WELCOME TO PAIN SPECIALISTS OF TEXAS!

 PATIENT INFORMATION:

NAME________________________________  BIRTHDATE________________   MARITAL STATUS _________________________

SOC. SEC #__________________________      SEX       F           M        

ADDRESS_______________________________  CITY___________________  STATE______ ZIP CODE______________________

 HOME PHONE________________________  CELL PHONE____________________ WORK PHONE_________________________

 REFERRING DOCTOR________________________  PHONE____________________  REASON____________________________

 
RESPONSIBLE PARTY:

NAME_______________________________  BIRTHDATE________________   SOC. SEC #_______________________________

RELATIONSHIP TO PT______________________ HOME PHONE______________________ CELL PHONE__________________

ADDRESS______________________________  CITY____________________  STATE_______ ZIP CODE____________________

EMPLOYER_______________________________________    WORK PHONE___________________________________________

INSURANCE PRIMARY

CARRIER NAME___________________________ TYPE________________ INSURANCE PHONE__________________________

CARRIER ADDRESS____________________________  CITY_________________STATE_____ ZIP CODE___________________

INSURED NAME_______________________________RELATIONSHIP TO PATIENT____________ BIRTH DATE____________

SOC. SEC #_____________________________  EMPLOYER________________________BUSINESS PHONE_________________

SUBSCRIBER ID________________________GROUP ID______________________ REFERRAL NEEDED     Y          N

REFERRAL # GIVEN_____________________________ FOR HOW MANY VISITS_____________________________

INSURANCE SECONDARY

 CARRIER NAME___________________________ TYPE________________ INSURANCE PHONE__________________________

 CARRIER ADDRESS____________________________  CITY_________________STATE_____ ZIP CODE___________________

 INSURED NAME_______________________________RELATIONSHIP TO PATIENT____________ BIRTH DATE____________

 SOC. SEC #_____________________________  EMPLOYER________________________BUSINESS PHONE_________________

 SUBSCRIBER ID________________________GROUP ID______________________ REFERRAL NEEDED     Y          N

 REFERRAL # GIVEN_____________________________ FOR HOW MANY VISITS_____________________________
 

EMERGENCY CONTACT

 IN CASE OF EMERGENCY NOTIFY___________________________________  RELATIONSHIP TO PATIENT________________

 HOME PHONE_________________________WORK PHONE______________________CELL PHONE_____________

 
ASSIGNMENT AND RELEASE:

I HEREBY AUTHORIZE ALL INSURANCE BENEFITS OTHERWISE PAYABLE TO ME TO BE PAID DIRECTLY TO PAIN SPECIALISTS OF TEXAS.  I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES, WHETHER OR NOT INSURANCE PAYS AND FOR ALL SERVICES RENDERED TO MY DEPENDENTS

 I ALSO AUTHORIZE PAIN SPECIALISTS OF TEXAS TO RELEASE INFORMATION TO SECURE PAYMENTS ON MY BEHALF.  I AUTHORIZE THE USE OF MY SIGNATURE TO BE USED ON ALL INSURANCE FORMS.

SIGNATURE OF PATIENT______________________________________________  DATE__________________________________

SIGNATURE OF AUTHORIZED PARTY, IF NOT PATIENT_________________________________________     DATE_____________