Patient Information Form - Green Valley Ranch Medical Clinic & Urgent Care (Page 2 of 6) in pdf

Secondary Medical Insurance

(copy of insurance card required)

_____________________________________________________________________________________________________________________

Secondary insurance company name

Member ID #

Group #

_________________________________________________________________________________________________________________

Address

City/State/Zip

Phone

__________________________________________________________________________________________________________________

Policy Holder Name

Member ID #

Date of Birth

Effective Date

I certify the previous information is true and correct to the best of my knowledge. I understand that it is my

responsibility to notify Green Valley Ranch Medical Clinic of any changes in the information listed above.

______________________________________________________________________________________

Patient/Responsibility Party

Date

Agreement to Pay For Treatment

I, the responsible party listed below, hereby agree to pay all charges submitted by this office during the course of

treatment for the patient. If the patient has insurance coverage with a managed care organization with which this

office has a contractual agreement, I agree to pay all applicable co-payments and deductibles which arise during

the course of treatment for the patient. The responsible party also agrees to pay for treatment rendered to the

patient which is not considered to be a covered service by the third party insurers or payors. Returned checks shall

have a $10.00 fee plus any bank fees incurred.

_______________________________________________________________________________________

Responsible Party

Date

Release and Statement to Permit Payment of Private Insurance Benefits to the Provider

I, the undersigned responsible party, hereby authorize Green Valley Ranch Medical Clinic or its employees to

release and disclosure all or any part of the patient’s medical records to any entity which is, or may be liable, for all

or part of the provider charges.

I authorize the release and disclosure of any and all of my or my child’s medical records to any other entity,

including, but not limited to specialty physicians, hospitals, or other health care providers which may be of

assistance in the opinion of this office, in providing treatment of the patient.

I authorize the release of records necessary to assist in the reimbursement of benefits to which I may be entitled.

I authorize Green Valley Ranch Medical Clinic and /or its employees to release, via fax machine, medical records

which are needed in order to provide the patient with the most appropriate medical care.

I authorize and request that the payment of any third party insurance company benefits the made directly to this

office for any service furnished to the patient. The signature furnished below shall suffice for all insurance forms

on a continuing basis.

_______________________________________________________________________________________

Responsible Party

Date

Patient Information Form - Green Valley Ranch Medical Clinic & Urgent Care Page 2

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