testing 20 June Step 3 - Amarillo Bone & Joint Clinic, PLLC


                
 
 
                        Date
                            
                            MM slash DD slash YYYY
                        
                        
Age 
Gender
			
					
					Male
			
			
					
					Female
			
Patient Name 
Address 
City 
State 
Zip 
Home Phone
Mobile
Email
                            
                        
Social Security Number 
Date of Birth
                            
                            MM slash DD slash YYYY
                        
                        
Race 
Ethnicity 
Primary Language 
Employer/School 
Occupation 
Employer/School Address & Phone 
Marital Status
			
					
					Single
			
			
					
					Married
			
			
					
					Widowed
			
			
					
					Divorced
			
RESPONSIBLE PARTY
Legal Name 
Relationship to Patient 
Social Security Number 
Date of Birth
                            
                            MM slash DD slash YYYY
                        
                        
Address 
Phone Number
Employer Name & Phone 
EMERGENCY CONTACT
Legal Name 
Relationship 
Address 
City 
State 
Zip 
Home Phone
Mobile
FAMILY ACCOUNTS
Do you have other family members in your household being treated at ABJC?
			
					
					Yes
			
			
					
					No
			
Name and Birthdate(s) 
INSURANCE INFORMATION
Insurance Company 
Policy Holder’s Name/Relationship 
Date of Birth
                            
                            MM slash DD slash YYYY
                        
                        
Policy # 
Group # 
Name as it appears on insurance card 
Secondary Insurance 
Policy Holder’s Name/Relationship 
Date of Birth
                            
                            MM slash DD slash YYYY
                        
                        
Policy # 
Group # 
Name as it appears on insurance card 
I authorize release of any medical or other information necessary to process this claim, including the appeal of claims for payment on my behalf.
I understand that services rendered today are my financial responsibility. Insurance is filed as a courtesy to you; there may be a difference between your benefits and fees.
I assign payment of medical benefits to: Amarillo Bone & Joint Clinic, J. Brian Sims, MD, PA, Brad Veazey, MD, PA, Toby Risko, MD, PA, Joshua North, MD, PA, Todd Bradshaw, MD, PA, and/or Creed Paris, MD, PA.
Hidden
I authorize release of any medical or other information necessary to process this claim, including the appeal of claims for payment on my behalf.
Signature 
Relationship