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Name (First, M.I., Last)
Date of Birth Age Male /
Marital Status: S M
Phone Number Social Security # Driver’s License #
Employer Phone
Employer Address
Referring Physician
If Student, School Name Full-Time / Part-Time

Responsible Party

Name Relationship to Patient
Phone Number Social Security #
Employer Phone Number
Employer Address
Emergency Contact Phone Number

Insurance Information

Insurance Company Phone Number
Group # Certificate or ID #
Insured’s Name Relationship to Patient: Self Spouse Dependent
Insured’s Employer Phone Number
Employer Address
Insured’s Social Security # Date of Birth Male / Female

I hereby assign, transfer, and set over to [PRACTICE NAME] all of my rights, title, and interest to my medical reimbursement benefits under my insurance policy. I authorize the release of any medical information needed to determine these benefits. This authorization will remain valid until I revoke it by written notice. I understand that I am financially responsible for all charges whether or not they are covered by insurance.

Patient Signature    Date

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