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Comprehensive Pain & Headache Treatment Centers, LLC   130 Division St Derby CT 06418 (203) 732 1570

New Patient Information

Patient's Name

Soc Sec #

Marital Status

Sex M/F

Age

Date of Birth

Patient's Address

Patient Home Phone

Whose Insurance will cover your claims?

Who employs that person?

Patient Bus Phone

Patient Employer's Name & Address

Spouse or Emergency Contact Name

Relationship to Patient

Phone

Spouse's Employer

Employer's Phone

Employer's Address (Street, City, State, Zip)

Primary Care Physician

Address

Phone

Referred By

Address

Phone

Primary Insurance Carrier

ID #

Group #

Address

Secondary Insurance Carrier

ID #

Group #

Address

Medicare

ID #

Work Injury: Employer at the time

Phone

Date of Injury

Name and Address of Worker's Comp. Carrier

Case Manager: Name & Phone

File#

Motor Vehicle or Other Accident - Describe

Date of Accident

Name and Address of Carrier

No Fault ID #

Were X-Rays, CAT Scans or MRIs taken for this? ( List place and date)

Please Read: All charges are due at the time of service.

  ® ®   To avoid a missed appointment charge at least 24 HOURS notice is required to cancel an appointment  203 732-1570

             

All professional services rendered are charged to the patient. Necessary forms will be completed to help expedite insurance carrier payments, however the patient is responsible for all fees, regardless of insurance coverage.

 

Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance any balance not paid for by your insurance. It is also customary to pay for services when rendered unless other arrangements have been made in advance with our office bookkeeper. If this account is assigned to an attorney for collection and/or suit, the prevailing party shall be entitled to reasonable attorney's fees and costs of collection. To the extent necessary to determine liability for payment and to obtain reimbursement, I authorize disclosure of portions of the patient's records.

 

I hereby assign all medical and/or surgical benefits to include major medical benefits to which I am entitled, including Medicare, private insurance and other health plans to: Comprehensive Pain & Headache Treatment Centers, LLC. This assignment will remain in effect until revoked be me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid be said insurance. I hereby authorize said assignee to release all information necessary to secure the payment.

 

I certify that I have been given, have read, understand and agree with the medication policy of the practice.

 

Signature of Patient or Responsible Party

Relationship to Patient

Date