Stephan Jankowski O.D. 93 S. Morse St. Sandusky, MI 48471 (810) 648-2456
Patient Information Form |
Patient Information Forms:
Please print out the the Patient information page (below) and the Medical History form. Fill in the blanks and bring them with you at the time of your appointment
PATIENT INFORMATION
(Please fill out and bring completed form with you on the day of your appointment)
PLEASE PRINT
1. Name ____________________________________________ Male _______Female _____
2. Address:____________________________________________________________________
Street City State
3. Date of Birth _______________________ Age ________ SS#______________________
4. Telephone (Daytime)__________________________ (Evening) ____________________
5. Occupation ______________________________ Employer ________________________
Single ________Married__________Divorced__________ Widowed_____________
6. Name of Spouse _________________ SS# _______________ Employer _____________
7. Person to Contact in an Emergency
Name __________________________________ Telephone ______________________
Address _________________________________ Relationship ____________________
8. Type of Insurance _______________________________ Policy # __________________
9. Secondary Insurance ____________________________ Policy # __________________
10. Family Physician _________________________________Telephone _______________
11. Whom may we thank for referring you to this office? ____________________________
12. Your Email address _______________________________________________________
ALL INSURANCE PATIENTS:
ASSIGNMENT OF BENEFITS FOR PHYSICIAN SERVICES / OPHTHALMIC MATERIAL: I assign all rights to benefits, insurance proceeds, settlement payments, or judgements to which I may be entitled for doctors services and/or ophthalmic material: I agree to pay any and all amounts that are not covered by my insurance.
Signature: ___________________________________________Date: _________________
MEDICARE PATIENTS (SIGNATURE FORM): I certify that the information given by me in applying for payment under title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Health Care Financing Administration or its intermediaries or carriers information needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for covered Medicare services to the physician or organization furnishing the service or authorize physician or organization to submit a clam to Medicare for payment to me. I request that payment under the medical insurance program be made to either me or the party who accepts assignment.
Medicare Patient’s
Signature: ___________________________________________Date: _________________