Patient Information Form - Severna Park Medical Assoc

Patient Information


Last Name: *
First Name: *
Middle Initial: *
Street Address: *
City: *
State: *
Zip Code: *
Sex M/F: *
Date of Birth: *
Home Phone: *
Work Phone: *
Cell Phone: *
Email address: *
Social Security Number: *

Primary Coverage:		Secondary Coverage:
Company:		Company:
Insured:		Insured:
Relationship:		Relationship:
Relationship DOB:		Relationship DOB:
Policy #		Policy #
Group #		Group #

I authorize Severna Park Medical Associates, to apply for benefits on my behalf for services rendered to Severna Park Medical Associates. I request payment from my insurance company be made directly to Severna Park Medical Associates.

I understand that it is my responsibility to verify with my insurance that the provider participates in my insurance plan.

I certify that the information I have reported with regard to my insurance coverage is correct and further authorize the release of any necessary information, including medical information for this or any related claims. I permit a copy of this authorization to be used in place of the original. This authorization may be revoked at any time in writing. I understand that nothing herein relieves me of the primary responsibility and obligation to pay for medical services provided.

Notice of Privacy Practices

I have received / read a copy of the Notice of Privacy Practices: Severna Park Medical
Associates