Please complete this form using your keyboard, then print it using the print function of your
browser.  You can then sign the form and bring it with you to your first appointment. This form
will not be submitted via the Internet, so security is not an issue.

The following questions are necessary so that we may properly file your insurance for you. These questions
are taken directly from the insurance form that we must fill out and file for you. Please answer as fully
as possible.

1. 

 Type of insurance:  Medicare     Medicaid      Champus
CampVA      Group Health Plan      Other

    

Insured’s ID Number

2. 

Patient Name:
3.  Insured's Name (as it appears on the insurance card):
4.  Patient's Address:

City:

 State:   Zip Code:
5.  Phone Nubmer
6.   Insured's Address (if
same as patient put
"same"):

City:

 State:   Zip Code:
7.  Patient Status: Single    Married     Other   
Employed  Full-time Student  Part-time Student
8. Other Insured's Name (if applicable):
9. Other Insured's Policy or Group Number:
10.  Other Insured's Date of Birth:   Male    Female
11.  Employer's Name or School Name:
12.  Insurance Plan Name or Program Name:
13.  Is the condition we are treating related to current or previous employment?  Yes    No
14.  Is the condition we are treating related to an auto accident?  Yes    No
15.  Is the condition we are treating related to another type of accident? Yes    No
16.  Insured's Policy Group or FECA Number:
17.  Insured's Date of Birth: Male    Female
18.  Employer Name or School Name:
19.  Insurance Plan Name or Program Name:
20.  Is there another health benefit plan? Yes     No
 

Patient's or Authorized Person's Signature: I authorize the release of any medical or
other information necessary to process my insurance claim. This is to serve as a 
long-term authorization card.
     

Signed:         Date:

     

Insured's or Authorized Person's Signature: I authorize payment of medical benefits to
for the services described on the insurance form. This authorization is to apply to all occasions
of service until it is revoked in writing. I agree to pay for services not covered by insurance and
understand that I am ultimately responsible for payment in full at this office.
     

Signed:         Date:

   

All doctors have been instructed to ask the following questions of all Medicare patients.

1. Do you or your spouse work for a company that provides you with health insurance? Yes    No
2. Are you entitled to Medicare because of End Stage Renal Disease? Yes    No
3. Is the illness or injury the result of an accident or illness that occurred at work? Yes     No
4. Is this illness or injury the result of an accident or other injury? Yes    No
5. Has the treatment for this accident or illness been authorized by the Veteran's Administration? Yes  No
6. Are you entitled to any benefits under the Federal Black Lung Program? Yes    No
7. Do you have a Medicare Medigap Policy? Yes    No
8. Do you have a Medicare Supplement Policy? (Policy provided by employer you retired from)? Yes  No