Intake Form

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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  _____________________