PATIENT INFORMATION FOR MEDICAL RECORDS
***PLEASE PRINT CLEARLY AND FILL OUT COMPLETELY!!!***
PATIENT INFORMATION:
PATIENT NAME:
MR/MRS/MISS _______________________________________
BIRTHDATE ______________________
HOME ADDRESS __________________________________________________________________
CITY ________________________ ZIP CODE _____________
HOME PHONE ____________________
WORK PHONE ________________________
SOCIAL SECURITY NO: ___________________________
MARITAL STATUS: ( ) S ( ) M ( ) W ( ) D
SPOUSES'S NAME _________________________________
INSURED PARTY (GUARANTOR):
NAME: ____________________________________________________________________
RELATIONSHIP TO PATIENT ____________________________________________________________
ADDRESS (IF DIFFERENT FROM PATIENT) ________________________________________________
HOME PHONE _______________________
SOCIAL SECURITY NO ____________________________
BIRTHDATE ___________________
EMPLOYED BY _________________________________________
WORK ADDRESS ____________________________________________________________________
CITY ___________________ ZIP CODE ______________
WORK PHONE _______________________
REFERRING PHYSICIAN _________________________________________
MEDICAL INSURANCE INFORMATION:
NAME OF INSURANCE _______________________________
ID NO ____________________________
ADDRESS _________________________________________
GROUP NO ________________________
NAME OF INSURANCE _______________________________
ID NO ____________________________
ADDRESS _________________________________________
GROUP NO ________________________
ARE YOU COVERED BY MEDI-CAL? ( ) YES ( ) NO -- IF YES, PLEASE SEE RECEPTIONIST.
HAS THIS OFFICE TREATED A MEMBER OF YOUR FAMILY? _________________________________
PLEASE SIGN AND RETURN TO RECEPTIONIST
I, the undersigned, assign directly to Dr. Kevin Ho, all surgical and medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by my insurance. I hereby authorize the doctor to realease all information necessary to secure the payment of benefits.
DATE ___________________
SIGNED ____________________________________________________
