GROUP#_____________________________________________
INSURED NAME______________________________ INSURED NAME______________________________________
INS. CO. PHONE#_____________________________ INS. CO. PHONE#_____________________________________
PATIENT'S RELATIONSHIP TO INSURED
PATIENTS RELATIONSHIP TO INSURED
SELF SPOUSE CHILD OTHER
SELF SPOUSE CHILD OTHER
ASSIGNMENT OF BENEFITS
I hereby assign all medical and/or surgical benefits to include major medical benefits to which I am entitled, including Medicare, private insurance and any other plan to KEITH S. FEDER, MD. I hereby authorize/consent to treatment, by Keith S. Feder, MD and Associates. I understand that I am financially responsible for all charges whether or not paid by my insurance company. I also understand that should legal action be necessary to collect any unpaid balance due for medical services rendered I will be held responsible for all attorneys' fees and other costs of collection to the full extent permitted by law. I hereby authorize said assignee to release information necessary to secure payment. A photocopy of this assignment is to be considered as valid as the original.
_______________________________________________ Signature of responsible party
___________________________ date
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