Doctor: (select one) Chart:_______ Facility:______________________
Referring Doctor: Phone:
Primary Doctor: Phone:
Patient Information
Name:
Address:
Phone: Home Work Other  
Phone: Home Work Other  
Date of Birth: Age:  
Social Security:  
Marital Status: Married Single Other  
Emergency Contacts
Name:
Phone:
Relationship:
   
Name:
Phone:
Relationship:
 
Spouse Information
Name:
Phone:
Employment
Employed Retired Unemployed Disabled
Employer:
Address:
Phone:
Responsible Party Information
Same as Patient
Name:
Address:
Phone:
Social Security:
Date of Birth:
   
Employer Information ( if applicable )
Name:
Address:
Phone:
Primary Insurance
Same as Patient Same as Responsible Party Other
Policy Holder Name:
Policy Holder Phone:
Relationship to Patient:
Insurance Name:
Insurance Address:
Insured ID#:
Insured Plan/Group:
Insurance Phone:
Secondary Insurance
Same as Patient Same as Responsible Party Other
Insured Party Name:
Insured Party Phone:
Relationship to Patient:
Insurance Name
Insurance Address
Insured ID#:
Insured Plan/Group#:
Insurance Phone:
Responsible Party Signature
Please verify all information contained above, if any changes need to be made simply mark through the item and write in the correct information. By signing below patient/guarantor agrees the above information is correct.

Authorization: I hereby authorize Cardiology Consultants of Texas to furnish information to insurance carriers concerning this illness/accident, and I hereby irrevocably assign to the doctor all payments for medical services rendered. I understand that I am financially responsible for all charges regardless of insurance coverage.
   
______________________________________ __________________
Responsible Party Signature Date



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