PLEASE COMPLETE THE FOLLOWING SECTION IF GUARANTOR IS DIFFERENT FROM PATIENT Last Name
First Name
Address Home Phone
Work Phone
MI City
State
Zip Code
Mobile Phone
Birth Date
Gender
PRIMARY INSURANCE
SECONDARY INSURANCE
Insurance Name
Insurance Name
Claims Address
Claims Address
City, State, Zip
City, State, Zip
Subscribers Name
Relationship to Patient
Gender M F
Subscribers Name
Group No.
ID#
Group No.
Subscribers Birth Date
Subscribers Birth Date
Effective Date
Patient’s Relation to Subscriber:
Patient’s Relation to Subscriber:
ID #
Self
Spouse
Child
Patient Co-Pay / Deductible: _______________
Other
Gender M
Self
Spouse
Amount Received today: _______________
Child
Credit Card
F
Other
Check
I authorize the release of any medical information necessary to process medical insurance claims for services rendered. I understand and agree that I am ultimately responsible for payment.
SIGNED________________________________________________________________ DATE ____/_____/_____
Cash
MISSION VIEJO FAMILY MEDICAL GROUP, A MEDICAL CORPORATION 26732 Crown Valley Pkwy Suite 461 Mission Viejo, CA 92691 949-347-2566 HOW MAY WE CONTACT YOU? We need to know how you would prefer to be contacted with your medical information. Please check all that apply: Home telephone: PH#
Yes
Message on home answering machine?
Yes
Work telephone: PH#
ext.
Message on work voicemail?
Yes
Cellphone: PH#
No
No
Yes
No
Yes
No
No
Message on cellphone voicemail?
Written communication?
Yes
No
Mailing Address May we have a conversation releasing your medical information with a family member or emergency contact? Yes
No
Please specify the persons allowed to receive medical information:
Name
Phone number
Relationship
Name
Phone number
Relationship
Patient Signature
Print Name
Date
You may modify this list at any time by presenting your request in writing to our office.
MISSION VIEJO FAMILY MEDICAL GROUP, A MEDICAL CORPORATION AUTHORIZATION FOR DISCLOSURE OF CONFIDENTIAL INFORMATION I hereby authorize and request: Dr.:
(please include first and last name)
Address: Phone: Fax: to furnish information or copy of my medical records (paper only, disc not accepted) to:
Dr. David R. Gonzalez 26732 Crown Valley Parkway, Suite 461 Mission Viejo, CA 92691 Phone 949-347-2566 · Fax 949-347-1606 Medical findings and treatment about my illness and/or treatment during the period from to
.
I understand that this is a required consent and I must voluntarily and knowingly sign this authorization before any records may be released and that I may refuse to sign, but in that event the records will not be released. I further release my physician from liability arising from the release of information to the individual(s)/agency designated herein. Print Name
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con calle 3, El CujÃ, Sector Valle. Lindo, Barquisimeto, Estado Lara,. Municipio Iribarren, Parroquia El cujÃ. Page 4 of 34. Alison Gonzalez diapositivas.pdf.
schedule of events culminating with the 2015-16 College Football Playoff Semifinal at the ... âFrank is a noted leader both in the firm and in the South Florida community,â ... practice in all offices, including the execution of processes and qua
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