Group # : _______________________________________________________
INSURANCE ASSIGNMENT & RELEASE I certify that I have insurance coverage with:
______________________________________________________________ Name of Insurance Co.
And assign directly to Dr. _________________________________________
all insurance benefits, if any, otherwise payable to me for services rendered. I
understand that I am financially responsible for all charges whether or not paid by insurance. I authorize to use my signature on all insurance submissions.
The above named physician may use my health care insurance and may disclose such information to the above named insurance Company (ies) and their agents for the purpose of obtaining payments for services and determining insurance benefits or the benefits payable for related services. The consent will end when my current treatment plan is completed or one year from the date signed below.
________________________
Date
_____________________________________
Relationship to Beneficiary
MEDICATE/MEDIGAP AUTHORIZATION
I request that payment of authorized Medicate benefits and, if applicable, Medigap benefits be made either to me or on my behalf to
____________________________________________________________ Name of Doctor or Clinic
for any services furnished to me by that provider.
_____________________________________________________________
Signature of Beneficiary, Guardian, or Personal Representative
_____________________________________________________________
Please Print Name of Beneficiary, Guardian, or Personal Representative
SKIN
Bruise Easily
Hives
Itching/Rash
Change in Moles
Scars
Soar that won’t Heal
MEN ONLY
Erection Difficulties
Lump in Testicles
Penis Discharge
Sore on Penis
Only
WOMEN ONLY
Abnormal Pap Smear Bleeding between Periods
Breast Lump
Extreme Menstrual Pain
Hot Flashes
Nipple Discharge
Painful Intercourse
Vaginal Discharge
Other
Date of last Period
__________________
Date of last Pap Smear __________________
Have you had a Mammogram?
Yes
No
Are you Pregnant?
Yes
No
Number of Children:___
Check
Conditions you have or have had in the past:
Aids
Appendicitis
Arthritis
Asthma
Bleeding Disorders
Breast Lump
Cancer
Cataracts
Chemical Dependency
Chicken Pox
Diabetes
Emphysema
Glaucoma
Heart Disease
Hepatitis
Herpes
High Cholesterol
HIV Positive
Kidney Disease
Liver Disease
Measles
Migraine Headaches
Multiple Sclerosis
Please describe serious illnesses or operations:_________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
►MEDICATIONS / ALLERGIES
List of Medications you are currently taking:
1.
2.
3.
4.
Others: ________________________________________________________
Pharmacy Name: ________________________________________________
Pharmacy Phone: ________________________________________________
List Allergies to Medications or Substances:
1.
2.
3.
Other: ________________________________________________________
►HEALTH HABITS
Check which you use and how much: Caffeine ____________________ Street Drugs _________________ Tobacco ____________________ Other_______________________
Check if your work exposes you to: Stress _____________________ Heavy Lifting ________________ Hazardous Substances ________ Other______________________
►SIGNATURES
To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child,
ever have a change in health.
___________________________________________ Signature of Patient, Parent, Guardian, or Personal Representative
___________________________________________ Please Print Name of Patient, Parent, Guardian, or Representative
___________________________________________ Referred By