DRS. WELCH, UYEMURA, BROTSKY & JENG PATIENT INFORMATION
PERSONAL INFORMATION
Today's Date:
Name
Social Security No.:
Mailing Address
City
State :
Zip :
Home Address :
City :
State :
Zip :
Home Phone :
Work Phone :
Employer :
Birth Date :
Current age: :
Gender :
Male
Female USA Citizen :
Yes
No
Marital Status:
Married
Widow
Single
Divorced
Spouse's Name :
Spouse's SS# :
Emergency contact not living with you:
Name :
Phone :
Relationship :
Personal physician:
Name :
Address or phone :
Referred by:
Name :
Address or phone :
BILLING INFORMATION FOR RESPONSIBLE PARTY
(Please fill in the information below ONLY if patient is NOT RESPONSIBLE PARTY or patient is a MINOR):
Name :
:
:
Social Security No. :
Mailing Address :
City :
State :
Zip :
Home Phone :
Work Phone :
Relationship to patient :
Birth Date :
EMPLOYMENT INFORMATION
Employed :
--> Name of employer :
Address :
City :
State :
Zip :
Phone :
Supervisor's Name_ :
Is this a Worker's Comp Claim? :
Yes
No. Claim #
Date of Injury/Accident? :
Is this an auto accident? :
Yes
No.
Employment Status:
Retired
Unemployed
Disabled
Name of last employer :
Student :
--> Name of school :
INSURANCE INFORMATION
(Please bring your insurance card on your first visit)
Primary Insurance
Name of Carrier :
Address :
City :
State :
Zip :
Phone :
Policy # :
Group# :
Policy Holder's Name :
Relationship to Patient :
Second Insurance
Name of Carrier :
Address :
City :
State :
Zip :
Phone :
Policy # :
Group # :
Policy Holder's Name :
Relationship to Patient :
Please let us know if you have more than two insurance policies.
LIFETIME SIGNATURE AUTHORIZATION
Your signature on the following Lifetime Signature Authorization will enable us to submit all insurance claims for you, With benefit payment made directly to our office. It acknowledges your responsibility for obtaining any necessary referrals. It acknowledges your acceptance of financial responsibility for charges not covered by your insurance carriers.
I request that payment of authorized insurance benefits by Medicare, Blue Cross/Blue Shield or other insurance companies be made on my behalf to Drs. WELCH & UYEMURA, LLC for any services furnished by Drs. Welch and/or Uyemura.
I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents or other healthcare provider that may render services or supplies that may request the information for purposes of treatment or billing, any information needed to determine these benefits, or benefits payable for related services.
I hereby release Drs. Welch. Uyemura, & Brotsky, its agents and employees, from all responsibility or liability that may arise from the release of such records.
I am aware that if I am to obtain a referral from my Primary Care Physician or insurance company in order to receive specialty care and have not done so and still receive service without the required referral, that I agree to accept full financial responsibility for any charges I incur.
The undersigned certifies that he/she is the patient or the duly authorized representative of the patient, and agrees to these terms.