Registration Form

Registration Form

PLEASE PRINT PATIENT INFORATION ACCT. NO. _____________________

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Workers Comp	Yes	NO		Date Symptoms First Appeared / /
Auto Accident	Yes	NO		Injured Part of Body
Other Injury	Yes	NO		Describe
			(ie, fall down stairs, hiking etc....)

LAST NAME		FIRST NAME	MIDDLE		NAME CALLED
STREET ADDRESS		APPT #	CITY	STATE	ZIP
AREA CODE	HOME PHONE	SOCIAL SECURITY #	SEX	DATE OF BIRTH	AGE	MARITAL STATUS
EMPLOYED BY			SPOUSE'S NAME			EMPLOYED BY
EMPLOYERS ADDRESS			EMPLOYERS ADDRESS
OCCUPATION		BUS. PHONE	OCCUPATION			BUS. PHONE
NEAREST FRIEND OR RELATIVE NOT LIVING WITH YOU			RELATIONSHIP TO PATIENT			PHONE

POLICY HOLDER INSURANCE INFORMATION COPIES OF INSURANCE CARD REQUIRED

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LAST NAME	FIRST NAME	MIDDLE		RELATIONSHIP TO PATIENT
STREET ADDRESS	APPT #	CITY	STATE	ZIP
DATE OF BIRTH	SOCIAL SECURITY #		HOME PHONE
Insurance Co. Name
Mailing AAddress		City, State, Zip,
(A/C) Phone # ( ) - ( ) -
Policy Contract #

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LAST NAME	FIRST NAME	MIDDLE		RELATIONSHIP TO PATIENT
STREET ADDRESS	APPT #	CITY	STATE	ZIP
DATE OF BIRTH	SOCIAL SECURITY #		HOME PHONE
Insurance Co. Name
Mailing AAddress		City, State, Zip,
(A/C) Phone # ( ) - ( ) -
Policy Contract #

REFERRAL INFORMATION Does your insurance require a referral from your primary physician ? Yes / No

REFERRING PHYSICIAN Referral #

Expiration Dates

Number of visits allowed

ID # EFFECTIVE DATE

I REQUEST THAT PAYMENT OF AUTHORIZED Medicare benefits be made to VINCENT BOSWELL, M.D., P.C.
I authorize any holder of medical information about me to release to the Health Care Financing Admiistration and its agents any information needed to determine these benefits or the benefits payable to related services.

DATE SIGNATURE_______________________________________

IF WORKERS COMP INJURY

Date of Injury / /

Employer At Time of Accident

Employer Address

Part of Body

IF AUTO ACCIDENT

YOU MAY PROVIDE INFO FOR RECORDS; HOWEVER; OFFICE DOES NOT FILE AUTO CLAIMS & YOU WILL BE FINANCIALLY RESPONSIBLE

Date of Injury / /

Insurance Company Handling Medical Bills

Insurance Company Address

Agent's Name Phone #

AUTHORIZATION ASSIGNMENT

I hereby authorize the release of any medical information, including information related to psychiatric care, drug and alcohol abuse and HIV/AIDS confidential information, necessary to process insurance claims or any medical information that is required for any health care related utilization review or quality assurance activities or any healthcare professional requiring this information.

I hereby assign and authorize payment to Vincent Boswell, M.D,, P.C. of all medical and/or surgical benefits, including major medical benefits, to which I am entitled to under any insurance policy or policies, under any self-insurance program, or under any benefit plan.

I understand and acknowledge that this assignment of benefits does not relieve me of my financial responsibility for all medical fees and charges incurred by me or anyone on my behalf and I hereby accept such responsibility, including, but not limited to, payment of those fees and charges not directly reimbursed to Vincent Boswell, M.D., P.C. by any insurance policy, self-insurance program or other benefit plan.

This authorization shall remain in effect until revoked by me in writing. A photocopy of this authorization shall be considered as effective and valid as the original. I understand that I have the right to receive a copy of this authorization.

PERSON PROVIDING THE AUTHORIZATION
RELATIONSHIP TO PATIENT IF NOT PATIENT
PATIENT UNABLE TO SIGN DUE TO
	DATE

General Orthopaedic Care with an emphasis in Occupational Medicine& Worker’s Compensation Care