Patient Information Form (Page 2 of 3) in pdf

Chart #:_____________________

Patient information

Please Print

PATIENT’S LAST NAME

FIRST NAME

MIDDLE/MAIDEN

SEX

Male

Female

BIRTH DATE

AGE

SOCIAL SECURITY #

CELL PHONE

PRIMARY PHONE #

PHYSICAL ADDRESS IF PO BOX

CITY

STATE

ZIP CODE

MAILING ADDRESS

CITY

STATE

ZIP CODE

MARITAL STATUS

E-MAIL ADDRESS

Single

Married

Divorced

Widowed

Legally Separated

EMPLOYED BY

OCCUPATION

WORK PHONE #

EXT

SPOUSE’S NAME

BIRTH DATE

SPOUSE’S SOCIAL SECURITY #

SPOUSE EMPLOYED BY

SPOUSE’S WORK PHONE #

REFERRING DOCTOR

ADDRESS

FAMILY DOCTOR

ADDRESS

LOCAL EMERGENCY CONTACT :

NAME

RELATIONSHIP

PHONE #

(NOT LIVING WITH YOU)

RACE:

White

Black or African American

Hispanic or Latino

Asian

American Indian

Alaska Native

Native Hawaiian or other Pacific Islander

Other ________________________________________________

STUDENT:

YES

insurance information

PRIMARY INSURANCE CO.

SECONDARY INSURANCE CO.

POLICY HOLDER

POLICY NO.

GROUP NO.

POLICY HOLDER

POLICY NO.

GROUP NO.

POLICY HOLDER BIRTH DATE

POLICY HOLDER SOCIAL SECURITY #

POLICY HOLDER BIRTH DATE

POLICY HOLDER SOCIAL SECURITY #

___________________

WILL YOU BE FILING WORKER’S COMP?

BODY PART BEING SEEN FOR:

YES

_____________________

DID YOU HAVE AN ACCIDENT?

DATE OF INJURY OR ONSET:

YES

IF PATIENT IS A MINOR, PLEASE COMPLETE CONSENT AND PARENT INFORMATION:

I, being the parent / guardian do hereby request and authorize Carolina Orthopaedic Specialists, P.A. or persons designated by them to perform necessary

services for my child, including, but not limited to: x-rays, and administration of anesthetics which are deemed advisable by the physician, whether or not I am

present at the actual appointment when the treatment is rendered.

_____________________________________________

_____________________________________________________________________________________

Parent / Guardian Signature

FATHER’S NAME

FATHER’S SOCIAL SECURITY NUMBER

BIRTH DATE

HOME PHONE #

______________________________________________________________________________________

FATHER’S ADDRESS

FATHER EMPLOYED BY

WORK PHONE #

EXT

_____________________________________________________________________________________

MOTHER’S NAME

MOTHER’S SOCIAL SECURITY NUMBER

BIRTH DATE

HOME PHONE #

_____________________________________________________________________________________

MOTHER’S ADDRESS

MOTHER EMPLOYED BY

WORK PHONE #

EXT

AUTHORIZATION TO RELEASE INFORMATION AND BENEFITS TO PHYSICIAN:

I hereby authorize Carolina Orthopaedic Specialists, P.A. to release any medical information to the Insurance company(s), Medicare, Medicaid, Third Party Liability, or Workers

Compensation. I designate and authorize payment directly to Carolina Orthopaedic Specialists, P.A. of any benefits payable to me for services rendered.

I understand that regardless of any insurance coverage applicable, I am responsible for any charges incurred in treatment.

I also understand that I will be responsible for all charges incurred in any collection efforts by Carolina Orthopaedic Specialists, P.A. All Self-Pay charges, co-pays and deductibles

are due in full at the time service is rendered. I further agree that this assignment will not be withdrawn or voided at any time until this account is paid in full.

_____________________________________________________

____________________________

SIGNATURE OF PATIENT / PARENT OR GUARDIAN

DATE

Rev.: June 2013

COS/080