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


Secondary Medical Insurance
(copy of insurance card required)
Secondary insurance company name
Member ID #
Group #
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
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
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


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