Patient Information

Patient Information
Date*
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Doctor*
Patient's Name*

First NameMiddle NameLast Name
Address*

Street Address

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E-mail*
Cell/Other Telephone #*

Area CodePhone Number
Home Telephone #*

Area CodePhone Number
Work Telephone #*

Area CodePhone Number
Employer*
Gender*

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Marital Status*
Date of Birth*

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Age*
Social Security Number*
Last 4 Digits of SSN
Emergency Contact*
Emergency Contact Telephone #*

Area CodePhone Number
Insurance*
ID #*
Responsible Party for Billing

(IF DIFFERENT THAN ABOVE)
Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Patients Relationship to Responsible Party

SelfChildSpouseOther
Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid for by your insurance.
Please Initial: In order to control your cost of billings, we request that our charges for office visits be paid at the conclusion of each visit.*
Please Initial: If this account is assigned to an attorney for collection and/ or suit, the prevailing party shall be entitled to reasonable attorney’s fee and cost of collection.*
Please Initial: To the extent necessary to determine liability for payment and to obtain reimbursement, I authorized disclosure of portions of the patient’s record.*
I hereby assign all medical and/ or surgical benefits to include major medical benefits to which I am entitled including Medicare’s, private insurance, and other health plans to: Premier ENT, A Medical Corp., Johnny Arruda, M.D., Inc.

This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as a valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorized said assignee to release all information necessary to secure the payment. I hereby authorize evaluation and treatment by Johnny Arruda, M.D., F.A.C.S.
Signed:*

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Date*
Financial Responsible Party Information
Full Name*

First NameMiddle NameLast Name
Social Security Number*
Driver's License Number*
Date of Birth*
Telephone Number*
Please provide all the information requested above. The undersigned responsible party agrees that they are responsible for all fees incurred, regardless of insurance coverage. All copayments and deductibles are due at the time of service. If payment has not been received from the insurance company within 60 days from the date of service, the patient or the financially responsible party accepts responsibility for payment in full.
Signed:*

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Patient Information

Responsible Party for Billing

Financial Responsible Party Information