Please print this form, complete it, and bring it to your visit.
CLIFFORD W. BASSETT, M.D.
Allergy & Asthma Care of New York
Midtown Office |
Gramercy Park Office 381 Park Ave South, Suite 1020 New York, NY 10016 Tel: 212-260-6078 |
Financial District 150 Broadway, Suite 1601 New York, NY 10038 Tel: 212-964-1295 |
Mercer Street Medical 77 Mercer Street New York, NY 10012 Tel: 212-274-0800 |
Brooklyn Heights 142 Joralemon St, Suite 3A (near corner of Clinton St) Brooklyn Heights, NY 11201 Tel : 718-246-3700 |
Patient's Name: __________________________ Street Address: __________________________ City: ___________________________________ State: _______________ Zip: ___________ Social Security Number: ____________________ |
Date of Birth:__________Age:
_______ Telephone (Home): _____________________________ Telephone: (Work): _____________________________ Cell Phone/Pager: ______________________________ Email Address: ________________________________ |
Patient's Employer/Address: _________________________________________________________________
Referring Physician/Address: ________________________________________________________________
Additional Physician Reports to: ______________________________________________________________
Sex: [ ]Male [ ]Female Marital Status: [ ]Married [ ]Single [ ]Divorced [ ]Widow
Chief complaint: _____________________________________
Other Referral Sources: ________________________________
Emergency Contact:____________________________________ ____________________________________
|
PRIMARY INSURANCE Address: _________________________________ ID or Policy #: ______________ Group #: __________ Effective date of insurance: ______________________ Who is Subscriber: (check one) [ ]Self [ ]Spouse [ ]Parent [ ]Other: _____________ If Subscriber is other than Self, complete following: Subscriber's name: ____________________________ Sex: [ ]Male [ ]Female Address: _________________________________ Date of birth: ________________________________ Social security number: ________________________ |
SECONDARY INSURANCE Address: _________________________________ ID or Policy #: ______________ Group #: __________ Effective date of insurance: ______________________ Who is Subscriber: (check one) [ ]Self [ ]Spouse [ ]Parent [ ]Other: _____________ If Subscriber is other than Self, complete following: Subscriber's name: ____________________________ Sex: [ ]Male [ ]Female Address: _________________________________ Date of birth: ________________________________ Social security number: ________________________ |
AUTHORIZATION INFORMATION (Assignment of Benefits)
I hereby assign to ___________________________any insurance
or other third-party benefits available for health care services provided
to me. I also understand that if benefits are assigned, or if by contractual
arraignment, payment to the practice will be made by any insurance, that
I am responsible for any co-payments and deductibles and that these amounts
are due at the time services are rendered. I understand that the above
practice has the right to refuse or accept assignment of such benefits
(except where prohibited by contract). I also understand that in the event
that services rendered are not covered under by "insurance"
I will accept financial responsibility for all services provided to me.
If benefits are not assigned to this practice, I agree to forward to the
practice, all "insurance" payments that I receive for services
rendered to me immediately upon receipt and/or to remake payment, in full,
for the services rendered to me (depending upon the assignment) at the
time.
Signature: _______________________________________________
Date: ___________________
FOR RELEASE OF INFORMATION
I authorize the release of any medical information or
other information as is necessary to process this claim based upon the
HIPAA Notice of Privacy Practices, informaiton provided to me under separate
cover. This information is on file as a permanent record and may be amended
as is necessary.
Signature: ________________________________________________
Date: ____________________