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500 East 9th Ave. Suite 710 Denver, Colorado 80220 Phone: (303) 320-7826 FAX: (303) 320-7842 |
Please print and fill out prior to your appointment
Dr. Barbara Schwartzberg Dr. Joyce Moore Lisa S. Weinstein M.D.
Last Name:________________________ First Name:_____________________
M.I.______
Address:___________________________________________________________________
City:____________________________ State:____________
Zip code:________________
Home Phone:____________________________ Work
Phone:_________________________
SS#___________________________ Employer: ___________________________________
Date of Birth:__________________
Age:________________ Sex: M
F
RESPONSIBLE PARTY: Self
Wife Husband
Parent Other_____________________
Name and Address:__________________________________________________________
SS#____________________________ Phone:____________________________________
Referring Doctor's Name:______________________________ Telephone:_____________
Primary Care Physician:_______________________________
Telephone:_____________
In case of emergency please notify (provide individual not living with patient)
Name:_______________________________
Relationship:_________________________
Address:________________________________________ Telephone:________________
Reasons for today's visit:______________________________________________________
INSURANCE INFORMATION: PLEASE PROVIDE YOUR CARD FOR COPYING
Primary Insurance Name:_______________________________________ Insured
DOB:
Member ID#___________________________
Group#_____________________________
Address:___________________________________________________________________
City:_________________________
State:__________ Zipcode:____________________
Work Comp: YES NO
Claim #_________________________________________________
Date of Injury:____________________________________________
Medicare Supplement Insurance Name: _________________________ID# ____________
Address:__________________________________________________________________
| Our office cannot accept responsibility for collecting your
insurance payments or referrals. Each patient, not the insurance company is responsible for payment of all charges incurred in our office. If you belong to a group plan that we participate with, we will bill your insurance directly for 90 days, but you are still liable for any deductible, co-payment, or charges that are not covered. WSC will bill secondary insurance only if Medicare is primary. The patient is responsible for all secondary insurance payments and authorizations, not our office. If your account goes to a collection agency, a collection agency charge may be added to your account balance, and you will not be allowed to return as a patient. I authorize release of any information necessary to process the claim. I authorize benefits to be made payable to Western Surgical Care, P.C.. I have read and understand the above. |
PATIENT or RESPONSIBLE PARTY: ______________________________________
DATE: ______________________________________