WRIGHT PLASTIC SURGERY,P.C. PATIENT INFORⅣ lAT10N

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WRIGHT PLASTIC SURGERY,P.C. PATIENT INFORⅣ lAT10N
WRIGHT PLASTIC SURGERY,P.C.
PATIENT INFORⅣ lAT10N QUESTIONNAIRE
(All Information Confidential)
RESPONSI BLE
PATIENT
Name
PARTY(if different)or Spouse lnfo.
Resp.Pa吻
MI
First
Last
or
Spouse Last
Address
Address
City,State
City,State
Zip Code
Zip Code
Home Phone
Home Phone
Business Phone
Business Phone
Employer
Employer
Occupation
Occupation
Age
Birthdate
MI
,・
`
Age
Birthdate
Social Security #
Social Security #
Family Physician
Marital Status
Sex
First
In Emergency Contact Q'Jame & Phone Number)
PRIⅣ 【ARY
INSURANCE
INSURANCE COPIPANY INFORPIATION
SECONDARY INSURANCE
Insurance Co.
ID#
Group #
FOR AUTO ACCIDENT CLAIPIS/WORKER'S COPIPENSATION CLAIⅣ
IS(Circle one)
Insurance Co
Date of Accident/Injury
Claim #
Policy #
Telephone #
Contact Person/Adjuster:
AUTHORIZAT10N FOR RELEASE OF INFORⅣ IAT10N
・
o
・
o
I HEREBY AUTHORIZE ASSIGNMENT AND PAYMENT DIRECTLY TO PHYSICIAN OF MAJOR MEDICAL BENEFITS DUE ME.
I HEREBY AGREE TO PAY ANY AND ALL CHARGES THAT EXCEED OR THAT ARE NOT COVERED BYINSURANCE.
I AUTHORIZE THE PHYSICIANS OF IVRIGHT PLASTIC SURGERY,P.C.T00BTAI「
TO PARTICIPATE IN ⅣIY MEDICAL CARE.
e ANY MEDICAL INFORMAT10N THEY MAY NEED
I HEREBY AUTHORIZE YOU TO TAKE APPROPRIATE PHOTOGRAPHS FOR PURPOSES OF COMPLETING MY RECORDS, AS
ILLUSTRAT10NS FOR LECTURES TO MEDICAL OR NON‐ MEDICAL AUDIENCES OR FOR PUBLICATIONS IN MEDICAL B00KS OR
JOURNALS.(YOU MAY DELETE ANY PHRASE YOU OBJECT TO.)
●
I AUTHORIZE THE PHYSICIANS OF WRIGHT PLASTIC SURGERY, P.C. TO RELEASE INFORル IAT10N, INCLUDING FAXED
FINRORMAT10N,TO ANY PERSON PARTICIPATING IN MY MEDICAL CARE.I RELEASE WRIGHT PLASTIC SURGERY,P,C.FROM ANY
LIABILITY IN THE EVENT THAT UNAUTHORIZED NDIVIDUALS RECEIVED ⅣlEDICAL INFORMAT10N NOT INTENDED FOR THEIR
llSE THROUGH FAXED TRANSMITTAL. I AUTHORIZE THE PHYSICIANS OF WRIGHT PLASTIC SURGERY,P.C. TO RELEASE
INFORMAT10N TO MY INSURANCE COMPANY OR WORKER'S COル IPENSAT10N CARRIER ACQUIRED IN THE COURSE OF MY
EXAMINAT10N OR TREATMENT.I AUTHORIZE MEDICARE TO FURNISH TO THE PHYSICIANS OFヽ
0
VRIGHT PLASTIC SURGERY,P.C
ANY INFORMAT10N RECARDING ⅣIY ⅣIEDICAL CLAIMS UNDER TITLE XVⅡ 1 0F THE SOCIAL SECURITY ACT.
1ACKNOヽ VLEDGE THATI HAVE RECEⅣ ED A COPY OF WRIGHT PLASTIC SURGERY,P.C.'S PRI1/ACY NOTICE.Yes□
Signature
Date
Relationship to Patient
No
□

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