Atlanta Riverdale Patient Information

Dominion Orthopedic Clinic

PATIENT INFORMATION

NAME*

DATE OF BIRTH*

ADDRESS*

Street Address City State / Province / Region ZIP / Postal Code

HOME PHONE

WORK PHONE

CELL PHONE*

SOCIAL SECURITY NUMBER*

SEX*

MALE
FEMALE

EMPLOYER*

EMERGENCY CONTACT*

EMERGENCY PHONE*

EMERGENCY RELATIONSHIP*

GUARANTOR INFORMATION

NAME*

DATE OF BIRTH*

ADDRESS*

Street Address City State / Province / Region ZIP / Postal Code

HOME PHONE

WORK PHONE

CELL PHONE*

SOCIAL SECURITY NUMBER*

EMPLOYER*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

INSURANCE INFORMATION

Primary Insurance*

Secondary Insurance*

Certificate #*

Group Number*

Group Name*

Copay*

Subscriber Name*

ADDITIONAL INFORMATION

Primary Care Physician*

Pharmacy Name*

Physician Phone Number*

Pharmacy Phone Number*

Physician Fax*

Pharmacy Fax*

Physician Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Pharmacy Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

COMPLETE INFORMATION BELOW IF APPLICABLE

Attorney Name*

Adjuster Name*

Attorney Phone*

Adjuster Phone*

Attorney Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Adjuster Fax*

Date Of Injury*

Authorization To Pay Benefits To Physician: I authorize the release of medical or other information necessary to process health insurance claims. I also request payment of benefits to myself or Dominion Orthopedic Clinic when they accept assignment.

Authorization To Release Medical Information. I hereby authorize Dominion Orthopedic Clinic to release any information necessary for my course of treatment.

Signature*

Date*