I certify that I, and/or my dependent(s), have insurance coverage with the specified insurance company provided above and assign directly to Dr. Stefan all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.
The above-named doctor may use my health care information and my disclose such information to the above-name Insurance Company and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.
What was the date of your last:
Health History (Continued)
Have you had any of the following injuries or surgeries? If so, please describe.