Please note: this form is not for on-line submission. Please print this page and bring this to the office for your visit.
General information form
James K. Baker, M.D.
Lone Star Orthopedics, PA
Patient name (last, first, middle)_________________________________________ Social Security#___________________
Address___________________________________________________________ E-mail address____________________
Employer Name____________________________ Address______________________________ Phone_____________
If patient is student, name of school_____________________________________________________
Primary care physician Name________________________ Address________________________ Phone______________
If you were referred by a doctor, who was this?_________________________________________________________________
In case of emergency, notify Name____________________ Relationship_____________________ Phone______________
Pharmacy Name___________________ Address________________________________________ Phone______________
Insurance information-Secondary Insurance Policy Holder
Name______________________ Relationship_____________ Social security#_______________ Phone_________________
Address________________________________Date of birth_______________ Employer______________________________
Insurance information-Primary Insurance Policy Holder
Name _______________________ Relationship____________ Social security#_______________Phone________________
Address________________________________Date of birth_______________ Employer_____________________________
In the event this claim is denied by my insurance company, I understand that I am responsible for all charges incurred as a result of this visit. I authorize the release of information to my insurance carrier (and, for worker's comp, to my employer). I authorize payment directly from my insurance carrier to Lone Star Orthopedics, PA for surgical and medical care performed for the patient. I understand that this authorization does not release me from my personal responsibility for payment of all charges.
(patient or parent/guardian for minors)