Patient Form – 1

Date

Last Name:

First Name:

Male Female

Date of Birth:

Age:

SS#:

Address

Home Phone:

Work:

Cell:

Employer:

Phone:

Address:

Occupation:

Referring Physician:

Phone:

Referring Physician's Address:

Name of Emergency Contact (not living with you):

Relationship:

Phone:

My signature below acknowledges the following:

I have received a copy/am aware of the Patient Bill of Rights; as required by law and have had an opportunity to receive assistance in understanding and exercising these rights.
I have received a copy/am aware of this office's Notice of Privacy Practices, including the Private Health Information (PHI) designated at the time of visit.
I have received information on/am aware of the Speak Up Program Campaign.

Signature of Patient/ Representative

Date

Above signature was not obtained because:

Patient is unable and unaccompanied by a representative. Patient left with all pertinent disclosures.

Patient refused to sign

Patient refused forms

Assignment of Benefits

I hereby assign all medical and/or surgical benefits, to include major benefits to which I am entitled, private insurance and any other health plan to Main Street Medical Services, PLLC.

This assignment will remain in effect until revoked by me in writing. A photocopy of this agreement is to be considered valid as original. I understand that I am financially responsible for all charged whether or not paid by said insurance. I hereby authorize said assignee to release all information to secure payment.

Signed

Date

Patient Form – 1

xczcx