Michael J. Krnacik, M.D., Ph. D. Orthopedic Surgeon

Michael D. Van Anrooy, M.D. 541-673-2252, 541-6776160

PATIENT INFORMATION

Patient’s Name ______Male Female
LastFirstMiddle Int.
Mailing Address ______
Box/Street City State Zip
Street Address______
Box/Street City State Zip
Date of Birth ______SS# ______Marital Status: S / M / D / W / Other
Home Phone ______Message Contact______Phone ______
Emergency Contact______Relationship ______Phone ______

RESPONSIBLE PARTY for the patient

Please circle one: Self / Spouse / Parent / Stepparent / Legal Guardian / Power of Attorney / In-Law / ______
Name ______Responsible Party’s Phone ______
Mailing Address ______
Box/Street City State Zip
Employer ______Work Phone ______Ext ______
Additional Guardian information ______Cell Phone ______

OTHER RESPONSIBLE PARTY for the patient

Please circle one: Self / Spouse / Parent / Stepparent / Legal Guardian / Power of Attorney / In-Law / ______
Name ______Responsible Party’s Phone ______
Mailing Address ______
Box/Street City State Zip
Employer ______Work Phone ______Ext ______
Additional Guardian information ______Cell Phone ______

PRIAMRY INSURNACE for the patient

Please circle one: Self / Spouse / Parent / Stepparent / Legal Guardian / Power of Attorney / In-Law / NONE
Insured/Employee’s Name ______Relationship to patient ______
Insurance Name______Group Name/Employer ______
Group# ______Policy ID# ______
Insured’s Date of Birth ______Insured’s SS# ______

TURN OVER

SECONDARY INSURANCE for the patient

Please circle one: Self / Spouse / Parent / Stepparent / Legal Guardian / Power of Attorney / In-Law / ______
Insured/Employee’s Name ______Relationship to patient ______
Insurance Name ______Group Name/Employer ______
Group# ______Policy ID# ______
Insured’s Date of Birth ______Insured’s SS# ______

THIRD PARTY PAYOR

Please circle one: Auto / Worker’s Comp / Home Owner’s Policy / Other ______
Date of Injury ______Place of Injury ______Claim# ______
Insurance Company ______Employer/Owner ______
Insurance Phone ______Claim Representative ______

ADDITIONAL INFORMATION

Please provide a list of all the parties we may speak with or leave a message in person or on a machine regarding the patient’s medical care, appointment scheduling, or payment information.
Yes / No Yes / No
______
Name Relationship Name Relationship
Yes / No Yes / No
______
Name Relationship Name Relationship
Yes / No Yes / No
______
Name Relationship Name Relationship
Yes / No Yes / No
______
Name Relationship Name Relationship
Yes / No Yes / No
______
Name Relationship Name Relationship

The undersigned patient, or individual acting on the behalf of the patient agrees as follows:

  1. Authority is granted to Roseburg Clinic, P.C., to render needed treatment to the above named patient.
  2. I authorize Roseburg Clinic, P.C., to release needed treatment to the above named patient.
  3. I authorize payment of medical benefits to Roseburg Clinic, P.C., for services rendered.
  4. I understand that I am responsible for all charges incurred through Roseburg Clinic, P.C.
  5. Authorization Period: From ______to ______(OR) Lifetime.

I request that payment under the medical insurance program be made to the provider named above on any bills forservices furnished me during the effective period of this authorization and I authorize the above named provider to release to the

Social Security Administration any information needed for this claim or any related Medicare claim. I further permit a copy

of this authorization to be used in place of the original. If it becomes necessary to effect Collection of my account the undersigned agrees to pay for all costs and expenses, including reasonable attorney fees and court costs.

Signature ______Date ______