The Women's Centre

The Women's Centre

John F. Dulemba, MD Suhas D. Mantri, MD

Amy Dean, WHNP-BC

Patient Name: First ______M _____ Last ______(former last name:______)

Preferred Name (If different from above) ______

Address: ______Home Phone: ______

City/State: ______Work Phone: ______

Zip: ______Cell Phone: ______

Email: ______Driver Lic # & State: ______SS#: ______Marital Status: S M D W DOB: _____/____/______

Employer: ______Address: ______

Nearest Relative not living with you: ______

Primary Physician: ______Phone: ______

I authorize you to provide my confidential medical information to: ______

Bill Patient Charges to (if other than patient): ______SS#: ______

Address: ______Phone: ______

Emergency Contact: ______Phone: ______

Spouse Name: ______DOB: ______/_____/______

Spouse SS#: ______Driver Lic # & State: ______

Employer: ______Employer Phone: ______

Employer Address: ______

Insurance Company: ______Phone: ______

Policy ID/Subscriber #: ______Group #: ______

Claims Address: ______

Subscriber Name: ______Relationship to you: ______

Subscriber SS#: ______Subscriber DOB: _____/_____/______

NOTE: “Subscriber” refers to the primary account holder on the insurance policy.

Insurance Company: ______Phone: ______

Policy ID/Subscriber #: ______Group #: ______

Claims Address: ______

Subscriber Name: ______Relationship to you: ______

Subscriber SS#: ______Subscriber DOB: _____/_____/______

It is the policy of our office that all visits must be paid for at the time of services; this will include all co-payments and deductibles. Your insurance will be verified at the time of your appointment.

I understand and agree that (regardless of my insurance status,) I am ultimately responsible for the balance of my account for any professional services rendered. I will notify this office of any changes in my information.

I consent to and authorize The Women's Centre to treat any conditions that I might have and seek treatment for.

I authorize The Women's Centre to release any medical information to my insurance company needed to process claims.

I acknowledge I have received a copy of this office’s Notice of Privacy Practices.

Patient Signature: ______Date: ______