(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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