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PLATTE VALLEY HEARING CENTER INC Please Print Clearly
Today’s Date _______________
Patient Name __________________________________ Date of Birth ___/____/_____ Age ________ Address ______________________________________________________________________________ City _________________________________ State _______________ Zip_________________ Home Phone (_____) ______-‐__________ Work Phone (____) _______-‐___________ Sex M F Cell Phone (_____) ______-‐____________ Email ____________________________________________ Employer __________________________ Marital Status _______ Social Security #________________ Is your Condition Accident related? Y N Auto Work Other ______________ Date of accident______________
Spouse/Parent/Guardian ____________________________________ Home Phone (_____) __________ Address ________________________________ City _______________ Work Phone (_____)__________ Family Physician_________________________________ Address________________________________ How did you hearing about our office? _____________________________________________________ Emergency Contact NOT living with you _____________________________ Phone (______)__________ Would you like to receive our newsletter? __________________ Be contacted by Email: Y N INSURANCE INFORMATION Primary Insurance __________________________________ Subscriber # ________________________ Group # ___________________________________ Name of Insured ____________________________ Relationship to Patient _________________________Birthdate of Insured _______/________/_______ Social Security # of Insured ________________________ Address _______________________________ Employer _______________________________ Home Phone _________________ Work ____________ Secondary Insurance __________________________________ Subscriber # ______________________ Group # ___________________________________ Name of Insured ____________________________ Relationship to Patient _________________________Birthdate of Insured _______/________/_______ Social Security # of Insured ________________________ Address _______________________________ Employer _______________________________ Home Phone _________________ Work ____________ Platte Valley Hearing Center, Inc Authorization and Release I hereby assign to Platte Valley Hearing Center all benefits for medical expenses. I hereby agree to pay any and all charges that exceed or that are not covered by insurance, including charges sent to collection agencies. I authorize Platte Valley Hearing Center to release my medical records and all medical information requested by my insurance company or Workman’s Compensation carrier. I also authorize Platte Valley Hearing Center to release information to any hospital or physician I may be referred to by this office.
Patient/ Guardian Signature ____________________________________Date _____________________