Date :

DO you have an answering machine ? Yes No

If YES, may we leave a message ?

Home : Yes No

Work : Yes No

Cell : Yes No

PATIENT INFORMATION

Name :

Soc Sec.# :

Address :

Home Tel : ( ) -

City :

State :

Zip :

Marital Status : S M D W

DOB :

Age :

Referred by :

Employer :

Occupation :

Email Address :

Work No : ( ) -

Cell No : ( )

Emergency contact :

Emergency Tel : ( ) -

Relationship to Patient :

PRIMARY INSURANCE

Policy Holder :

Relationship to patient :

Soc Sec.# :

DOB :

Address :

Home Tel : ( ) -

City :

State :

Zip :

Employer :

Insurance Co :

Insurance ID# :

Group# :

ASSIGNMENT and RELEASE

I, the undersigned certify that I (or my dependent) have insurance coverage with and assign directly to Spring SPRING OB/GYN PC all insurance benefits, if any, otherwise payable to me for service rendered. I understand that i am financially responsible for all changes whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment benefits. I authorize the use of the signature on all insurance submissions.

By signing this page I am also acknowledging receipt of the privacy notice provided by Spring Ob/Gyn, Pc. I have read and understand my rights as a patient, as provided this letter.