File # _____________ Date: ______________
PATIENT INFORMATION/INSURANCE AUTHORIZATION FORM
PATIENT INFORMATION
FIRST NAME ________________________ M.I. ______
LAST NAME ____________________________
ADDRESS _____________________________________
CITY ___________________________ STATE _____________________ ZIP ________
DATE OF BIRTH _________________________
PHONE (Home) ___________________ PHONE (Cell) ___________________
EMPLOYER ___________________________
EMPLOYER ADDRESS ______________________________
GUARANTOR INFORMATION (RESPONSIBLE PARTY)
FIRST NAME ________________________ M.I. ______
LAST NAME ____________________________
ADDRESS _____________________________________
CITY ___________________________ STATE _____________________ ZIP ________
DATE OF BIRTH _________________________
PHONE (Home) ___________________ PHONE (Cell) ___________________
EMPLOYER _________________________
EMPLOYER ADDRESS ______________________________
PAYMENT & INSURANCE INFO (WE WILL NEED A COPY OF YOUR CARD)
PRIMARY INSURANCE ________________________________
AGREEMENT OF BENEFITS, RELEASE OF INFORMATION,
PAYMENT AGREEMENT, HIPAA GUIDELINES
I UNDERSTAND THAT PAYMENT IS DUE AT THE TIME OF SERVICE UNLESS OTHER ARRANGEMENTS HAVE BEEN MAD. I UNDERSTAND THAT MEL LANGSTON PROFESSIONAL SERVICES, INC. WILL BE FILING MY INSURANCE ON MY BEHALF. I AGREE TO HAVE THE BENEFITS FROM MY INSURANCE ASSIGNED TO MEL LANGSTON. I PERMIT MEL LANGSTON TO RELEASE ANY INFORMATION DEEMED NECESSARY TO ANY INSURANCE OR THIRD PARTY, WITHIN THE GUIDELINESS OF HIPAA (HEAHT INSURANCE PORTABILITY & ACCOUNTABILITY ACT). I AGREE THAT I AM RESPONSIBLE FOR FULL PAYMENT OF THIS ACCOUNT AND ANY COURT COSTS OR ATTORNEY FEES ASSOCIATED WITH COLLECTION OF THIS ACCOUNT.
RESPONSIBLE PARTY _________________________ DATE _________________
RESPONSIBLE PARTY _________________________ DATE _________________
