Face Sheet 2020 (Form 62012)

Guarantor Number

Rx: (please type order description)*

Diagnosis:*

Photo of Rx

Medicare ID#

Patient Information

Patient*

First NameMiddle NameLast NameSuffix

Date of Birth*

Last Four of S.S. #*

Address*

Address

Street Address Line 2

CityState

Zip Code

Phone Number*

Gender*

MaleFemale

Referring Physician*

Primary Physician

If patient is a child or dependent, complete this section

(ONE PERSON ONLY)

Name of Responsible party (Can only be one person)

First NameMiddle NameLast NameSuffix

Relationship to Patient

Date of Birth

Last Four of S.S. #

Check Yes if Address is same as above

Yes

Address

Street Address Line 2

CityState

Zip Code

Phone Number

Primary Insurance

Self-Pay

(Not filing with insurance; paying out-of-pocket)

Insurance Company*

Insurance ID #*

Group #*

Policy Holder*

Relationship to Patient*

Policy Holders Date of Birth*

Last Four of Policy Holders S.S.#*

Check Yes if Address is same as above

Yes

Address

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number

Front of Primary Insurance Card

Back of Primary Insurance Card

Do you have Secondary Insurance information you'd like to enter?*

YesNo

Secondary Insurance

Insurance Company

Ins. ID #

Group #

Policy Holder

Relationship to Patient

Policy Holders Date of Birth

Last Four of Policy Holders S.S.#

Check Yes if Address is same as above

Yes

Address

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number

Front of Secondary Insurance Card

Back of Secondary Insurance Card

Front of Third Insurance Card (if you have one)

Back of Third Insurance Card (if you have one)

I certify the insurance information I provided above is true, accurate and complete. I have read and understand the Fred Toenges Pedorthics Payment/Return Policy. I understand that Fred Toenges Pedorthics is acting solely as an agent for filing insurance benefits assigned to it. However, Fred Toenges Pedorthics assumes no responsibility for guaranteeing payment of covered charges. I authorize the release of any medical information necessary to process this claim through Fred Toenges Pedorthics. The products and/or services provided to me by Fred Toenges Pedorthics are subject to the supplier standards contained in the Federal regulations shown at 42 Code of Regulations Section 424.5(c). These standards concern business professional and operational matters (E.G. honoring warranties and hours of operation). The full text of these standards can be obtained at http://eefr.gpoaccess.gov. Upon request we will furnish you a written copy of the standards.

By completing and signing this form I, the undersigned, consent to the treatment and/or services provided to me or an individual I represent by Fred Toenges Pedorthics.

Signature of Responsible Party*

Date*

Date

Please verify that you are human*

Face sheet Form 62012 Rev. 12/2021