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Registration Form 2015 .pdf


Original filename: Registration Form 2015.pdf
Title: Microsoft Word - Registration Form 2015
Author: Kelly

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McLean County Foot and Ankle

GERALD W. PAUL D.P.M.
BRIAN L. HAMM D.P.M.

MPATIENT INFORMATION RECORD (Please print or write legibly. Please use blue or black ink).
PATIENT’S NAME
TODAY’S DATE
MARITAL STATUS
DATE OF BIRTH SEX
S M W D SEP
M F

AGE

MOBILE PHONE NUMBER
(
)

EMAIL
CITY AND STATE

STREET ADDRESS (PERMANENT)

HOME PHONE NUMBER
(
)

ZIP CODE

SOCIAL SECURITY NUMBER

PATIENT’S EMPLOYER
ADDRESS

CITY AND STATE

ZIP CODE

SPOUSE’S NAME

SOCIAL SECURITY NUMBER

WORK PHONE NUMBER
(
)

SPOUSE’S DATE OF BIRTH

SPOUSE’S EMPLOYER NAME
ADDRESS

CITY AND STATE

ZIP CODE

WORK PHONE NUMBER
(
)

EMERGENCY CONTACT (NAME AND PHONE NUMBER)

ARE YOU COLLECTING SOCIAL SECURITY DISABILITY?
CURRENT WORK STATUS: WORKING

DISABLED

YES
UNEMPLOYED

NO
RETIRED

WHAT TYPE OF WORK DO YOU DO?

SOCIAL SECURITY START DATE

/

WORK RESTRICTIONS:

SICK LEAVE

_/

YES

DOES YOUR JOB CONTRIBUTE TO YOUR PAIN?

NO
YES

NO

RESPONSIBLE PARTY INFORMATION (IF OTHER THAN PATIENT)
MOTHER’S NAME

STREET ADDRESS, CITY, STATE AND 10 DIGIT ZIP CODE

MOTHER’S SOCIAL SECURITY NUMBER

MOTHER’S DATE OF BIRTH
OCCUPATION

MOTHER’S EMPLOYER

BUSINESS PHONE NO. & AREA CODE

EMPLOYER’S STREET ADDRESS

CITY AND STATE

FATHER’S NAME

STREET ADDRESS, CITY, STATE AND 10 DIGIT ZIP CODE

FATHER’S SOCIAL SECURITY NUMBER

FATHER’S DATE OF BIRTH

10 DIGIT ZIP CODE

OCCUPATION

FATHER’S EMPLOYER
EMPLOYER’S STREET ADDRESS

HOME PHONE NO. & AREA
CODE

BUSINESS PHONE NO. & AREA CODE
10 DIGIT ZIP CODE

CITY AND STATE

NAME OF HOSPITAL OR PHYSICIAN WHO REFERRED YOU TO OUR PRACTICE
FAMILY PHYSICIAN (FIRST & LAST NAME)

STREET ADDRESS

WHICH PHYSICIAN IN OUR PRACTICE ARE YOU SEEING TODAY

CITY,STATE & 10 DIGIT ZIP CODE
DR. PAUL

DR. HAMM

HAVE YOU EVER BEEN TREATED BY ANY OTHER PHYSICIAN AT MCLEAN COUNTY FOOT AND ANKLE?
IF SO, WHO AND WHAT YEAR?

YES

NO

INSURANCE INFORMATION
PRIMARY INSURANCE CARRIER (MEDICARE, PRIVATE, IDPA, SELF EMPLOYED, ETC.)
ADDRESS

GROUP NUMBER

POLICY NUMBER

SECONDARY INSURANCE CARRIER (PRIVATE, IDPA, SELF EMPLOYED, ETC.)
ADDRESS

GROUP NUMBER

IS THIS A WORK INJURY?

YES

NO

CLAIM #

WORKMAN’S COMPENSATION INSURANCE CO.
WORK COMP INSURANCE ADDRESS

IS THIS A LIABILITY CLAIM (I.E. CAR ACCIDENT)?

POLICY NUMBER

YES

WORK COMP ADJUSTOR :
NAME:

PH:

WORK COMP NURSE CASE
MANAGER:
NAME:

PH:

NO

LIABILITY INSURANCE:
NAME:

CLAIM #:

LIABILITY INSURANCE ADDRESS
POLICY HOLDER NAME:
FIRST NAME

LAST NAME

DOB:

POLICY HOLDER ADDRESS:
INSURANCE CONTACT PERSON?
PHONE:

NAME:

DID AN INJURY CAUSE OR AGGRAVATE YOUR PROBLEM?

CAUSED

AGGRAVATED

NO INJURY

WHEN WAS THE FIRST OR MOST SERIOUS INJURY? __________________________________________________________________________________
PLEASE DESCRIBE THE INJURY, YOUR MAIN SYMPTOM (INDICATE LEFT OR RIGHT)
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
LIST ANY SURGERIES YOU HAVE HAD IN RELATION TO THIS PROBLEM (INCLUDE DATE/TYPE)
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
YES

DO YOU HAVE AN ATTORNEY WHO WILL BE REPRESENTING YOU REGARDING THIS INJURY?
IF SO, PLEASE
INDICATE
STREET ADDRESS

NO

ATTORNEY’S NAME:
CITY,STATE

ZIP

PH:

AUTHORIZATION
The undersigned authorizes McLean County Foot and Ankle to release and/or obtain information in the course of treatment regarding medical
condition of (patient’s name) __________________________________________to the previous named Insurance Company(s) and Physician(s).
This consent shall expire 1 year from the date I sign this form. It is my intent that this consent shall cover any and all services from this provider
during this time. The undersigned also authorizes that their medical benefit payment be made directly to McLean County Foot and Ankle. In
order to control our cost of billing we request that co-pays be made at the time the service is rendered. All patient balances are expected to be
paid upon receipt of bill unless other arrangements are made for payment. If the undersigned fails to pay any remaining balance for services
rendered and collection efforts become necessary, the undersigned agrees to be responsible for all collection cost incurred. A collection fee will
be assessed on the account balance at the time the account is laced for regular collection with the collection agency. In the event legal action is
taken, the patient is responsible for payment of all court costs.

Patient Signature

Date
McLean County Foot and Ankle | 1404 Eastland Drive, Suite 104 | Bloomington, IL 61701
www.mcleancountyfootandankle.com


Registration Form 2015.pdf - page 1/2
Registration Form 2015.pdf - page 2/2

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