Name
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First Name
Last Name
Patient DOB
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Month
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Day
Year
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SSN
Patient Address
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City
*
State
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Zip
*
Pt. Primary Phone
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Secondary Phone #
Tertiary Phone #
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Pt. Sex
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Patient Employer
Patient Occupation
Emergency contact
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Relationship to pt.
Emerg phone #
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Alternate phone #
Referring Physician
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Responsible Party for Minors
Name:
Responsible Party DL
DL Issuing state
Responsible party Address
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Primary Phone
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Relationship to patient
Other Authorized Person
Insurance Information
Policy Holder Name
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DOB
Relationship to Patient
Phone:
Address
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Occupation
Ins Company
Member ID#
Group ID#
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Secondary Insurance if Applicable
Policy Holder Name
DOB
SSN
Relationship to Patient
Phone:
Address
City
State
Zip
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Occupation
Ins Company
Member ID#
Group ID#
Ins Address
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Assignment of Benefits and Financial Agreement
I hereby consent to treatment by the physicians and/or associates of Frisco Obstetrics and Gynecology , P.A.
Name
*
Date mm/dd/yyyy
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Authorization
I hereby authorize payment of insurance benefits to be made to Frisco Obstetrics and Gynecology, PA and any assisting physicians, for services rendered. I understand that I am financially responsible for all charges whether or not they are covered by insurance. In the event of default, I agree to pay all costs of collections and reasonable attorney fess. I also authorize Frisco Obstetrics and gynecology, PA to release any and all information necessary to secure payment of benefits. I further agree that a photocopy of this agreement or electronic signature is as valid as an original.
Name:
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Date mm/dd/yyy
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