friscoobgyn.com

Name *

First Name Last Name
Patient DOB *

Month Day Year
SSN
Patient Address *
City *
State *
Zip *
Pt. Primary Phone *
Secondary Phone #
Tertiary Phone #
Marital Status
Pt. Sex
Patient Employer
Patient Occupation
Emergency contact *
Relationship to pt.
Emerg phone # *
Alternate phone #
Referring Physician
Phone #
Responsible Party for Minors
Name:
Responsible Party DL
DL Issuing state
Responsible party Address
City
State
Zip
Primary Phone
Secondary Phone
Relationship to patient
Other Authorized Person
Insurance Information
Policy Holder Name *
DOB
Relationship to Patient
Phone:
Address
City
State
Zip
Employer
Occupation
Ins Company
Member ID#
Group ID#
Ins Address
Ins Phone
Secondary Insurance if Applicable
Policy Holder Name
DOB
SSN
Relationship to Patient
Phone:
Address
City
State
Zip
Employer
Occupation
Ins Company
Member ID#
Group ID#
Ins Address
Ins Phone
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 *
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: *
Date mm/dd/yyy *
Electronic Signature

Clear
Should be Empty:

Responsible Party for Minors

Insurance Information

Secondary Insurance if Applicable

Assignment of Benefits and Financial Agreement

Authorization