Patient Information
Last Name ________________________________ First Name _______________________________ MI ________

Date of Birth ____________________ Age ___________ Sex M FPatient Social Security # ________________

Marital Status S MDW SEPEmployment Status 1. FT2. PT3. None4. Self5. RetiredFT Student Home
Patient Mailing Address __________________________________________________ Phone (_____) __________
Work
City _________________________________ State ____________ Zip ____________Phone (_____) ___________

Person Responsible for this Account (If same as above, need only indicate "same")
Last Name _________________________________ First Name ______________________________ MI ________
Date of
Relationship to Patient SpouseParentGuardian OtherBirth _____________ SS# ______________________

Mailing Address ______________________________________________________________________________
HomeWork
City/State/Zip _____________________________________Phone (____)____________ Phone (____)__________

Employer ____________________________________________________________________________________
Full name of Referring Doctor _______________________________________ Phone_______________________
City/
Address _____________________________________________________State/Zip ________________________

Insurance Information (Please provide us with your current insurance card(s).)
Name of Insurance Company _____________________________________________ Medical / Dental (please circle)

Group # _________________________________ Contact or ID # _______________________________________
Insurance
Address ________________________________________________________ Phone _______________________
City/Policy Holder's
State/Zip ______________________________________________________ Employer ______________________
Relationship
Policy Holder ________________________________ DOB ____________________ to Patient ________________

Policy Holder Address _________________________________________________________________________
---------------------------------------------------------------------------------------------------------------------------------------------
Name of Insurance Company ____________________________________________ Medical / Dental (please circle)

Group # _______________________________ Contact or ID # ________________________________________
Insurance
Address ______________________________________________________ Phone _______________________
City/Policy Holder's
State/Zip _____________________________________________________ Employer ______________________
Relationship
Policy Holder _______________________________ DOB ____________________ to Patient ________________

Policy Holder Address _________________________________________________________________________
I hereby request and authorize direct payment of insurance benefits to Maplewood Oral and Maxillofacial Surgery. I understand that my insurance is an agreement between my insurance company and me. I also understand that I am responsible for my balance regardless of insurance. I also understand that if I have no insurance, I will be required to pay the cost of the services at the time I am seen and that finance charges will accrue on balances over 60 days. This form also authorized the release of any medical information necessary to process this claim and to my referring physicians and other providers involved in my care.

Date _______________ Signed ________________________________________ Date ________________ Signed _____________________________________
Medicare Authorization: I request that payment of authorized Medicare benefits be made to me or on my behalf to Maplewood Oral and Maxillofacial Surgery, for any services furnished me by that clinic. I authorized any holder of hospital or medical information about me to release to HCFA and its agents any information needed to determine these benefits or the benefits payable for related services. I permit a copy of this authorization to be used in place of the
Date ___________________ Signed ______________________________________