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DR. GARY J. SCHMIDT, LLC Patient Information Form

Last Name:________________________________

First Name:

________________________

Middle Initial:

_____

Title: (circle one)

Mr.

Mrs.

Miss

Ms.

Dr.

Social Security Number:

-

-

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Date of Birth: Month__________

Day______

Year______

Gender: (circle one) Male

Female

Marital Status:

Single

Married

Divorced Widow/er

Life Partner

Address:

_____________________________________________________________

Suite/Apt. #

________________

C i t y : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

State:____________

Zip Code:

__________________

Phone Numbers: Home: (

_______)________-___________

W o r k : ( _ _ _ _ _ _ _ ) _ _ _ _ _ _ _ - _ _ _ _ _ _ _ _ _ _

Ext.

________

C e l l : ( _ _ _ _ _ _ _ ) _ _ _ _ _ _ _ - _ _ _ _ _ _ _ _ _ _ _

E-Mail:

________________________________________________________

IS THIS A VISIT DUE TO A MOTOR VEHICLE ACCIDENT?: YES

NO

A WORK COMP INJURY?:

YES

NO

Employment Status: (circle one)

Full Time

Part-Time

Retired Not-Employed

Student

E m p l o y e r : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Occupation:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Employer Address:

__________________________________________________________ Suite/Apt. #

________________

C i t y : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

State:

____________

Zip Code:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Primary Care Physician:

________________________________________

P h o n e N u m b e r ( _ _ _ _ _ _ _ ) _ _ _ _ _ _ _ _ - _ _ _ _ _ _ _ _

Referring Physician:

____________________________________________

P h o n e N u m b e r ( _ _ _ _ _ _ _ ) _ _ _ _ _ _ _ _ - _ _ _ _ _ _ _ _

Emergency Contact:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Ph

o n e : ( _ _ _ _ _ _ _ ) _ _ _ _ _ _ _ - _ _ _ _ _ _ _ _ _

Alternate Name: Not living with patient: First:

__________________________

Last:

________________________________

Primary Insurance:

_____________________________________________________

P h o n e : ( _ _ _ _ _ _ _ ) _ _ _ _ _ _ _ - _ _ _ _ _ _ _ _ _

Guarantors Name:

___________________________

Relationship:__________

Date of Birth: Month_____

Day____

Year____

ID Number:

___________________________________

Group Number:

__________________________________________

Secondary Insurance:

___________________________________________________

P h o n e : ( _ _ _ _ _ _ _ ) _ _ _ _ _ _ _ - _ _ _ _ _ _ _ _ _

Guarantors Name:

___________________________

Relationship:__________

Date of Birth: Month_____

Day____

Year____

ID Number:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Group Number:

__________________________________________

Unless you are a member of an insurance company that is contacted with Dr. Gary J. Schmidt, LLC (including verified workman’s compensation patients) full payment is expected on the day of the visit. All co-payments must be paid at time of service. Payment may be made by check, cash, or credit card. Further, I authorize the release of any information acquired in the course of my examination or treatment to my insurance company, other physicians and/or health care facilities in order to file a claim or provide for my care. I also authorize payment directly to and assign to Dr. Gary J. Schmidt, LLC any surgical/medical benefits. I understand that there may be a balance due from me after my insurance pas their portion. I understand that if my account is not paid when due, I will be responsible for all costs incurred in the collections process of my account. I further understand that my account will be reported to a credit bureau. A copy of this release shall be as valid as the original. Dr. Gary J. Schmidt, LLC does not deny benefits or services because of race, color, national origin, age, sec, and disability, religious or political beliefs. If you feel you have been discriminated against, you may file a Complaint of Discrimination with the Administrator of this facility. You will not suffer any penalty because you file a complaint. By signing this form I acknowledge that I am giving my permission to be examined and treated by the physician.

Date:

___________

Signature of Patient/Responsible Party:___________________________________________________

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