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:  _________________________________________________________________