Patient Information Sheet Name* First Middle Last SS#Date Of Birth* Gender* Male Female Status* Single Married Divorced Widowed Street Address*City/State/Zip Code:Home Phone w/Area Code:Cell Phone w/Area CodeWork Phone w/Area CodeEmail Patient EmployerSpouse's NameSpouse's EmployerSpouse best phoneResponsible Party*Relationship* Self Spouse Parent Other if patient is a Minor,are parents Married Divorced Guardian ParentGuardian AddressGuardian SSBest phone # w/Area CodeDate Of Birth Emergency ContactPhone Number w/Area CodeRelationship to patientPrimary Care PhysicianAddressOfficeDate Last Seen Referring Physician's Name First Last Referring Physician's Phone Numberis this ? Work-related MVA PI If yes, exact date of injury ClaimAdjuster name/PHAttorney name/PH PLEASE PRESENT INSURANCE CARD(S) & PHOTO ID FOR COPYING AND COMPLETE THE REQUESTED INFORMATIONInsurance Company #1Phone NumberPrimary Subscriber Name First Last Date Of Birth Address Street Address City State / Province / Region ZIP / Postal Code PolicyGroupRelationship Insurance Company #2Phone NumberPrimary Subscriber Name First Last Date Of Birth Address Street Address City State / Province / Region ZIP / Postal Code PolicyGroupRelationship ** IF A REFERRAL IS NEEDED, IT IS THE PATIENT’S RESPONSIBILITY TO OBTAIN AND PRESENT AT THE TIME OF SERVICE ▪ I hereby authorize the payment of medical benefits to Facaros Foot & Ankle for services rendered. I understand that I am financially responsible for any services not covered by my insurance carrier. ▪ I hereby authorize Facaros Foot and Ankle to release any medical information necessary to complete and process my insurance claims.I hereby consent and authorize Facaros Foot and Ankle (FFA) to release to the Social Security Administration and Centers for Medicare and Medicaid services, its intermediaries or carriers, and to any other insurance or managed care company covering me or my dependents or insurance beneficiaries, any information, including protective health information, needed for processing of claims for payment for services rendered. I request that payment of Medicare, insurance or managed care benefits for services rendered to me (or my dependents/beneficiaries) be made directly to FFA. I further understand and agree that if my insurance plan sends payment to me rather than FFA, I will endorse/forward the check to FFA to apply towards my account.* I have read and understand the above information. NameThis field is for validation purposes and should be left unchanged.
