PATIENT’S NAME: ___________________________________ SEX: oMALE oFEMALE AGE: ___________

LAST FIRST MIDDLE

ADDRESS: ________________________________________________________________________________________

CITY STATE ZIP

CIRCLE THE

PREFERRED-- CELL: ( ) ________________ WORK TEL: ( ) ______________HOME: ( )____________

BIRTHDATE: ___________/____________/__________ SOCIAL SECURITY #: ___________-________-_________

E-MAIL (used for lab results)_________________________________________ DRIVER’S LIC. #: ____________________

MARITAL STATUS: (MARRIED____ SINGLE____ DIVORCED______ LIVING TOGETHER_______________ )

OCCUPATION: ____________________________________________________________________________________

EMPLOYER: ______________________________________________________________________________________

WORK ADDRESS: _________________________________________________________________________________

CITY STATE ZIP

NEXT OF KIN OR EMERGENCY CONTACT: ___________________________ TEL: ( ) _____________________

RELATIONSHIP: ___________________________________________________________________________________

REFERRAL SOURCE: oINS. CO WEBSITE oCEDARS-SINAI oTMS WEB oDR.____________________

oPATIENT ___________________ oDR. SARNO oATTORNEY ___________________ OTHER:___________

INSURANCE INFORMATION: oPPO oWORK COMP oPI oMEDICARE oCASH/CREDIT CARD/CHECK

CARRIER’S NAME: ___________________________________________________________ (YOUR CARD WILL BE COPIED)

ASSIGNMENT OF BENEFITS:

ASSIGNMENT OF BENEFITS/FINANCIAL RESPONSIBILITY: I hereby authorize payment directly to the Provider. I understand that my insurance policy is a contract between myself and my insurance provider and I agree to be financially responsible for non-covered services. The Provider will file my insurance claim only as a courtesy. I understand that if I fail to cancel an appointment with 24 hours notice that I will be charged a fee and that insurance companies typically do not pay this fee; it is my responsibility alone. The fee will typically be $30-$100. I understand that I may be charged for completion of forms by the doctor. I understand that failure to pay my bills promptly may result in interest or penalty charges, dating back to the first day the payment was due.		MEDICARE FINANCIAL RESPONSIBILITY: I understand that the Provider as a Medicare provider is entitled to collect my 20% co-insurance and unfulfilled deductible amount of the Medicare approved service. The Provider accepts assignment for its Medicare patients. I acknowledge that any lab tests not covered by medicare that are ordered by this office are my responsibility and will be billed directly to me.
AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize the Provider to release any information to insurance companies required to process my claim. I have read the doctor’s HIPAA notice and understand the priority the office places upon patient confidentiality. GENERAL: I agree that all of the above shall apply to Dr. Schechter’s other office, as well.		REFERRAL INFORMATION: I understand that I am ultimately responsible to check on any referral doctor or facility and determine if he/she/it is a provider for my PPO insurance and whether any preauthorization is required.
	Patient’s Signature		Date

Updated 8 07