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Mellman Medical New Patient Form
Please fill out the following form. If you do not know the answer to any of the following questions, please answer with "N/A."
Patient Infomation
This data will be added to the demographics requested by your insurance company and if applicable Medicare. Feel free to abstain from answering any questions that you feel are inappropriate.
Name:
Date Of Birth:
MM
/
DD
/
YYYY
Address:
City:
State:
Zip:
Cell Phone:
Home Phone:
Work Phone:
Sex:
Required
Marital Status:
Required
Race:
Email Address:
Pharmacy Name:
What is the city your pharmacy is located in?
What are the cross streets and or telephone/fax no?
Employer:
Employer Address:
Emergency Contact:
Emergency Contact Phone Number:
How did you hear about us?
INSURANCE INFORMATION
Primary Insurance Name:
Insurance ID #:
Group #:
Secondary Insurance Name:
Insurance ID #:
Group #:
Workers Compensation:
Required
Claim #:
Workers Compensation Address:
Workers Compensation Phone #:
ASSIGNMENT AND RELEASE
I certify that I and/or my dependant(s), have insurance coverage with:
and assign directly to Michael F. Mellman, MD and/or Rebecca Pestle, PA-C all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above-named doctor / physician’s assistant may use my health information and may disclose such information to the above-named insurance company(ies) and their agents for purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. Please type your name in the space below as form of electronic signature to confirm you understand the information above.
Date:
MM
/
DD
/
YYYY
Relationship to Patient:
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