sample - Mahendra Mahatma, M.D., P.A.

PATIENT NAME:	Last Name First Name MI
Email:
Home Phone:
Cell/Alternate Phone:
Sex:
Birth Date:	Age:
SS#
Home Address:	Stress Address APT# City ST Zip
Martial Status:	____Married ____Single ____Divorced
Reason For Visit:
Primary Care
Physician: Phone:
Referring Physician: Phone:

Insurance Provider:
Insurance ID#
Insurance Group #
Insurance Provider Phone #

Employer:
Employer Address:
Work Phone:
	____Married ____Single ____Divorced

Person to be reached in case of emergency:
Relation:
Phone:
I hereby authorize Dr. Mahendra Mahatma’s office to release written or verbal information to my doctor or insurance carrier (if the information is requested). In consideration of services rendered, I hereby assign to Dr. Mahatma benefit payments due from my insurance company for medical expenses incurred which are payable to me. I have been informed of or received a copy of the “Notice of Privacy Practices.” Payment is due at time of service! This includes all copays, deductibles, and any other non-covered items. A $25 fee will be charged for all “NO SHOW” appointments not canceled at least 24 hours in advance.