Big Pine Medical and Minor Emergency Center

BIG PINE MEDICAL AND MINOR EMERGENCY CENTER

NAME: DATE OF BIRTH: AGE:

ADDRESS: CITY: STATE: ZIP:

PHONE: SEX: MARITAL STATUS: SS#:

CELL PHONE: EMPLOYER:

ADDRESS: PHONE:

NAME OF CLOSEST RELATIVE/FRIEND: PHONE:

ARE YOU ALLERGIC TO ANY MEDICATIONS? IF YES, PLEASE LIST:

VISIT TO BE PAID BY: CASH/CHECK CREDIT CARD MEDICARE W/C INSURANCE

I AUTHORIZE TREATMENT OF THE ABOVE PATIENT AND AGREE TO PAY ALL FEES FOLLOWING TREATMENT ON THE SAME DAY. I UNDERSTAND THAT INSURANCE IS NOT ACCEPTED AS PAYMENT IN FULL. I ALSO UNDERSTAND THAT I WILL BE RESPONSIBLE FOR AND ADDITIIONAL FEES IF MY ACCOUNT IS TURNED OVER TO A COLLECTION AGENCY OR IT MY CHECK IS RETURNED FROM THE BANK.

SIGNATURE: DATE:

EMAIL:

PATIENTS WITH INSURANCE TO FILL OUT THE INFORMATION BELOW:

PRIMARY INSURANCE: SECONDARY INSURANCE:

POLICY HOLDER: POLICY HOLDER:

ID#: GROUP: ID#: GROUP:

SEND CLAIMS TO: SEND CLAIMS TO:

PHONE: PHONE:

I REQUEST THAT PAYMENT OF AUTHORIZED MEDICARE/OTHER INSURANCE COMPANY BENEFITS BE MADE EITHER TO ME OR ON MY BEHALF TO DAVID F. GRIDER, D.O., FOR ANY SERVICES FURNISHED MY BY THE PHYSICIAN/SUPPLIER. I AUTHORIZE ANY HOLDER OF MEDICAL INFORMATION ABOUT ME TO RELEASE TO THE HEALTH CARE FINANCING ADMINISTRATION AND ITS AGENTS ANY INFORMATION NEEDED TO DETERMINE THESE BENEFITS OR THE BENEFITS PAYABLE TO RELATED SERVICES.

I UNDERSTAND MY SIFNATURE REQUESTS THAT PAYMENT BE MADE AND AUTHORIZES RELEASE OF MEDICAL INFORMATION NECESSARY TO PAY THE CLAIM. IF ITEM 8 OF THE HCFA-1500 CLAIM FORM IS COMPLETED MY SIGNATURE AUTHORIZES RELEASING OF THE INFORMATION TO THE INSURER OR AGENCY SHOWN IN MEDICARE/OTHER INSURANCE COMPANY ASSIGNED CASES THE PHYSICAN OR SUPPLIER AGREES TO ACCEPT THE CHARGE DETERMINATION OF THE MEDICARE/OTHER INSURANCE COMPANY AS THE FULL CHARGE AND PATIENT IS RESPONSIBLE ONLY FOR THE DEDUCTIBLE, COINSURANCE, AND NON-COVERE SERVICES. COINSURANCE AND THE DEDUCTIBLE ARE BASED UPON THE CHARGE DETERMINATION OF THE MEDICARE/OTHER INSURANCE COMPANY.

SIGNATURE: DATE: