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 ____________________________________________________
Kevin Ki-Hong Ho, MD

Ear, Nose & Throat specialist

Kevin Ki-Hong Ho, MD
San Francisco
Ear, Nose & Throat Specialist

Golden Gate ENT
Kevin Ki-Hong Ho, MD
San Francisco
Ear, Nose & Throat Specialist

Kevin Ki-Hong Ho, MD
San Francisco
Ear, Nose & Throat Specialist
415-682-8181