Center For Advanced Orthopedics , P.A. Cenna Professional Buildings . #7 Post Office Road , Suite Y . Waldorf, MD 20602
Patient Registration – Please print Clearly – Please do not leave any blanks Patient Name
First
Middle
Last
Date of Birth
Age
Street Address
Apt No.
City
State
Zipcode
Mailing Address
Apt No.
City
State
Zipcode
Occupation
Employed
FT
Retired
PT
Student
Social Security number
S Sex
Employer (Or Previous Employer, If retired)
Spouse (or Patient's Name)
Family Physician
Patient E-Mail Address
Spouse's (or parent's ) employer
Address
Marital Status
M
F
M
D
W
Home Phone Patient Work Phone
Spouse's (or parents ) work phone )
Telephone
Our Policy is that payment is to be made at the time services are rendered. Whether or not your insurance company pays in full, a portion or no portion of your medical bills is a matter between you and your insurance carrier. Unless other arrangements have been made, any unpaid balances are due within 30 days of treatment. Payment is accepted in the form of cash, check or money order.
PERSONAL HEALTH INSURANCE Workers Compensation and Auto Insurance should be listed on the back of this form Insurance Company Name
ID/ Or Policy Number
Group / Code
Insurance Company Address
Subscriber's Social Security No:
Date Effective
Subscriber's Name
Sex M
Location of Accident / Injury
Relationship to Patient
Subscriber's Work Phone :
Subscriber's Date of Birth:
F
Medicare Only : Secondary Insurance
Co- Pay
Subscriber's Home Phone :
Date of Illness/Injury
This is not an Injury / Accident Home
Work
Automobile Accident
Others
Initials
PATIENT AUTHORIZATION I,
, hereby authorize the Center for Advanced Orthopedics , P.A. to apply for benefits on my
behalf for covered services. I request that payment from Advanced Orthopedics, P.A.
Insurance company be made to the Center For
I certify that the information that I have reported with regard to my insurance coverage is correct and further authorize the release of any necessary information , including medical information for this or any related claim , to the above billing agent, (or in the case of Medicare Part B benefits , to the Social Security Administration and Health Care Financing Administration ) and/or the insurance company named by me, including automobile insurance or workers Compensation insurance. I permit a copy of authorization to be used in place of the original . This authorization may be revoked by either me or above named insurance carrier at any time in writing. I request that payment of authorized medical benefits be made to the above named provider for any services furnished me by that physician/supplier. I understand that I am directly responsible for any amount not covered by insurance . I agree that if I do not supply a valid referral or if my referral has expired and I fail to supply a new referral, I will be responsible for all incurred charges. I agree to pay any and all costs of collection (including attorney fees and court costs ) that may be incurred by this office for collecting the balance . In conjunction with this agreement. I agree to waive the statue of limitations as it pertains to the collection of accounts past 3 years of age . I certify that I have given in writing, all injury or illness information (including information if the injury was incurred in an automobile accident or on the job). If the information was not supplied in writing prior to the first examination. I agree to pay a $100 service fee for the additional staff time it takes to correct , reimburse, and resubmit for all involved charges. I agree to notify the Center for Advanced Orthopedics, P.A. immediately of any changes that may occur. I agree that if my workers compensation claims is denied . I will be responsible for all charges. I agree that if charges incurred have not been paid within 60 days, I will responsible for payment of those charges.
Date
Signature of Subscriber or Beneficiary
Account number PLEASE COMPLETE THE INFORMATION ON REVERSE SIDE
CENTER FOR ADVANCED ORTHOPEDICS, P.A. Shaheer Yousaf, M.D., F.A.C.S.
GENERAL MEDICAL INFORMATION - Must Complete REASON FOR TODAYS VISIT - PLEASE DESCRIBE THE LOCATION ON THE BODY AND TYPE OF PROBLEM YOR ARE HAVING
IF ACCIDENT OR INJURY , PLEASE DESCRIBE -IF THIS IS NOT AN ACCIDENT OR INJURY , PLEASE WRITE "N/A"
WORKERS COMPENSATION INSURANCE Work related injuries Compensation Insurance Carrier
Employer at time of accident
Was injury reported to Supervisor Yes
Claim number if known
Address
Name of Supervisor
Date of Injury
Phone Number
No
Adjuster's Name
Phone Number
Auto Mobile Insurance Auto or Personal injury Date of Accident
Date PIP Exhausted
Your Auto Insurance company Name
Yes
No
Address
Calim# Policy#
Other Auto Insurance company Name
Address
Calim# Policy#
Attorney Name
Phone Number
Lien Signed
Address
If emergency Services were rendered, where
When
Yes
No