Advanced Neurological Evaluation and Treatment Center, P.C

Advanced Neurological Evaluation and Treatment Center, P.C.

PATIENT REGISTRATION

PATIENT NAME: (LAST - FIRST - MIDDLE INTIAL)

ADDRESS_______________________________CITY, STATE , ZIP_____________________________

HOME PHONE__________________________ WORK PHONE________________________________

PATIENT SS#_____________________ BIRTHDATE_________SEX_______

MARITAL STATUS S M D W O

How did you hear about us ____Yellow pages ___Newspaper ___Friend ___Dr’s Office ____ Internet

EMPLOYER’S NAME ADDRESS AND PHONE # __________________________________________

AUTO ACCIDENT/ WORKMAN’S COMPENSATION BILLING INFORMATION

NAME OF INSURED:___________________________________ DATE OF ACCIDENT____________

NAME OF INSURANCE:________________________________________________________________

BILLING ADDRESS: STREET CITY STATE ZIP:____________________________________________

___________________________________________________ CLAIM #:__________________________

ADJUSTER:______________________________________ PHONE #:____________________________

ATTORNEY:______________________________________ PHONE #:___________________________

PRIMARY CARE PHYSICAN OR REFFERRING DOCTOR: ___________________________________

DID YOU DO AN OPT OUT PIP WITH YOUR INSURANCE COMPANY Y N

DO YOU HAVE A DEDUCTIBLE Y N

I here by authorize ANETC treat the patient identified above. I acknowledge that I am responsible to pay all charges for all treatments administered by the physician to the patient identified above. I understand that insurance may not pay for all charges, and I understand that I am obligated to pay for all charges not paid by insurance. I also agree to pay reasonable attorney fees if my account is turned over to an attorney or collection agency.

Assignment and Release : I hereby authorize my insurance benefits to be paid directly to the physician and I am financially responsible for non covered services. I also authorize the physician to release any information required in the processing of this claim and all future claims.

Date:_______________ Signature:__________________________________________________