Patient Information Page 2
NEAREST RELATIVE INFORMATION
(This information will be used when we are unable to contact the patient.
For example. If your doctor is called out in an emergency and your appointment must be canceled)
Name: ___________________________________________________________________________________________
Address: ________________________________City: ___________________________ State: ______ Zip: ____________
Home Phone: __________________________________Work Phone: ___________________________________
INSURANCE INFORMATION (PLEASE CHECK ONE AND COMPLETE INFORMATION BELOW.)
Private Insurance (Group). _______ Worker's Comp: _______ Auto Accident: _______ Individual:. Other. ________
Is this visit due to:
Injury on the job? ________ Date of injury ___________ / Auto Accident? _________ Date of injury ___________
Insurance Company Name: _________________________________________________________________________
Phone:_______________________________________ W.C. Adjuster: _____________________________________
Address: ________________________________City: ___________________________ State: ______ Zip: ____________
Policy Number: ___________________ Group Number: __________________ Policy Holder: ___________________
Patient's Relationship to Policy Holder:_________________________________________________________________
Other Insurance Authorization: _________________________________________________________________________
SECONDARY INSURANCE
Insurance Company Name: ___________________________ Group Insurance: __________ Individual: __________
Phone:____________________________________________________________________________________________
Address: ____________________________City: ___________________________ State: ______Zip: ____________
Policy Number: ___________________ Group Number: __________________ Policy Holder: _____________________
Have you at this time engaged the services of an attorney in connection with your present illness? Yes___ No ___
If "Yes", who is the attorney? ________________________________________ Phone: _________________________
If "No", do you anticipate retaining an attorney?Yes _______No _______
AUTHORIZE TO RELEASE INFORMATION: I hereby authorize the above named agency to release any treatment
information requested by attorneys, physicians, insurance companies, employers, health care providers, or any other
entity which may be concerned with the payment of charges incurred for the treatment services of Calvon Voong, M.D.
(Date) _______________Patient (Parent or Guardian if patient is a minor) _________________________________
ASSIGNMENT OF INSURANCE BENEFITS: I hereby authorize payment directly to Calvon Voong, M.D. of the Insurance
benefits otherwise payable to me. I am responsible for payment of all services rendered by Calvon Voong, M.D. not
covered by insurance.
(Date) _______________Insured: _________________________________________________________________