Patient Information Form

ERIC HORST, MD MARJAN KAREGAR, MD LAURA LABOONE, MD JANELLE HINSON, PA-C MEREDITH EVERETT, FNP
Date

MonthDayYear
Date
PATIENT'S NAME*

First NameLast Name
Age*
DATE OF BIRTH*

MonthDayYear
Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Work Phone
Cell Phone
EMERGENCY CONTACT*
Name
PHONE NUMBER*
Patient's SSN*
Referring Physician
Marital Status*

MarriedSeparatedWidowerSingleDivorced
Employer
Your Email Address*
example@example.com
PHARMACY*
PHARMACY PHONE NUMBER*
PRIMARY INSURANCE CO*
POLICY ID #*
Name of Insured*

First NameLast Name
Date of Birth*

MonthDayYear
Relation to Patient*
SSN*
SECONDARY INSURANCE CO
POLICY ID #
Name of Insured

First NameLast Name
Date of Birth

MonthDayYear
Relation to Patient
SSN
Employer
Group Number
AUTHORIZATION OF RELEASE OF MEDICAL INFORMATION TO:

LAUREL ENDOCRINE AND THYROID SPECIALISTS, P.A.

J. Robert Brennan, M.D. Eric Horst, M.D. Marjan Karegar, M.D. Laura LaBoone, M.D. Janelle Hinson, P.A. Meredith Everett, N.P.

I authorize Laurel Endocrine and Thyroid Specialists, P.A. to obtain any medical information needed from any physician or hospital.
Patient Signature*

Clear
ASSIGNMENT OF INSURANCE BENEFITS

I request payment of medical benefits be made to Laurel Endocrine and Thyroid Specialists, P.A. or their physicians for services rendered to me.

I UNDERSTAND THAT IN THE EVENT MY INSURANCE DOES NOT PAY, I AM RESPONSIBLE FOR PAYMENT IN FULL. IAUTHORIZE LAUREL ENDOCRINE AND THYROID SPECIALISTS, P.A. TO RELEASE TO THE SOCIAL SECURITY ADMINISTRATION OR ITS INTERMEDIARIES ANY INFORMATION NEEDED FOR THIS CLAIM OR A RELATED MEDICARE/INSURANCE CLAIM. I permit this authorization or a photostatic copy of the original to be used and request payment of medical benefits be made to Laurel Endocrine and Thyroid Specialists, P.A.
Patient Signature*

Clear
Date*

MonthDayYear
Should be Empty: