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903A South Greeley Highway, Cheyenne, WY 82007
307-633-8100 Fax: 307-633-8108
Demographics
Information
Referring Physician:
________________________________________________
Physician Address:
_________________________________________________
Patient Name:
___________________________________________________
Date of Birth:
_______/_______/_____
Age:_________
M
F
Physical Address:
_____________________________________
City: ________________State: _____
Zip: __________
Phone Number: ( ) ______-_______
Second Phone: ______________
Employer: ___________________________
Business Phone: ( ) _____-
__________
Current, or if unemployed: Past
Occupation:
_____________________________________________
Social Security Number:
___________________
Martial Status: M S W D
Spouse’s Name:
__________________________________________________
Spouse’s Date of Birth:
____/_____/____
Spouse’s SSN: __________________
PERSON
RESPONSIBLE FOR PAYMENT
(If patient, write same; if student, parent’s address)
Name:
__________________________________
Relationship to
Patient:________________
Physical Address:
____________________________________
City:___________________
State:_______
Zip:___________
Home Phone Number : ( )
______-________
Social Security Number:
__________________ Date of
Birth: ____/_____/___
Employer: _____________________
Business
Phone: ( ) _____-_______
Current, or if
Unemployed: Past
Occupation:
____________________________________________
PERSON TO NOTIFY
IN CASE OF EMERGENCY
(Other than person listed above)
Name:
______________________________ Relationship:
____________________
Phone Number:
( ) _____-_________
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I verify that all the information above is complete and
accurate.
_____________________________
___________________
Signature of
Patient Date
Copy of Cards
__________
Date/Initials
PAIN CONSULTANTS OF THE ROCKIES,
PC
INSURANCE INFORMATION
(Please present insurance card(s) to our
receptionist)
Workers Compensation
Have you notified your employer?
Yes
No
Case Number: ______________________
Date of Injury:
______________________
State Injury
Occurred:________________
Area of Body Injured:
______________
Other Accident (Auto, Home-owners, etc.)
Claim Number: _______________________
Date of Injury:
______________________
State Injury Occurred:__________________
Area of Body Injured:
________________
Briefly describe
how accident / injury occurred:
____________________________________________________________________________________
____________________________________________________________________________________
Primary
Insurance:
Medicare BC/BS
T19
WinHealth
Tricare
Other: ____________________
Policy Holder Name: ___________________________
Policy
Holder’s DOB: _____/______/____
Policy Holder’s SSN: _______________________
Policy Holder’s Gender: _____
Is this PPO Insurance?
Yes
No
Policy Number: ________________
Grp Name: _______________________________________
Grp Number:__________________
Effective Date: _____/______/______
Phone Number: ( ) _______-___________
Insurance
Address:
___________________________________________________________________________
Secondary
Insurance:
Medicare BC/BS
T19
WinHealth
Tricare
Other: __________________
Policy Holder:
___________________________
Policy Holder’s DOB:
_____/______/____
Policy Holder’s SSN:
________________________
Policy Holder’s Gender: _____
Is this PPO Insurance?
Yes
No
Policy Number: _____________ Grp Name: ___________ Grp
Number:__________________
Effective Date: _____/______/______
Phone Number: ( ) _______-___________
Insurance
Address:
___________________________________________________________________________
Tertiary
Insurance:
Medicare BC/BS
T19
WinHealth
Tricare
Other: _____________________
Policy Holder:
___________________________________Policy Holder’s DOB:
_____/______/____
Policy Holder’s SSN:
________________________
Policy Holder’s Gender: _____
Is this PPO Insurance?
Yes
No
Policy Number: ______________
Grp Name: ____________ Grp Number:
__________________
Effective Date: _____/______/______
Phone Number: ( ) _______-___________
Insurance
Address:
___________________________________________________________________________
YOU
are responsible to provide us with CORRECT information.
All expenses incurred are YOUR responsibility.
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