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PATIENT INFORMATION
Las t Name __________________________________ Firs t ____________________________________ Middle______________________
Address ________________________________________________________________________________________________________
Ci ty_________________________________________________________ State ________________ Zip Code ______________________
Home Phone _____________________________ Cell Phone ___________________________ Work Phone ________________________
Soc. Sec. _______________________________ D.O.B _____/______/_____ Age ______ Sex ______Ma rital Sta tus ___________________
Email Address _________________________________________ Referri ng Physi cian___________________________________________
Spouse Name _____________________________________________ Social Securi ty #_________________________________________
Phone #_______________________________________________ Spouse Employer ___________________________________________
IN CASE OF EMERGENCY (PERSON NOT RESIDING WITH PATIENT)
Name _________________________________________________ Relationship to Pa tient ___________________________________
Phone # _______________________________________________
PAYMENT OPTIONS (Please check mark the payment option you are using):

HEALTH INSURANCE
Pri ma ry Insurance ___________________________________________________________Phone ________________________________
Poli cy # ________________________________________ Group# __________________Subs cribers Na me _________________________
Rela tionship to Subs criber _______________________________Social Securi ty # _______________________D.O.B._________________
Secondary Insurance ____________________________________________________ Phone____________________________________
Poli cy #_____________________________Subs cribers Name ________________________ Rela tionship to Subs criber_______________
Were you involved in an accident: ____Yes____ No
Date of Injury: _____/_____/_____
Please circle one Auto / WC / Miscellaneous Which State: ___VA____DC____ MD or _____ Other___________

WORKERS COMPENSATION OR PERSONAL INJURY INFORMATION

Insura nce Name_____________________________________________ Phone#: __________________________________
Adjus tor/ Case Manager Name: ________________________________________Phone #: _________________________
Claim #: _____________________________________ Da te of Injury: ___________________________________________
3rd Pa rty Insura nce Na me: ____________________________________Phone #: __________________________________
Adjus tor/ Case Manager Name: ____________________________________Phone #: ______________________________
Claim #:_____________________________________________________________________________________________

AUTO INSURANCE/ MED PAY

Auto Ins./Medpa y Company: ____________________________________________________ Phone #: ___________________________
OR Auto Ins ./Lien Company: _______________________________________________________ Phone #: ________________________
Claim Number: ____________________________________ Name of Adjus ter: ______________________________________________
Adjus ter Phone #: _____________________________________ Da te of Injury: ____________________________________
ATTORNEY INFORMATION
Name: ______________________________________________ Phone #___________________________ Fa x#_____________________
Please rememb er that Insurance is considered a method of reimbu rsing the pati ent for fees paid to the doctor and is not a sub stitute for payment. Some compani es may p ay
fixed allowances for c ertain proc edures; th ey someti mes ref er to as R easonable and customary fees. We do not accept this as pay ment in full (unless oth erwise restricted by
law or agreement we may hav e with your insurer). Also some of the insuranc e compani es only pay a p ercent age of the charge. It is your responsibility to pay any deductibl e
amount, co-insurance or any other bal ance not paid for by your insuranc e. IN ORD ER TO C ONTROL YO UR CO ST OF BILL INGS, WE D O R EQU EST THAT O UR CH ARGE FO R OFFIC E
VISITS B E P AID AT THE IN ITIATION OF EACH VISIT . In the ev ent th e account is turn ed ov er for coll ections, th e coll ection f ees and /o r l egal fees, including attorn ey f ees, s hall b e
your responsibility. I hereby assign all medical and /or surgical benefits to include major medical benefits to which I am entitl ed, M edicare, pri vat e insurance and oth er health
plans to the facilit y list ed in th e top h ead er of this page. This assignment will remain in eff ect until revoked by me in wri ting. A photocopy of this assign ment is to b e considered
as valid as an ori ginal . I h ereby autho rize said assignee to rel eas e al l information nec essary to secure the pay ment , vi a fax t ransmitt al or h ard copy.

Pa tient/Pa rent or Legal Gua rdian Si gna ture ____________________________________________ Da te ________________________