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 Information

 

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.

 

Signature___________________________________________    Date___________________

                (patient or parent/guardian for minors)