EILEEN C. COMIA, M.D. LLC
DATE NEW UPDATE
PRIMARY CARE PROVIDER PHARMACY NAME
REFERRED BY PHARMACY PHONE
HIPAA AUTHORIZATION CODE
PATIENT INFORMATION
Acct Numbe
LAST FIRST MI. BIRTHDATE SEX
M F
ADDRESS CITY STATE ZIP
MARITAL
STATUS
HOME PHONE WORK PHONE
CELL PHONE EMAIL ADDRESS
PATIENT SOCIAL SECURITY # Preferred Contact Phone
RACE AMERINDIAN BLACK HISPANIC ASIAN WHITE
ETHNICITY HISPANIC NON-HISPANIC PREFERRED LANGUAGE:
EMPLOYER/SCHOOL OCCUPATION
EMPLOYER'S ADDRESS CITY STATE ZIP START DATE
NEXT OF KIN/EMERGENCY CONTACT
(PERSON NOT LIVING WITH YOU)
RELATIONSHIP PHONE
PARENT/GUARANTOR INFORMATION- PERSON FINANCIALLY RESPONSIBLE FOR BILL
LAST FIRST MI.
PARENT (IF PATIENT A MINOR)
BIRTHDATE
SPOUSE
OTHER ________________________
ADDRESS
(IF DIFFERENT FROM PT.)
CITY STATE ZIP SOCIAL SECURITY #
HOME PHONE WORK PHONE CELL PHONE EMAIL ADDRESS
EMPLOYER/SCHOOL OCCUPATION
EMPLOYER'S ADDRESS CITY STATE ZIP START DATE
INSURANCE INFORMATION
Please complete all information to ensure accuracy in claim submission
INSURANCE COMPANY #1 POLICY/MEMBER ID # GROUP # COPAYS
SPEC
$
PRIM
$
POLICY HOLDER ADDRESS
(IF DIFFERENT)
SSN RELATION TO INSURED
SELF
SPOUSE
DOB CITY ST ZIP
CHILD
OTHER
INSURANCE COMPANY #2 POLICY/MEMBER ID # GROUP # COPAYS
SPEC
$
PRIM
$
POLICY HOLDER ADDRESS
(IF DIFFERENT)
SSN RELATION TO INSURED
SELF
SPOUSE
DOB CITY ST ZIP
CHILD
OTHER
INJURY INFORMATION
IS INJURY
WORK RELATED
AUTO RELATED CLAIM #_________________ DATE OF INJURY
PATIENT/GUARANTOR SIGNATURE DATE
(PARENT IF PATIENT IS A MINOR)
I, THE PATIENT OR GUARANTOR, CERTIFY THAT THE INFORMATION ON THIS FORM IS TRUE TO THE BEST OF MY KNOWLEDGE. I ACCEPT
RESPONSIBILITY FOR THE MEDICAL CHARGES INCURRED BY THE PATIENT AND AGREE TO PAY ALL BILLS AT THE TIME OF SERVICE UNLESS OTHER
ARRANGEMENTS ARE MADE. I AUTHORIZE PHYSICIAN AND PRACTICE TO RELEASE ANY INFORMATION TO PROCESS INSURANCE CLAIMS. I ALSO
AUTHORIZE MY INSURANCE CLAIMS TO BE PAID DIRECTLY TO THE PRACTICE OR ITS REPRESENTATIVE. I UNDERSTAND THAT IT IS MY RESPONSIBILIT
TO CONTACT BY INSURANCE AND PRIMARY CARE PROVIDER TO ENSURE THAT ANY REQUIRED REFERRALS ARE INITIATED. I UNDERSTAND THAT ALL
SERVICES NOT COVERED BY MY INSURANCE WILL BE MY RESPONSIBILITY.
