SCHWEINSHAUPT WALK-IN & FAMILY CARE

6502 Gunn Highway – Tampa, FL 33625

Telephone:  (813) 969-2030  Fax:  (813) 969-2399

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FAMILY IDENTIFICATION AND BUSINESS INFORMATION

Spouse/Parent  [Spouse-name]   Date of Birth [dobmonth-sp] / [d_dobday-sp] / [d_dobyear-sp]

Address [r_Patient-Address] City, State [Patient-City]  Zip [Patient-Zip]  

Mailing Address [Patient-Address2]  City, State  [Patient-City2]  Zip [Patient-Zip2]  

Employment Information

Patient’s [Employer] Occupation  [Occupation] Phone [Patient-Work-Phone]

Spouse’s [Employer-sp] Occupation  [Occupation-sp] Phone [Patient-Work-Phone-sp]

Insurance Information

Primary Company  [r_Health-Ins-Name] Other Insurance: [OtherIns] Policy ID#  [r_Insurance-ID]

First Name: [r_Billing-First-Name]  Last Name:  [r_Billing-Last-Name]    Policyholder’s SSN [r_Billing-SS1]

Birthday:  [Resp_month] / [Resp_day] / [Resp_year]        

Secondary Company  [Health-Ins-Name2] Other Insurance: [OtherIns2] Policy ID#  [Insurance-ID2]

First Name: [Billing-First-Name2]  Last Name:  [Billing-Last-Name2]    Policyholder’s SSN [Billing-SS2]

Birthday:  [Resp_month2] / [Resp_day2] / [Resp_year2]

Medicare yes no   Medicare Number [medicare]  Responsible party [mcare resp]

Important Information PLEASE READ

If you would like your medical information released to anyone (other than yourself) please list their names.

1.  [Info release]  2.  [Info release2]

Please present all insurance cards & copayments to the receptionist each time you come in to be seen

I understand that all charges (including those not paid by insurance), collection fee, bank/returned check fees, legal fees and failure to keep appointment fees are the financial responsibility of the patient (or the parent/guardian in the case of a minor). I hereby authorize Dr. Schweinshaupt to release all information concerning my illness (es) and treatments to my insurance carriers/health plans. In the event that Dr. Schweinshaupt participates with my insurance carrier/health plan, I hereby assign all available benefits and payments directly to him for medical services rendered. I understand that I am financially responsible for all balances not covered by my insurance carrier/health plan, and authorize Dr. Schweinshaupt to charge my credit card for the full amount of any unpaid balances.  I acknowledge notification of the privacy practice act.

Do you have a living will or wish to discuss one? have one discuss not interested

  I agree

                                                                                r2/15/06