Patient Forms

About Patient





Name

Responsible Party, If Minor

Street Address

Billing Address, If Different

Sex

male female 

Age

Date Of Birth

Marriage Status

Single married Widowed Separated Divorced 

Patient Employed By

Business Address

Spouse Name (Or Responsible Party)

Business Name & Address

In Case Of Emergency Who Should Be Notify?

Do You Have Medical Insurance?
Yes No 
If Yes, Complete Insurance Info Below
ASSIGNMENT AND RELEASEI, the undersigned, have insurance coverage with and assign directly to 8920 Medical Associates Inc. all medical benefits, if any , otherwise payable to me for services rendered. I understand that i am financially responsible for all changes whether or not paid by insurance, I hereby authorize the doctor to release all information necessary to secure payment of benefits. I authorize the use of this signature on all my medical insurance submission.

MEDICARE AUTHORIZATIONI , request that payment of authorized Medicare benefits be made either to me or on my behalf to 8920 Medical Associates Inc. for any services furnished me by these physicians. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services. I understand my signature request that payment be made and authorizes release of medical information necessary to pay the claim. If "other health insurance" is indicated in item 9 of HCFA 1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing information to the insurer or agency shown.

Download Patient Registration Form