Patient Face Sheet - North Florida Pain Clinic printable pdf download

Pain Management Specialists of North Florida, PA

Raul A. Monzon, M.D.

Patient Face Sheet

Print Patient’s Name Exactly As It Appears On The Insurance Card

_____________________________________________________________________________________________________________

Male

Female

LAST

FIRST

MIDDLE

Age __________ Birth Date ___________________ Social Security #______________________________________ Marital Status (circle one) S M D W

Home #(________)______________________Work #(________)____________________________ Cell # (________)_________________________________

Home Address ______________________________________________________________________________________________________________________

Mailing Address _____________________________________________________________________________________________________________________

(If Different From Above Address)

Current Employer___________________________________________________ Address__________________________________________________________

E-Mail ______________________________ Spouse’s Name________________________________________ Cell# ____________________________________

Emergency Contact_____________________________________________________________________________ Relationship___________________________

Home #(_______)__________________________Work #(_______)____________________________Cell # (_______)_________________________________

Medical Doctor ____________________________________________City_____________________________Phone #__________________________________

Who referred you to our practice? ________________________________________________________Phone # _______________________________________

Have you or any of your family members had services here before ?

No If yes, give name and date of services_____________________________________

Do you require a Language Interpreter?

Yes

How did you find out about our facility?

Yellow Pages

Magazine Ad

Internet

Oher_________________________________________________

Is this visit related to an Accident?

YES

Auto (Date of Accident)__________________

Work (Date of Injury)_________________

Attorneys Name:__________________________________Phone #___________________________________Contact___________________________________

Primary Insurance

Secondary Insurance

Company________________________________________________

_____________________________

Policy Holder’s Name

(As it appears on the card)

Birth Date __________________SS#_________________________________

Policy #___________________________________Group#________________

Relationship to policy holder:

Spouse

Self

Other

Relationship to policy holder:

Spouse

Self

Other

WORKERS COMPENSATION

Name of Employer at the time of injury_____________________________________________________________ Case #________________________________

Address___________________________________________________________________________ Phone #__________________________________________

Adjuster ‘s Name___________________________________________________Nurse Case Manager’s Name__________________________________________

Phone#_____________________________Fax#__________________________ Phone#____________________________Fax#___________________________

Financial Responsibility Agreement and Signature Authorization

I authorize Raul A. Monzon, M.D. to administer medical care as necessary to use and disclose my protected health information for the purposes of Treatment,

Payment and Health Care Operations. Pain Management Specialists of North Fl, PA will file my insurance as a courtesy on my behalf. I request that payment of

authorized Medicare or any insurance benefits be made payable to Raul A. Monzon, M.D., Incorporated under Pain Management Specialists of North Fl, PA. I

authorize any medical information or documentation about me in their possession be released to the Centers of Medicare and Medicaid Services (CMS) or Any

Insurance Carrier, their Agents and Carriers as needed to determine these benefits or the benefits payable for related services, now or in the future. I agree to be

financially responsible for all medical charges and services rendered to myself whether or not covered by my insurance. I accept responsibility for any balance not

paid by my insurance company if not paid in 45 days. There will be a $30.00 fee on all returned checks. I agree to any cost of collections including attorneys fees,

court cost and legal interest, which may be incurred in enforcing this obligation. I agree to contact Pain Management Specialists of North Fl, PA in the event my

insurance and contact information changes. I have received and agree to the terms and conditions set by Pain Management Specialists of North Fl, PA’s Financial

Policy. I hereby authorize and direct that a copy of this authorization be accepted in place of the original and effective the date signed until revoked in writing.

Print Name:___________________________________________ Signature_________________________________________ Date_____________________

Witness Print Name:____________________________________ Signature_________________________________________ Date_____________________