lone star orthopedics, p.a.

NOTE: This form is not for online submission. Please print this form and bring completed form to your office visit.

Patient contact and insurance information form            Back to Welcome

 
Patient name
 		 Home phone
 
Address
 		 Work phone
 
City State Zip
 		 Mobile phone
 
Date of birth
 		 Social security#
 

 

Employer

 

 Address/phone

 
Person responsible for bill
 		 Relationship
 
Address
 		 TX Driver's license/ SSN#
 
Spouse name
 		 Phone number
 
Emergency Contact
 		 Phone number
 

 

Primary insurance
 		 Phone
 
Policy holder's name
 		 Date of birth
 
Policy#
 		 Group#
 
Secondary insurance
 		 Phone
 
Policy holder's name
 		 Date of birth
 
Policy#
 		 Group#
 
Referring physician's name
 		 Primary care physician
 

 

Assignment of Benefits & Responsibility for Payment
In the event that my insurance company does not pay for services performed by this organization, I understand that I am responsible for all charges incurred as a result of this and subsequent visits and/or surgery. I authorize this organization to release information to my insurance carrier (and employer for worker's compensation care).

I authorize payment directly to this medical practice for benefits otherwise payable to me for its services. I understand that this authorization does not release me from personal responsibility for all charges.
_______________________ ____/____/______
Signature Patient/Parent/Legal Guardian Date