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Patient Information


PATIENT INFORMATION Email
Last Name
 First Name
 M.I.
 Home Phone
 Work Phone
Street Address
 Social Security #
 Driver's License #
City
 State 
 Zip
 Sex

M    F
Marital Status

S   M   W   DIV   SEP
Date of Birth
Employer Name
 Address
 Occupation
Are You a Full Time Resident?

Yes     No
If No, Permanent Address and Phone #
Family Physician
 Address
 Phone
Who Can We Thank for Referring You to Our Practice?         Phone  
Family   Friend    Doctor Name Address Phone  
Employer    Newspaper    TV    Radio    Direct Mail Yellow Pages Billboard   Other
SPOUSE/RESPONSIBLE PARTY
Last Name
 First Name
 M.I.
 Home Phone
 Work Phone
Employer Name
 Address
 Date of Birth
 Social Security #
COMMUNICATION/DISCLOSURE AUTHORIZATION
I authorize MFEC group to discuss my personal medical and account history with the following individuals:
  Name Relationship Phone Number
1)
2)
Please note this authorization will remain in effect unless a written request to rescind authorization is received.
EMERGENCY INFORMATION
Name-Not Living With You
 Relationship
 Home Phone
 Work Phone
Street Address
 City/State/Zip

INSURANCE INFORMATION/MANAGED CARE PLAN

Please Give Insurance Cards and Driver's License To The Receptionist To Copy For Your File.
Primary Insurance
Secondary Insurance
Insurance Company
 Insurance Company
Patient ID
 Group ID #
Patient ID
 Group ID #
Name of Insured
 D.O.B.
 Social Security #
Name of Insured
 D.O.B.
 Social Security #
Relationship to Insured:

Self    Husband    Parent   Wife   Child   Other
Employer Insurance Plan    Yes     No    Name:
Relationship to Insured:

Self    Husband    Parent   Wife   Child   Other
Employer Insurance Plan    Yes     No    Name:
CONSENT FOR TREATMENT AND LIFETIME AUTHORIZATION FOR ASSIGNMENT OF BENEFITS AND INFORMATION RELEASE

I hereby give consent to MFEC to provide whatever treatment they may deem necessary to the patient above.
I understand that I am responsible for charges incurred for services. I understand I am responsible for charges not covered by the insurance policy or Medicare, and should it become necessary to collect these charges through an attorney or other collection process, I shall be responsible for all court costs, interest, collection costs, and attorney's fees.

I hereby request payment of authorized Medicare benefits and/or any other, including supplemental and Medigap insurance benefits for me to be paid directly to MFEC for any services furnished me by MFEC. I authorize MFEC and staff to release to my insurance carrier and its agents any information concerning health care advice, treatment or supplies provided me needed to determine these benefits or the benefits payable for related services. I understand this is a lifetime authorization.

I have read and understand the MFEC FINANCIAL POLICY.

__________________________

Patient Signature Authorization
_________________

Date
________________________________

Signature of Spouse or Guardian
_________________

Date

 


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