Patient Name: Sex: M [ ] F [ ] First Middle Initial Last Email address: Patient’s SS#: Date of Birth: / / Race: Address: City: State Zip - Home #( ) - Cell #( ) - Work #( ) - (If Minor /Responsible Party) Responsible Party Name (if different than patient) Sex: M [ ] F [ ] First Middle Initial Last Name: DOB / / SS# - - Home #( ) - Emergency Contact: Relationship Name of Insured: Primary Insurance Name: ID or Policy Number: Group Number: Insurance Phone # Effective Date: Name of Insured: Secondary Insurance Name: Id or Policy Number: Group Number: Insurance Phone # Effective Date: I authorize Sean M. Hamilton, MD with Victoria Vein & Surgery Clinic to furnish information to insurance carriers concerning my medical condition and care. I assign to Sean M. Hamilton, MD all payments for medical services rendered to me or my dependents. I also request payment of government benefits to the party who accepts assignment. This authorization is valid as long as I am a patient of Sean M. Hamilton M.D. Any person signing below guarantees payment of the health care costs incurred on behalf of patient and in the event such costs are not incurred on behalf of patient and in the even such costs are not timely paid further guarantee payment of the cost of collection of such bills including attorney fee’s. collection agencies and interest. Signature Signature Date The signature is of the: Patient Parent of Minor Legal Guardian Patient’s Power of Attorney We reserve the right to charge a no-show fee of $10.00 if you fail to notify our office of your cancellation within 24 hours of your appointment. Insurance will not cover this fee.
Patient Name: Sex: M [ ] F [ ] First Middle Initial Last Email address: Patient’s SS#: Date of Birth: / / Race: Address: City: State Zip - Home #( ) - Cell #( ) - Work #( ) - (If Minor /Responsible Party) Responsible Party Name (if different than patient) Sex: M [ ] F [ ] First Middle Initial Last Name: DOB / / SS# - - Emergency Contact: Home #( ) - Relationship Primary Insurance Name: Name of Insured: ID or Policy Number: Group Number: Insurance Phone # Effective Date: Secondary Insurance Name: Name of Insured: Id or Policy Number: Group Number: Insurance Phone # Effective Date: I authorize Sean M. Hamilton, MD with Victoria Vein & Surgery Clinic to furnish information to insurance carriers concerning my medical condition and care. I assign to Sean M. Hamilton, MD all payments for medical services rendered to me or my dependents. I also request payment of government benefits to the party who accepts assignment. This authorization is valid as long as I am a patient of Sean M. Hamilton M.D. Any person signing below guarantees payment of the health care costs incurred on behalf of patient and in the event such costs are not incurred on behalf of patient and in the even such costs are not timely paid further guarantee payment of the cost of collection of such bills including attorney fee’s. collection agencies and interest. Signature Signature Date The signature is of the: Patient Parent of Minor Legal Guardian Patient’s Power of Attorney We reserve the right to charge a no-show fee of $10.00 if you fail to notify our office of your cancellation within 24 hours of your appointment. Insurance will not cover this fee.
NP-Demo-Sheets-November-2017.docx