| Patient Information
Thank you for choosing Calvert Internal Medicine! In order to serve you properly, we need the following information. Please print out this form and bring it with you to your first appointment. Please print or type all answers. All information will be kept confidential. Date__________ Patient Name_____________________________________________________________
Account #_______________ Address:_____________________________________________City____________ State______ Zip_______________ ___ Male ___ Female Home Phone:________________Work Phone_________________Extension:____________ Patient or Parent’s Employer:________________________________ Address:________________________________ Date of Birth: ____________ SSN: _________________________________Married ____Single _____Other________ Spouse or Parents Name:_____________________________________________ Phone: _______________________ Spouse’s Employer: _________________________________________________Phone:________________________ If patient is a student, name of school/college:_________________________ City__________________ State ______ Person to contact in case of an emergency:
Are you here for an Auto accident or Personal Injury? ___(Yes) On the Job Injury? ___(Yes) If yes, and you have an attorney, what is his/her name? ______________________________________________________________________ Driver’s License # __________________________________
Responsible Party Name of the person responsible for this account: _________________________ Relationship to Patient: __________ Address (if different than above)__________________________________________ Home phone:_________________ His/Her Birth Date: _______________________ Employer:______________________________________________________________Work phone:_______________ Is this person currently a patient with Calvert Internal Medicine? ____ (Yes) ____ (No)
Insurance Information (please let us copy your insurance cards)
Name of insured: ______________________________________________Relationship to Patient: ________________ Birth Date: ___________ SSN: _________________ Home Phone: ____________ Work Phone: _________________ Address (if different from patient): ____________________________________________________________________ Insurance Co: _________________________________________ ID# __________________ Group # ______________ How much is your copayment? ______________Who is your Primary Care Physician? ________________________ Do you have any additional or second insurance? ____ (Yes) _____( No) If yes, complete the following:
Name of insured: ______________________________________________ Relationship to Patient: _______________ Birth Date: ___________ SSN: _____________ ____Home Phone: ____________ Work Phone: _________________ Address (if different from patient): ____________________________________________________________________ Insurance Co: _________________________________________ ID# __________________ Group # ______________ How much is your deductible? _______________________ How much is your copayment? ___________
Assignment and Release: I hereby request that my authorized Medicare or other insurance benefits submitted for payment by Calvert Internal Medicine Group be paid directly to them for services furnished to me or my child. I authorized them to release any information required to process submitted claims to my insurance company or, if applicable, to the Health Care Financing Administration or it’s agents. I also agree to be responsible for non-covered services, deductibles, and co-payments.
X_______________________________________________
Date: ___________ (please detach and keep for your records) Policy Concerning Payment We participate with AETNA U.S. Healthcare, Alliance, Blue Choice, CareFirst Blue Shield of Maryland, CareFirst Blue Cross/Blue Shield NCA, Cigna, Freestate Health Plan, Medicare, NCPPO, MDIPA, Optimum Choice, and the PHCS Network. If we participate with your insurance, we ask you to pay your co-payment and any unpaid balance while you are here. We will ask you to pay this after your visit. If we do not participate with your insurance, you will be required to pay your entire visit charge while you are here. The copy of your encounter form can be attached to your claim form when you submit your insurance claim; please ask if you need a copy. We accept payment by cash, check, MasterCard, Visa, or American Express. Please ask any questions you may have about your bill or about our financial policies. We are happy to help you. |