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Personal Information: Last Name ___________________ First Name ___________________ MI _____ Street ________________________________________________________________ City ___________________________ State _________________ Zip ___________ Phone: ( _____ )____________________ Date of Birth _____ / _____ / _____ Social Security # ___________________ Marital Status ______________________ Who to Contact in case of an emergency: Last Name ____________________ First Name ____________________ Relationship _________________ Telephone Number ( _____ )________________ Employment Information: Occupation ________________________ Employer __________________________ Street ________________________________________________________________ City ___________________________ State _________________ Zip ___________ Phone: ( _____ )____________________ ext. __________ Who Referred you to our office? _________________________________________ Family Physician _______________________ Date last seen _____ / _____ / _____ Insurance Information: Please present card to be photocopied Primary Insurance Company ________________________________________________ ID# ____________________________ Group # ____________________________ Is your policy? Yes or No If No, spouses or parent? _________________________ Name of Policy Holder ______________________ Date of Birth _____ / _____ / _____ Employer ______________________________________________________________ Secondary Insurance Company (if applicable) ID# ____________________________ Group # ____________________________ Is your policy? Yes or No If No, spouses or parent? _________________________ Name of Policy Holder ______________________ Date of Birth _____ / _____ / _____ Employer ______________________________________________________________ LIFETIME MEDICARE RELEASE STATEMENT. I authorize payment of medical benefits to Allentown Family Foot Care Professional Corporation. I authorize the Doctor to release any information needed to submit and process my claim. In the case of co-payments, deductibles or non-covered services, I will be responsible for payment. Signature ______________________________ Date of Birth _____ / _____ / _____ STATEMENT OF INSURANCE COVERAGE. I authorize payment of medical benefits to Allentown Family Foot Care Professional Corporation. I authorize the Doctor to release any information needed to process my claim. In the case of co-payments, deductibles or non-covered services, I will be responsible for payment. Signature ______________________________ Date of Birth _____ / _____ / _____ |
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