Rockland Orthopedics & Sports Medicine, P.C.
NO FAULT
PATIENT INFORMATION SHEET
Patient Name______Date of Birth ______/______/______
First Middle Last
Gender: Male _____ Female _____ Social Security #______-______-______
Home Address: ______
City ______State ______Zip ______
Mailing Address (if different) ______
Home Phone (______) ______- ______Cell Phone (______) ______- ______
Marital Status: S____ M____ D____ W____ Occupation ______Primary Physician ______
Guardian’s Name (if a minor)______Relationship to Patient ______
Patient/Guardian’s Employer ______Work Phone (______) ______- ______
Employer’s Address ______
Spouse’s Name ______
Spouse’s Employer ______Spouse’s Work Phone (______) ______- ______
Spouse’s Employer’s Address______
If full-time student Indicate school currently attending ______
Emergency Contact ______Phone (______) ______- ______
NO FAULT INFORMATION - FILL OUT IF YOU WERE INJURED IN A CAR ACCIDENT
Insurance Company: ______
(FOR VEHICLE YOU WERE IN AT TIME OF ACCIDENT)
Insurance Company Address: ______Phone (______) ______- ______
______File #: ______
CITY STATE ZIP
Date of Accident: ______/______/______Policy #: ______Claim #:______
Name of Insured (If other than Claimant): ______
Address of Insured: ______Date last Worked: ______/_____/______
______Location of Accident: ______
CITY STATE ZIP
History of Accident: ______
______
Attorney: ______Firm Name:______
Address: ______Phone (______) ______- ______
______
CITY STATE ZIP
In consideration of services rendered to me, I hereby authorize payment directly to Rockland Orthopedics & Sports Medicine, P.C., of any and all first party no-fault automobile insurance benefits to which I may otherwise be entitled for services rendered by the provider, but not to exceed the provider’s regular charges for such services.
In the event the provider’s charges are outstanding and I fail to file an application for benefits under the New York State No-Fault Insurance Law, I hereby authorize the provider to file such claim in my behalf so that the provider may realize payment of its charges. I understand that, if the provider does not receive payment from the insurer, I am personally responsible for the payment of the provider’s charges.
Signed: ______
I hereby authorize Rockland Orthopedics & Sports Medicine, P.C. to release medical Information on my injury to the no-fault carrier______.
Signed: ______
PRIMARY INSURANCE CARRIER ______
Policy # ______Group # ______Phone (______) ______-______
Address ______
Guarantor’s Name ______Relationship to Patient ______
Guarantor’s SS# ______-______-______Guarantor’s Date of Birth ______/______/ ______
Employer ______Employer’s Phone (______) ______-______
SECONDARY INSURANCE CARRIER ______
Policy # ______Group # ______Phone (______) ______-______
Address ______
Guarantor’s Name ______Relationship to Patient ______
Guarantor’s SS# ______-______-______Guarantor’s Date of Birth ______/______/ ______
Employer ______Employer’s Phone (______) ______-______
ASSIGNMENT OF BENEFITS: I authorize payment of benefits directly to Rockland Orthopedics & Sports Medicine for services rendered. For purposes of payment or audit. I authorize the release of any information acquired in the course of my examination or treatment, I understand that I am financially responsible to the provider for charges not covered by my benefit plan.
SIGNED: ______DATE: ______
I understand that I am personally responsible to the provider for payment for services rendered.
SIGNED: ______DATE: ______
BILLING INFORMATION ACKNOWLEDGMENT
I ______, understand and agree that it is my responsibility to be familiar with my medical insurance policy. I agree to provide correct referrals and authorizations. I will pay in full at the time of service if I do not have this information, and I accept responsibility for payment of the entire bill.
Furthermore, I accept and understand that any balances not covered by my insurance(s) are to be paid upon receipt of my bill. If my insurance company has not provided payment, I am responsible for the balance and for contacting the insurance company.
I agree that if my balance due to Rockland Orthopedics and Sports Medicine, PC remains unpaid I will be responsible for interest on the unpaid balance at the rate of 18% per annum, plus cost of collection and reasonable legal fees.
______
Name Signature Date