Date______________________                                 Preferred Doctor______________________

Patient name ___________________________________________________________________________________________
                   Last                             First                               Middle                         Suffix       

Address____________________________________________City________________State_______ Zip___________________
(must have a street address if PO Box is listed)      

Social Security #_________________________Date of Birth______________ Sex______    Marital Status: M  S  D  W

Home #___________________________ Work #______________________Ext_______ Cell # __________________________ 

Employer _______________________________________________

Spouse____________________________________ Date of Birth______________ Social Security #____________________

Employer ____________________________ Work # ____________________Ext_____ Cell # __________________________

Person who is responsible for the bill: ________________________________________________________
(if different from patient)
Address___________________________________________City_________________________  State________ Zip__________

Home # __________________________ Work # ____________________________ Cell # ______________________________

Date of Birth ____________  Social Security No ___________________ Employer _________________________________

Nearest relative living outside the home________________________________________ Relation____________________

Home # _________________________Work # _______________________________Cell # ______________________________

INSURANCE

Primary Insurance Co ____________________________________Effective Date: __________Copay $______________

Address for claims______________________________________________________________________________________
                       Mailing/PO Box          City          State              Zip              

ID # ______________________________ Group # ____________________ Subscriber _____________________________

Relationship:______________________________DOB: _______________________Social Security No: __________________

Secondary Insurance Co ____________________________________Effective Date __________Copay $______________

Address for claims ______________________________________________________________________________________
                             Mailing/PO Box          City          State              Zip      

ID # ______________________________ Group # ____________________ Subscriber _____________________________

Relationship: _____________________________ DOB: ________________________Social Security No: _______________________

Assignment & Release
I, the undersigned, have insurance coverage and assign directly to Comcare, Statcare, or Wellplan all medical 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 hereby authorize the doctor to release all information necessary to secure the payment of benefits.  I authorize the use of this signature on all my insurance submissions. 

__________________________________________________________       _________________________________________
Signature of Insured/Guardian                                                                           Date

Medicare Authorization:
I request that payment of authorized Medicare benefits be made either to me or on my behalf to Comcare, Statcare, or Wellplan for any services furnished me by that physician.  I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services.  I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim.  If “other health insurance” is indicated in item 9 of the HCFA-1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown.  In Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, and non-covered services.  Coinsurance and the deductible are based upon the charge determination of the Medicare carrier. 

__________________________________________________________     ____________________________________________
Signature of Insured/Guardian                                                                          Date