Date:

Name:
Address:
Birth Date: Patients SS#:
Phone: Cell Phone: E-Mail:
Present Employer: Phone: EXT:
Spouse:  Status: Single Married Widowed Divorced

Name of person(s) whom we can discuss your medical information with:

Name: Relationship:
Phone:
Name: Relationship:
Phone:

Financial Responsibility

Primary Insurance: Insured SS#:
Relationship of Insured: Self Spouse Child Other
Insured Name: Birthdate:
Insured Employer: Phone: EXT:
Secondary Insurance: Insured SS#:
Relationship of Insured: Self Spouse Child Other
Insured Name: Birthdate:
Insured Employer: Phone: EXT:

Referring Doctor: Phone:
Family / Primary Care Doctor: Phone:
Would you like your records released to this / these doctors? yes no
If yes, whom: Phone:
 

I HEREBY AUTHORIZE SURGICAL ASSOCIATES OF MACOMB TO RELEASE MY RECORDS TO MY REFERRING AND/OR PRIMARY CARE.

SIGNATURE:                                           DATE:                       

MEDICARE/INSURANCE AUTHORIZATION: I AUTHORIZE THE USE OF THIS FORM FOR ALL OF MY INSURANCE SUBMISSIONS; AS A RELEASE OF INFORMATION FOR ALL INSURANCE CARRIERS.  I AUTHORIZE MY DOCTOR TO ACT AS MY AGENT IN OBTAINING PREAUTHORIZATION AND PAYMENT FROM MY INSURANCE CARRIERS.  I AUTHORIZE PAYMENT DIRECTLY TO MY DOCTOR.  I UNDERSTAND THAT ULTIMATELY I AM RESPONSIBLE FOR MY BILL.  I PERMIT A COPY OF THIS AUTHORIZATION TO BE USED IN PLACE OF THE ORIGINAL.

SIGNATURE:                                           DATE: