Last Name __________________________________ Firs t ____________________________________ Middle______________________

Address ________________________________________________________________________________________________________

Ci ty_________________________________________________________ State ________________ Zip Code ______________________

Home Phone _____________________________ Cell Phone ___________________________ Work Phone ________________________

Soc. Sec. _______________________________ D.O.B _____/______/_____ Age ______ Sex ______Marital Status___________________

Email Address _________________________________________ Referring Physician___________________________________________

Spouse Name _____________________________________________ Social Securi ty #_________________________________________

Phone #_______________________________________________ Spouse Employer ___________________________________________

IN CASE OF EMERGENCY (PERSON NOT RESIDING WITH PATIENT)

Name _________________________________________________ Relationship to Patient ___________________________________

Phone # _______________________________________________

HEALTH INSURANCE

Primary Insurance ___________________________________________________________Phone ________________________________

Policy # ________________________________________ Group# __________________Subscriber’s Name_________________________

Relationship to Subscriber _______________________________Social Securi ty # _______________________D.O.B._________________

Secondary Insurance____________________________________________________ Phone____________________________________

Policy #_____________________________Subscriber’s Name________________________ Relationship to Subscriber_______________

Were you involved in an accident: ____Yes____ No Date of Injury: _____/_____/_____

Please circle one Auto / WC / Miscellaneous Which State: ___VA____DC____ MD or _____ Other___________

WORKERS COMPENSATION OR PERSONAL INJURY INFORMATION

Insurance Name_____________________________________________ Phone#: __________________________________

Adjustor/ Case Manager Name: ________________________________________Phone #: _________________________

Claim #: _____________________________________ Date of Injury: ___________________________________________

3rd Party Insurance Name: ____________________________________Phone #: __________________________________

Adjustor/ Case Manager Name: ____________________________________Phone #: ______________________________

Claim #:_____________________________________________________________________________________________

AUTO INSURANCE/ MED PAY

Auto Ins./Medpay Company: ____________________________________________________ Phone #: ___________________________

OR Auto Ins ./Lien Company: _______________________________________________________ Phone #: ________________________

Claim Number: ____________________________________ Name of Adjuster: ______________________________________________

Adjuster Phone #: _____________________________________ Date of Injury: ____________________________________

ATTORNEY INFORMATION

Name: ______________________________________________ Phone #___________________________ Fax#_____________________

Please rememb er that Insurance is considered a method of reimbu rsing the patient for fees paid to the doctor and is not a sub stitute for payment. Some companies may p ay

fixed allowances for c ertain proc edures; th ey sometimes ref er to as “R easonable and customary fees.” We do not accept this as payment in full (unless oth erwise restr icted by law or agreement we may have with your insurer). Also some of the insuranc e companies only pay a p ercentage of the charge. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insuranc e. IN ORD ER TO C ONTROL YOUR COST OF BILL INGS, WE D O REQU EST THAT OUR CH ARGE FOR OFFIC E

VISITS BE P AID AT THE IN ITIATION OF EACH VISIT . In the event th e account is turn ed over for collections, th e collection f ees and /o r legal fees, including attorn ey f ees, s hall b e your responsibility. I hereby assign all medical and /or surgical benefits to include major medical benefits to which I am entitled, M edicare, private insurance and oth er health

plans to the facility listed in th e top h ead er of this page. This assignment will remain in eff ect until revoked by me in wri ting. A photocopy of this assign ment is to b e considered as valid as an original . I h ereby autho rize said assignee to releas e al l information nec essary to secure the payment , via fax t ransmittal or h ard copy.

Patient/Parent or Legal Guardian Signature ____________________________________________ Date ________________________

How did you hear about us? __________________________________________________________________

PAYMENT OPTIONS (Please check mark the payment option you are using):

PATIENT INFORMATION