Patient Account Information

Name Account Number
Address Date of Service
City SSN
State Home Telephone
Zip Code Work Telephone
Primary Insurance Secondary Insurance
Medicare
MediCal/Medicaid
Do not fill in information in yellow block for Medicare or Medical/Medicaid. Medicare
MediCal/Medicaid
Do not fill in information in yellow block for Medicare or Medical/Medicaid.
Other Other
Policy # Policy #
Group # Group #
Address Address
City City
State State
Zip Code Zip Code
Phone # Phone #

Primary Physician Physician Telephone
Is the patients condition work related (current or previous)? Yes No
Is the patients condition related to an auto accident? Yes No

Please list any additional information that you believe will help get this claim paid.
By submitting this form you are authorizing the release of any medical information necessary to process the above account and any future trips. Additionally, you are requesting payment of government benefits for this and future trips.