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Associates in Ear, Nose and Throat of Greater Nashua
Patient’s Name______________________________________ Primary Care Physician________________
Street or PO Box________________________________________________________________________
City____________________________State_____________Zip__________________________________
Telephone______________________Sex______Age________Date of Birth________________________
Social Security #____________________________________________Marital Status_________________
Medications Allergic to__________________________________________________________________
Employed by___________________________________________Telephone_______________________
Employer’s Street or PO Box______________________________________________________________
City_________________________________State__________Zip________Occupation_______________
Parent/Guardian (if patient is under 18)
Name_____________________________________________________Relationship__________________
Address_______________________________City________________State________Zip______________
Social Security #_____________________Home Phone_______________Work_____________________
Phone________________
Employed by___________________________________________________Telephone_______________
Employer’s Street or PO Box_____________________________________Occupation________________
City_____________________________________State____________Zip__________________________
In Case of Emergency
Name___________________________________________________Relationship____________________
Address____________________________City_________________State__________Zip______________
Phone______________________________
Insurance Information
Name of Primary Insurance Company_______________________________________________________
Policy Holder’s Name_________________________________________Relationship_________________
Name of Secondary Insurance Company_____________________________________________________
Policy Holder’s Name________________________________________Relationship__________________
I understand that health insurance is designed to help me meet the cost of medical service, but the responsibility for payment is mine. I authorize release of any medical information necessary to process my insurance claims. I authorize direct payment of benefits to Associates in Ear, Nose and Throat of Greater Nashua . A photocopy of this authorization shall be as valid as the original.
Signature__________________________________________________Date________________________
FOR MEDICARE RECIPIENTS ONLY:
MEDICARE BENEFICIARY’S LIFETIME PAYMENT AUTHORIZATION:
I request payment of authorized benefits be made to me or on my behalf to Associates in Ear Nose and Throat of Greater Nashua for any services furnished to me. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits of related services.
Signature___________________________________________________Date_______________________
HIPPA Acknowledgement:
In order to prevent any possible delays, I agree to allow Dr. Donovan’s office to leave messages regarding laboratory and x-ray results as well as office appointments on my answering machine. Yes______No_____
I have been offered the HIPPA information pamphlet “Notice of Privacy Practices”
Signature:_____________________________________________________Date____________________
Payment Policy: We ask that you be prepared to pay for services at the time they are rendered. Should you have any questions regarding fees or billing, we encourage you to inquire beforehand.