Quality Family Physicians

SHORE COMMUNITY MEDICAL, LLC

Patient Information Record

(Please Print)
Today’s date: / Physician: Thomas F. Kelly, MD,MPH.

PATIENT INFORMATION

Patient’s last name: / First: / Middle: / q Mr.
q Mrs. / q Miss
q Ms. / Social Security #:
Birth date: / / / Age: / Sex: q M q F / Marital status : Single / Mar / Div / Sep / Wid / Part
Street address: / City, State, Zip:
Home Phone: / Work Phone: / Cell Phone: / Other Family Seen Here:
E-Mail Address:

INSURANCE INFORMATION

(Please give your insurance card to the receptionist.)
Name of primary insurance:
Subscriber’s name: / Subscriber’s S.S. no.: / Birth date: / Group no: / Policy no: / Co-payment:
/ / / $
Patient’s relationship to subscriber: / q Self / q Spouse / q Child / q Other: ______
Name of secondary insurance (if applicable):
Subscriber’s name: / Subscriber’s S.S. no.: / Birth date: / Group no: / Policy no: / Co-payment:
/ / / $
Patient’s relationship to subscriber: / q Self / q Spouse / q Child / q Other: ______

IN CASE OF EMERGENCY

Name of friend or relative: / Relationship to patient: / Home phone no.: / Work phone no.:
( ) / ( )

I hereby assign all medical and/or surgical benefits to include: Medicare Major Medical, Blue Cross Major Medical, PA Blue Shield, and all other Blue Shield plans to which I am entitled, including Private Insurance and any other Health Plan to: Shore Community Medical, LLC. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I hereby authorize said assignee to release all information necessary to secure payment.

I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES WHETHER OR NOT PAID BY MY INSURANCE CARRIER.

I authorize use of this form for all my insurance submissions.

I authorize release of information to my insurance company.

I authorize my doctor to act as my agent in helping me obtain payment from my insurance company.

I understand that I am responsible for obtaining any referrals that are needed.

I understand that any or all of my medical information may be used for blinded-data research in which none of the data will be linked to my identity. I understand that my medical information may be electronically submitted to any or all of my treating physicians, hospitals and/or healthcare entities.

Signed: ______Relation to Patient: ______Date: ______