Rockland Orthopedics & Sports Medicine, P.C

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