Medical Authorization
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22765 Bee Caves Road, Suite 205
Austin, TX 78746
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1730 E. Whitestone Blvd., Suite 100
Cedar Park, TX 78613
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4112 Links Lane, Suite 204
Round Rock, TX 78664
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512-328-7722
Fax: 512-328-7724
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Patient Information
(Please Print)
Today’s Date____/____/____
Name_________________________________________________________________________________________
Last
First
M.I.
Address_______________________________________________________________________________________
Street
Apt #
City
State
Zip
Home Phone (_____) _______________ Cell Phone (_____) _______________ Email ________________________
SS#______________________ Date of Birth _____/_____/______ Age _________ Sex __________
In case of an Emergency, who should be notified? ________________________ Phone (_____)_________________
Do we have permission to:
Y / N Leave a message on your HOME answering machine?
Race: African American, Caucasian, Hispanic, Asian, Other
Y / N Leave a message at work?
Ethnicity: Hispanic or Latino, Not Hispanic or Latino
Y / N Leave a message on cell phone or text?
Preferred Language: English, Spanish, Other ____________
Y / N Send email regarding your medical care?
Y / N Discuss your medical condition with any member of your household?
If so, with whom ______________________________Relationship_____________________________
Referring Physician_______________________ PCP___________________________________
Guarantor (Responsible party---if different from patient)
Name_________________________________________________________________________________________
Last
First
M.I.
Address_______________________________________________________________________________________
Street
Apt #
City
State
Zip
Home Phone (_____) _______________ Cell Phone (_____) ________________________ Ext. ________________
SS#___________________ Date of Birth _____/_____/______ Age ______ Relationship to Patient: _____________
Primary Insurance Information
Primary Insurance Name ________________________________ Employer (Group) __________________________
Policy Holder ________________________________________DOB____/____/____SS#______________________
Last
First
M.I.
Effective Date _____/_____/_____
Secondary Insurance Information
Secondary Insurance Name___________________________ Employer (Group) ____________________________
Policy Holder ________________________________________DOB____/____/____SS#______________________
Last
First
M.I.
Effective Date _____/_____/_____
PLEASE CONTINUE...
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Parent category: Medical