Dr. Stall's Office--Patient Information Sheet--Demographics/Insurances (created 8/30/97)

Dr. Stall's Office--Information/Assessment Packet

Patient Information Sheet--Demographics/Insurances

Name:
Address:
Phone:
Date of Birth:
Social Security Number:

Sex:

M

F

Marital Status:

Divorced

Married

Never Married

Separated

Widowed

Living Situation:

Alone

With Spouse

With Child

With Other Relative

With Friend

Medicare Number:
Medicaid Number (if applicable):

Medigap/Secondary Insurance:
Address:
Phone:
Policy Number:
Group Number:
Name of Policy Holder (if different from patient):

Other Insurance:
Address:
Phone:
Policy Number:
Group Number:
Name of Policy Holder (if different from patient):

ASSIGNMENT OF BENEFITS

Name of Policy Holder: ______________________

I HEREBY AUTHORIZE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS THIS CLAIM. I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I request payment of authorized Medicare or other insurance benefits be made either to me or on my behalf to Dr. Stall for any services furnished me by him. I authorize any holder of medical information about me to release to HCFA/Health Insurance Carrier and its agents any information needed to determine these benefits payable for related services.

I ALSO AUTHORIZE PAYMENT TO BE MADE DIRECTLY TO:
Robert S. Stall, M.D. 14 Heritage Road West Williamsville NY 14221

Signature Date: _