Patient Profile

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PATIENT INFORMATION
Name
Email
Sex
Address
Date of Birth
Social Security #
City / State
Marital Status
Single
Married
Divorced
Phone
Referring Physician
Primary Physician
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PATIENT EMPLOYMENT
Employment
Employed
Retired
Other
Employer
Phone
Contacts
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GUARANTOR
Guaranter
Same as patient
Name
Address
Date of Birth
Social Security #
Phone
Employer
City / State
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Primary Insurance
Primary Insurance
Same as patient
Same as Guaranter
other
Insured Party
Insured Phone
Company
Relationship to Patient:
Social Security #
Insured ID
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SECONDARY INSURANCE
Secondary Insurance
Same as patient
Same as Guaranter
other
Insured Party
Insured Phone
Date Of Birth
Company
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I hereby authorize direct payment of surgical/medical benefits to GI Consultants, LLC for services rendered by him/her in person or under his/her supervision. I understand that I am financially responsible for any balance not covered by my insurance.
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I hereby authorize GI Consultants, LLC to release any medical or incidental information that may be necessary for either medical care or in processing applications for financial benefit.
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I certify that the information given by me in applying for payment is correct. I authorize release of all records on request. I request that payment of authorized benefits be made on my behalf. A photocopy of these assignments shall be valid as the original.
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