(Please print out and fax to (301) 570-7989)
Demographics
for patients of Diabetes & Metabolism, PC
InitialDate:_____________________ [Control Number:
]
Title:___ First Name:____________________MI:___Lastname:____________________________________
Street:_______________________________________________________________Apt:_________________
City:__________________________ State:____ Zip:__________________
Date of Birth (DOB)___________ Age: years ____ Sex: _____ Social Security:
Home Telephone:_______________ WorkPhone:_______________ Pharmacy Phone:_______________
Marital Status:________________ Name of Spouse_____________________________________
PRIMARY (1°) INSURANCE or 1° RESPONSIBLE PARTY INFORMATION
[1°InsurRef: ] 1°Insurance Co:____________________________________________________________
1°Group Name:__________________________1°Group No:_______________________________
1° [Holder] Lastname:_______________________1°First:_________1°MI:___1°ID#:______________
Relationship to 1°Holder/Payer:_______1°Street:_______________________________________________
1°City:_____________________________1°State:_____1°Zip:__________1°Telephone:_______________
1°Birthday:_______________________ 1°Sex_____
SECONDARY (2°) INSURANCE INFORMATION
[2°InsurRef: ] 2°Insurance Co:_____________________________________________________________
2°Group Name:___________________________________________2°Group#:________________________
2°[Holder] Lastname:______________________ 2°First:_____________2°MI:____2°ID#:_____________
Relationship to 2°Holder:____ 2°Birthday:_________________________ 2°Sex___
2°Street:__________________________________________________________________________________
2°City:________________________2°State:______2°Zip:_________________
I request that payment of authorized Medicare [or other relevant insurance]
benefits be made either to me [or if accepted on my behalf, to Diabetes &
Metabolism, PC] for any services furnished me by its physicians.
I authorize any holder of medical information about me to release to (1) HCFA
(2) relevant insurance companies (3) Diabetes & Metabolism, PC or (4) their
agents, any information needed to ascertain significant clinical data
or to determine these benefits or the benefits payable for related services.
If benefits for any services rendered now or at any time in the future to me by
Diabetes & Metabolism, PC are not
(1) covered by my insurer[s] or
(2) specifically contracted for by Diabetes & Metabolism, PC or
(3) accepted by Diabetes & Metabolism, PC,
then I [or the responsible party for me] agree[s] to pay for these services
in full.
SIGNATURE_____________________________________
Date:__________________
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Is medicare 1° insurance for you? Yes No
Is medicare 2° insurance for you? Yes No
Do you have medicaid or "medigap" as 3° insurance for you? Yes No
Is there a legal representative involved here? Yes No
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