Patient Information Form
Diagnosis Date: Dx___________ Dx___________ Dx___________ Dx___________
Procedure (CPT Codes) ________________________________________________
Patient Information
Patient's Name______________________________Date of Birth_______________
Address ____________________________________________________________
City ________________________ State _______________________ Zip ________
Day Phone__________________________Evening Phone ____________________
SSN ______________________________________________ Gender ___ M ___ F
Marital Status: ____ Single ____Married ____Divorced____Widowed ___Separated
Employer Name_______________________________________________________
Employer Address_____________________________________________________
Work Phone___________________________Home Phone ____________________
Student Status: ______Full ______Part time Name of school: _________________
Responsible Party Information
*If you are the responsible party mark "self" and move down to "insurance information"
Patient's relationship to responsible party:_______self_______spouse ______child
Name_____________________________________Date of Birth_______________
Address ____________________________________________________________
City ________________________ State _______________________ Zip ________
Day Phone__________________________Evening Phone ____________________
SSN ______________________________________________ Gender ___ M ___ F
Marital Status: ____ Single ____Married ____Divorced____Widowed ___Separated
Employer Name_______________________________________________________
Employer Address_____________________________________________________
Work Phone___________________________Home Phone ____________________
Occupation __________________________________________________________
Insurance Information
(if you have more than two (2) insurance companies, please use the back of this form)
Insurance Co # 1: ____________________________________________________
Insurance Phone #: ___________________________________________________
Claims address: ______________________________________________________
City: ___________________________________State:________Zip:____________
Group or Policy #:_____________________________________________________
Effective Date: ________________________ Deductible: _____________________
Family Ded. $______________________ Ded. Remaining ____________________
Co-pay Amount: $_____________________________________________________
Insurance Co # 2: ____________________________________________________
Insurance Phone #: ___________________________________________________
Claims address: ______________________________________________________
City: ___________________________________State:________Zip:____________
Group or Policy #:_____________________________________________________
Effective Date: ________________________ Deductible: _____________________
Family Ded. $______________________ Ded. Remaining ____________________
Co-pay Amount: $_____________________________________________________
Assignment and Release
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I hereby assign, transfer and set over to Microcurrent Shoes all of my rights, title, and interest to my medical reimbursement benefits under my insurance policy. I authorize the release of any medical information needed to determine those benefits. This authorization shall remain valid until written notice is given by me revoking said authorization. I understand that I am financially responsible for all charges whether or not they are covered by insurance. |
Patient's Signature: ___________________________________ Date___________
Print out (CTRL P TO PRINT) and mail or fax form to
Microcurrent Shoes.
2200 N.E.2nd ave
Boca Raton, FL, 33432
Phone: 561-251-0332
FAX: 561-251-0332
